Health inspection·September 2, 2021

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for six (Resident #17, #28, #33, #38, #65 and #191) of six residents sampled for nutritional status, from a total of 26 residents in the sample. Inaccurate assessments leave residents at risk for not receiving necessary care and services to ensure their highest practicable functional level and mental or psychosocial well-being. Residents Affected - Few The findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 3/13/21, with a primary diagnosis of Metabolic Encephalopathy. A quarterly MDS assessment dated [DATE] revealed Section K (Swallowing/Nutritional Status) was signed as completed by the Certified Dietary Manager (CDM) and Resident #17 was coded as being on a physician prescribed weight gain regimen. (Copy obtained) A review of Resident #17's physician orders revealed, she was on a regular diet with regular texture, 30 ml house stock protein supplement three times a day, and a nutritional treat one time a day. However, there was no active order for a physician prescribed weight-gain regimen. During an interview with the CDM on 09/02/2021 at 11:07 AM, he was asked about his process for evaluating the residents and completing the MDS. The CDM stated, he takes the information from the dietician and inputs it into the system. He goes by the recommendations of the dietician. When completing Section K of the MDS, he looks for the resident's diagnoses, along with the recommendations and answers the questions to the best of his abilities. 2. Review of the medical record for Resident #28 revealed an admission date of 10/28/17, with a primary diagnosis of acute and chronic respiratory failure. A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #28 was coded as being on a physician prescribed weight gain regimen. (Copy obtained) A review of Resident #28's physician orders revealed a fortified diet. However, there was no active order for a physician prescribed weight-gain regimen or a physician prescribed weight loss regimen. Resident #28 has a documented height of 73 inches and a weight of 235 pounds, with a body mass index (BMI) of 31, which according to the CDC (Centers for Disease Control) falls into the obesity range (BMI greater than 30). 3. Review of the medical record for Resident #33 revealed an admission date of 1/22/19 and re-admit date of 7/5/19, with diagnoses of pressure ulcer of the sacrum, obesity, and heart failure. A Page 1 of 3 105735 105735 09/02/2021 Orange City Nursing and Rehab Center 2810 Enterprise Rd Debary, FL 32713

F 0641 Level of Harm - Minimal harm or potential for actual harm quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #33 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Residents Affected - Few Resident #33 has a documented height of 70 inches and weight of 207 pounds, with a BMI of 31.5. Review of Resident #33's current physician orders revealed no prescribed weight gain regimen. 4. Review of the medical record for Resident #38 revealed an admission date of 10/16/17 and re-admit date of 4/1/18, with diagnoses of end stage renal disease, bilateral above the knee amputations, and major depressive disorder. A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #38 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #38 has a documented height of 61 inches and weight of 184 pounds, with a BMI of 34.8. Review of Resident #38's current physician orders revealed no prescribed weight gain regimen. 5. Review of the medical record for Resident #65 revealed an admission date of 11/4/20, with diagnoses of dysphagia, chronic obstructive pulmonary disease, and dementia. A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #65 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #65 has a documented height of 64 inches and weight of 174 pounds, with a BMI of 29.9, which according to the CDC falls into the overweight range (BMI 25.0 to <30). Review of Resident #65's current physician orders revealed no prescribed weight gain regimen. 6. Review of medical record for Resident #191 revealed an admission date of 2/6/21, with diagnoses of gastro-intestinal bleed, acute kidney failure, and dementia. A quarterly MDS assessment dated [DATE] revealed Section K was signed as completed by the CDM and Resident #191 was coded as being on a physician prescribed weight gain regimen. Further review of section K revealed resident was marked under Weight gain of 5% or more in the past 30 days or 10% or more in the past 6 months. (Copy obtained) Resident #191 has a documented height of 62 inches and weight of 196 pounds, with a BMI of 35.8. Review of Resident #191's current physician orders revealed no prescribed weight gain regimen. During an interview with the Registered Dietetic Technician (DTR) on 9/2/21 at 11:07 AM, he confirmed that Residents #17, #28, #33, #38, #65 and #191 were not on a physician prescribed weight gain regimen and the MDS assessment for each resident had been miscoded. During an interview with the MDS Coordinator on 9/2/21 at 11:50 AM, she confirmed the MDS assessments had been miscoded for Residents #17, #28, #33, #65 and #191. She stated, as an RN, she attests to 105735 Page 2 of 3 105735 09/02/2021 Orange City Nursing and Rehab Center 2810 Enterprise Rd Debary, FL 32713

F 0641 Level of Harm - Minimal harm or potential for actual harm the best of her knowledge the information is accurate and complete, however, the MDS is interdisciplinary, so other disciplines fill out sections. . Residents Affected - Few 105735 Page 3 of 3