Health inspection·June 1, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to update and revise a care plan to reflect a significant weight loss for one (Resident #38) of twenty-one sampled residents. Findings Included: On 5/30/2023 at 10:00 a.m., and 1: 20 p.m., 5/31/2023 at 1:00 p.m., and 6/1/2023 at 12:00 p.m., Resident # 38, was observed lying down in her bed with her head elevated and her call light within her reach. She presented without behaviors, pain, or discomfort. The room appeared clean and well lit. A review of Resident #38's admission record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease, Unspecified, Gastro-Esophageal, Ileus Unspecified, and Reflux Disease Without Esophagitis. A review of the most current Minimum Data Set (MDS), dated [DATE], show in Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the electronic health record weights and vital record showed, on 4/3/2023 Resident #38 weighed 129.6 Lbs., on 4/18/2023 111.8 Lbs., and on 5/3/2023 110.0 Lbs. A review of the Registered Dietitian (RD) weight loss follow-up note, dated 4/19/2023, showed, Current Body Weight, CBW 111.8 lbs. (4/18/23), ht 60, Body Mass Index, BMI 21.8. Reweigh for verification, CBW represents a 13.7 % loss x 30d (4/3/23 129.6 lbs). Current diet order is clear liquid due to constipation/ KUB. Resident # 38 was previously on a regular diet, regular texture thin liquid, magic cups every day, QD, mighty shakes every day and Medpass 2.0 every day. A recommendation was made to allow nutrition supplements on Clear Liquid Diet (CLD). A review of the physician order summary sheet dated 6/1/2023, showed a diet order for thin consistency, clear liquid diet, that started on 4/17/2023 to 5/5/2023. Further review showed clear liquid diet order currently discontinued. A review of the current care plan with an initial date of 9/25/2020 and a revision date of 5/8/2023, indicated the following areas: Resident is at risk for altered nutritional status related to (r/t) Parkinson's, convulsions, HTN (hypertension), hypothyroidism, occlusion/stenosis of carotid arteries, pacemaker presence, MDD (major depressive disorder), anxiety, insomnia, GERD (Gastroesophageal reflux disease), constipation, ileus, dysphagia, recent hx clear liquid diet. A review of the care plan interventions with an initial date of 9/25/2020 and a revision date of 11/24/2020, showed to honor Page 1 of 2 105629 105629 06/01/2023 Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few food preference as able, monitor s/s (signs and symptoms) of dehydration and/ or fluid overload, monitor skin integrity, monitor wt per protocol, offer supplement as ordered. Further review showed the nutritional care plan was not revised after 4/18/2023 to reflect Resident #38's weight loss. On 5/30/2023 at 1: 20 p.m., an interview was conducted with Resident #38, in her room. She said she could not recall if she had lost any weight in the previous few months because no one had ever mentioned it to her. She said she was on a clear liquid diet a month ago since she was experiencing stomach issues; therefore, if she had lost any weight, it might have been because of the clear liquid diet. She said she has a healthy appetite and consumed most of her meals. On 5/31/2023 at 5:04 p.m., an interview was conducted with the Director of Nursing (DON). The DON said she thought, [Resident #38's] weight loss was a result of the several health issues she was dealing with. [Resident #38] was on an IV (intravenous) antibiotic from April 5 through April 16 for a UTI (urinary tract infection) and suffered a seizure on April 11. We wanted to send her out to the hospital since she was experiencing gastrointestinal issues that were making her constipated, but she refused to go to the hospital at that time. After we attempted to use fleet enemas to help the resident move her bowels, her doctor was informed regarding how she was still having constipation, so he gave the go-ahead to begin her on a clear liquid diet to help soften up her bowels. On April 3, [2023], a monthly weight for [Resident #38] showed she weighed 129.6 pounds. However, because the resident began a clear liquid diet on April 17, [2023], we chose to reweigh her again on April 18, [2023], and at that time, she weighed 111.8 pounds. We reweighed her on May 3rd, [2023], and her weight was 110.0 pounds. In order to help her regain weight, the Registered Dietitian intervened at that point and placed an order to restart the resident back on her nutritional supplements. The care plan was not revised to reflect Resident #38's weight loss because truthfully everything was happening so fast during that time and she was sent out to the hospital shortly after. On 6/1/2023 at 9:36 a.m., an interview was conducted with Staff A, Registered Nurse (RN), MDS coordinator. Staff A said it was not the MDS coordinator's responsibility to update or make revisions in the nutritional care plan section. However, she did reach out to the Registered Dietitian to let her know when the care plan needed to be updated or a revision needed to be made. Staff A said the only update she made on Resident #38's care plan was when she came back from the hospital. Staff A said she did not add a revision to show the resident's weight loss on the care plan. Review of the facility policy and procedures, titled, Person Centered Care Planning, revision dated 12/2016. Showed care plans were to be revised as changes in the resident's condition warrant or when there was a change in resident's preference or choice of treatment. 105629 Page 2 of 2