§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-
§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;
§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;
§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
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Observations:
Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to consistently monitor resident weights and implement nutritional interventions after significant weight changes were identified to promote and maintain residents' nutritional status for two of 21 residents reviewed (Residents 43 and 87).
Findings include:
A review of the facility policy titled "Weight Resident Policy," last reviewed February 28, 2026, revealed all residents will be weighed upon admission, reweighed the following day for accuracy, and then weighed weekly for four weeks. If weights remain stable, residents will then be weighed monthly or as ordered by the physician. The policy revealed residents with a weight gain or loss of three pounds or more will be reweighed within 24 hours to verify the weight. If the weight change is confirmed, nursing staff will notify the physician and the dietary manager or registered dietitian.
Clinical record review revealed Resident 43 was admitted to the facility on January 31, 2025, with diagnoses including chronic kidney disease (a condition in which the kidneys become damaged and are unable to adequately filter waste and excess fluid from the blood).
Weight records revealed Resident 43 weighed 103.8 pounds on May 15, 2026. Following hospitalization, the resident returned to the facility on June 1, 2026, weighing 96 pounds, representing a 7.5 percent weight loss over 16 days. Weight records further revealed the resident weighed 92.4 pounds on June 16, 2026, reflecting an additional 4-pound weight loss over the following two weeks.
Clinical record review revealed the resident should have been placed on weekly weights following the significant weight loss in accordance with facility policy. However, the clinical record contained no documented evidence that staff obtained a weekly weight during the week of June 8, 2026.
A dietary progress note dated June 16, 2026, at 10:16 AM documented that Resident 43 experienced an unplanned significant weight loss. The registered dietitian noted the resident was receiving Ensure (a high-calorie, high-protein oral nutritional supplement) twice daily with good acceptance and recommended increasing the supplement to three times daily.
Clinical record review failed to reveal documented evidence that the dietary recommendation to increase Ensure to three times daily was implemented.
During an interview on July 30, 2026, at 11:00 AM, Employee 1, Certified Dietary Manager (CDM), confirmed residents who experience significant weight loss are placed on weekly weights in accordance with facility policy and acknowledged Resident 43 was not weighed weekly during June 2026. Employee 1 further confirmed the registered dietitian's recommendation to increase Ensure to three times daily was not implemented and could not provide a reason why.
Clinical record review revealed Resident 87 was admitted to the facility on May 4, 2026, with diagnoses including Alzheimer's disease (a progressive brain disorder that causes worsening memory, thinking, and behavior) and dysphagia (difficulty swallowing that increases the risk for poor nutrition, dehydration, choking, and aspiration).
On May 6, 2026, Employee 1, a Certified Dietary Manager (CDM) completed a Mini Nutritional Assessment (MNA is a validated nutrition screening and assessment tool that can identify geriatric residents age 65 and above who are malnourished or at risk of malnutrition based on numeric scoring. A score of 12 -14 points is normal nutritional status, 8 - 11 points is at risk of malnutrition, and 0 - 7 points is malnourished) that revealed Resident 87 scored five points reflecting malnutrition.
A review of the resident's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 8, 2026, , revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) because of severe cognitive impairment.
A progress note completed by the Director of Nursing (DON) dated July 17, 2026, at 11:46 AM documented discussion with Resident 87's spouse and responsible party regarding the resident's declining appetite and weight loss. The DON reviewed meal intake and weight trends and explained oral nutritional supplements, including Ensure and Two Cal (a high-calorie, high-protein oral nutritional supplement), would be initiated if the resident continued to lose weight. The resident's spouse requested weekly weights.
Weight records revealed Resident 87 weighed 142.3 pounds on July 18, 2026, at 9:48 AM and 137.8 pounds on July 25, 2026, at 10:19 PM, representing a 4.5-pound weight loss in one week.
Clinical record review failed to reveal documented evidence that staff obtained a reweigh within 24 hours to verify the significant weight loss as required by facility policy.
Clinical record review also failed to reveal documented evidence that staff notified the resident's physician or responsible party after the significant weekly weight loss.
The above findings were reviewed during an interview on July 30, 2026, at 12:15 PM, with the Director of Nursing and confirmed the facility did not obtain a reweight and could not provide documented evidence that the physician or responsible party had been notified of the weight loss.
28 Pa Code 211.10 (c) Resident care policies.
28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 09/01/2026
1.Resident 87's weight loss has been reviewed with the MD, RP and weights are now in accordance with the facility policy. Resident 43's weight is currently 102.2 and is stable. Her ensure supplement was increased to tid.
2.An audit will be completed by the DON/ Designee to ensure all current residents that had a significant weight loss within the last 30 days had a reweight within 24 hours. MD and RP notification will also be audited for compliance. Dietary recommendations for supplements on current residents with weight loss will be reviewed to ensure implementation. Any corrective action needed will be completed.
3.All Licensed staff, CNA's and Dietary Manager will be in-serviced on the Resident Weight Policy.
4.DON/ Designee will audit weekly X 3 months a random selection of residents with a significant weight change to ensure the reweight was completed, the MD and RP were notified. An audit will also be conducted on all new dietary recommendations for supplements to ensure correct implementation. Corrective action will be completed. Results of audits will be reviewed at the Quality Assurance and Performance Improvement committee for review and recommendations.
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