§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 the clinical record, review of facility's policy and staff interviews, it was determined that the facility failed to ensure that re-weights were completed in a timely manner for one of 18 clinical records reviewed. (Resident R7).
Findings include:
Review of the facility policy, "Weight, Loss or gain/re-weights," dated July 2, 2023, indicated that the physician, dietician, and MDS (Minimum Data Set- assessment of resident's care needs) Assessment Coordinator will be notified of the results of the monthly weights as indicated in the physician orders. Continued review of the order indicated that for significant weight loss, labs may be recommended to see if indicators of malnutrition are present.
Review of the April 2025 orders for Resident R2 included the following diagnosis: anemia (a condition characterized by a deficiency of healthy red blood cells); chronic pain; diabetes (failure of the body to produce insulin); osteoarthritis (condition in which the protective cartilage that cushions the ends of the bones wears down over time) and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest).
Review of the resident's weight record revealed than on October 17, 2025 the resident weight wa 168.6 pounds. Review of October 24, 2025 weight recorded by nursing staff was 148.8 pounds, totaling a 12.04-pound significant weight loss from October 17, 2025 to October 24, 2025.
Continued review of Resident R7's clinical record did not show evidence that a re-weight was completed in a timely manner to ensure accuracy. Further review of the weight records revealed that a reweight was completed 5 days later on October 29, 2025.
During an interview with the clinical dietician (Employee E3) on April 2, 2026, the -12.04 significant weight loss from the recorded weights of October 17, 2026 and October 24, 2026 was confirmed. The clinical dietician also reported that a weight discrepancy of 5 pounds or more from a resident's most recent requires a re-weight completed by nursing staff.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.12(d)(1)(3) Nursing services
| | Plan of Correction - To be completed: 05/13/2026
1. The recorded weight was incorrect due to a data entry error.
2. Resident R7's weight was completed to confirm the resident's current weight and accuracy of prior documentation.
3. Nursing staff will be reeducated on timely reweight procedures, documentation requirements and proper attention to data entry.
1. All residents' weight records for the past 30 days will be reviewed to identify any errors in weight changes.
2. Any resident with a discrepancy of 5 pounds or more or a significant weight loss/gain will have an immediate re-weight and all appropriate interventions as needed.
3. Nursing staff will be reeducated on recognizing and responding to significant weight changes and review.
1. The DON or designee will audit resident weight weekly for 8 weeks to ensure reweights are completed timely and within normal limits.
2. Audit results will be reviewed during QAPI meetings.
3. Any identified noncompliance will result in immediate corrective action and additional staff training.
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