§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 facility policy, clinical records, and staff interviews, it was determined that the facility failed to accurately assess and monitor weight loss for one of one resident reviewed who experienced significant weight loss. (Resident R1)
Findings include:
Review of facility policy titled "Unintended Weight Loss" revealed the purpose of the policy aims to ensure residents maintain a healthy body weight unless prevented by a medical condition. The community monitors weight closely, with a goal of minimizing unintended weight loss (less than 5% across residents). Any resident experiencing weight loss is assessed by an interdisciplinary team, which creates and adjusts care plans to prevent further loss and promote weight gain. The Director of Wellness and Dietary Manager oversee all processes related to identifying, preventing, treating, and tracking weight loss. Data on weight loss is reviewed monthly and used to guide quality improvement efforts. High rates of weight loss signal potential care issues and require corrective action. Residents are weighed regularly (monthly or more often if at risk), and those at higher risk are monitored weekly. When weight loss occurs, staff must assess causes, notify providers and family, involve dietary specialists, and implement interventions. Compliance is met when proper assessment, care planning, intervention, and ongoing evaluation are performedeven if weight loss cannot be prevented (e.g., end-of-life care or unavoidable clinical conditions). The facility must document and continuously improve its processes to maintain residents' nutritional health.
Review of Resident R1's Admission Minimum Data Set (MDS- assessment a resident's care needs) revealed that the resident was admitted to the facility on February 6, 2026, with diagnoses of Gastroesophageal Reflux Disease (a digestive disorder in which stomach acid frequently flows back into the esophagus; arthritis (characterized by inflammation of the joints leading to pain, stiffness, and decreased mobility); dementia (a decline in cognitive function affecting memory, thinking, and daily functioning) traumatic brain injury (brain dysfunction caused by an external force and may result in cognitive, physical, or emotional impairments) and anxiety (a mental health condition marked by excessive worry, nervousness, or fear). Under the eating assessment, the resident was able to use suitable utensils, bring food and liquids to (her/his) mouth, and swallow safely. Resident R1 required supervision during this task. The resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition.
Review of Resident R1's "Mini" nutrition notes dated February 21, 2026, revealed that the resident weighed 94 pounds, during the last three months the resident had no decrease in food intake and no weight. Resident R1 has scored nine on the nutrition score indicating at risk of malnutrition.
Review of Resident R1's care plan revealed interventions initiated in February 2026 related to gastrointestinal alteration (diverticulitis- inflammation of abnormal pouches in the large intestine), nutritional risk factors, and significant weight loss. The care plan included recommendations for small frequent meals, monitoring intake, providing and serving nutritional supplements, documenting intake each meal, and reporting signs and symptoms of malnutrition and weight loss to the physician as needed.
Review of Resident R1's clinical record revealed that the resident experienced a 7.4 % weight loss between February 6, 2026, and March 3, 2026, as follows:
2/6/26- 97 (pounds) lbs.
2/19/26- 94.0 lbs.
2/27-93.5 lbs.
3/1-86 lbs.
3/3-87 lbs.
Review of nursing notes dated 2/12/2026 revealed that Resident R1 needed encouragement to eat. Continued review of nursing notes revealed that on February 21-22, 2026, resident had poor appetite.On February 25, 2026, a Dietitian consult was ordered.
Review of Resident R1's March 2026 physician orders revealed orders were obtained on March 4, 2026, for a nutritional supplement and March 9, 2026, for weekly weights.
Review of nutritional progress notes revealed that there was not documented evidence that Registered Dietician, Employee E2 evaluated Resident R1's nutritional status and significant weight loss.
Phone Interview with Registered Dietitian (RD), Employee E2 on April 22, 2026 at approximately 1:00 p.m. who is present in the facility approximately 10 hours per week, stated she was unable to recall specific details regarding this resident was unable to provide specific details regarding the resident due to lack of access to the clinical record at the time of the interview. While the resident's name was familiar, the RD could not recall when she was first notified of the resident's poor appetite or weight loss. RD, Employee E2 reported she is responsible for completing nutritional assessments and typically initiates interventions when a resident is identified as at risk for malnutrition. Interventions may include recommending nutritional supplements, monitoring weights, and collaborating with the interdisciplinary team.The RD, Employee E2 indicated that nursing staff are expected to notify her when a resident has poor intake or is not eating, and she relies on this communication to address concerns. She also stated that she communicates primarily with nursing staff regarding weight loss concerns and may recommend referrals, such as speech therapy, if swallowing issues are suspected.Additionally, RD, Employee E2 reported that typical protocol includes monitoring weights, encouraging supplements, considering diet liberalization to improve intake, and suggesting family involvement in providing preferred supplements if needed.The RD was unable to confirm whether timely interventions were implemented for this resident.
28 Pa. Code 201.18 (1) Management
28 Pa. Code 201.20 (a)(6) Staff Development
28 Pa. Code (d)(3)(d) Medical Director
28 Pa. Code 211.12 (d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 05/29/2026
No residents were harmed by this deficient practice. The Dietician and or DOW will complete education with RNs, LPNs and CNAs on facility policy of unintended weight loss to ensure residents maintain a healthy body weight unless prevented by a medical condition. The community monitors weight closely, with a goal of minimizing unintended weight loss (less than 5% across residents). Any resident experiencing weight loss is assessed by an interdisciplinary team, which creates and adjusts care plans to prevent further loss and promote weight gain. The DOW and Dietician oversee all processes related to identifying, preventing, treating, and tracking. Maintain acceptable parameters of nutritional status, such as usual body weight or desired body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or residents' preference indicate otherwise. The resident is offered sufficient fluid intake to maintain proper hydration and health. Residents offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. Education will be completed by May 29, 2026. The Dietician will conduct audits weeklyx4, then monthly x3 to ensure 100% compliance with meeting residents' nutritional needs. Audits and findings will be presented at monthly QAPI meeting.
Education
All staff in Skilled will attend mandatory meetings on residents who experience significant weight loss. It is the responsibility of DOW to ensure all staff attend mandatory meetings reach 100% attendance. Dietician will be conducting audits as outlined to ensure compliance.
Going Forward
All staff will have attended the mandatory meeting as evidenced by sign-in sheets by designated completion date. All significant weight loss will be discussed during morning clinical and weekly Risk meeting and addressed in care plans and progress notes in EMR. All audits will be kept in DOW office in binder
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