Health inspection·April 17, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain acceptable parameters of nutritional status and failed to provide nutritional interventions in a timely manner for 1 of 2 sampled residents reviewed for nutrition (Resident #23). Residents Affected - Few The findings included: Review of the facility's policy titled, Weight Management, dated 06/2021, included the following: Residents will have their weight obtained on admission, re-admission and monthly or at a frequent determined by the interdisciplinary team or provider. Definitions: Significant weight change- As defined in RAI Manual is any unplanned weight change of 5% change over 1 month, 7.5% over 3 months or 10% change over the past 6 months. Procedure: 4.The case associate and or Medication Aide obtains the weight and documents the weight into Touchscreen and or in myUnity. 5. Once weights have been entered into the EMR (Electronic Medical Record), the licensed nurse reviews myUnity's Resident Weight Report/and or Weight Changes +Report for residents obtained on the last day of the Month for any of the following weight changes: a.5 percent (5%) change over 1 month b.7.5 percent (7.5%) change over 3 months or c. 10 percent (10%) change over the past 6 months. 7.When a significant weight change is identified the following will occur: a. PA/CS: The licensed nurse or designee notifies the Dietitian of any resident with a weight change of 5 pounds from the previous weight or a significant weight change. 11. Guest/residents with significant weight change should be discussed in High Risk Rounds/Utilization Review. 12. When a significant weight change is identified, the guest/resident plan of care will be Page 1 of 4 106013 106013 04/17/2025 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0692 Level of Harm - Minimal harm or potential for actual harm reviewed, evaluated and revised, as applicable, to reflect interventions to support the guest/resident goals and preferences after medical consideration and interdisciplinary discussion. Record review for Resident #23 revealed that the resident was admitted to the facility on [DATE] with diagnoses to include: Alzheimer's Disease, Major Depressive Disorder, Atrial Fibrillation, and Dementia. Residents Affected - Few Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) of 00, which indicated that he was severely cognitive impaired. Review of Section GG of the same MDS revealed Resident #23 was dependent on staff assistance for eating/nutrition and all his Activities of Daily Living (ADLs). In addition, review section O revealed Resident #23 was not on the Hospice care program. Review of the Physician's Orders showed Resident #23 had orders dated 10/24/24 for ascorbic acid (vitamin C) 500 mg tablet daily, Vitamin B-12 500 mcg tablet daily, diet: Pureed, Nectar Thick Liquid, continuous; Barrier Cream, apply barrier cream to buttocks 3 times daily and as needed. Review of the Physician's Orders showed Resident #23 had orders dated 12/03/24 for Calcium 600 + Minerals 600 mg (as carbonate) 200-unit tablet daily and on 12/30/24 for cholecalciferol (vitamin D3) 1,250 mcg (50,000 unit) tablet Every 1 Week. Review of the Holistic Care Plan dated 01/29/25 under Nutritional Status documented Resident #23 enjoys eating in the dining room and requires Puree diet with double portions. Care Plan approaches were to provide prescribed diet at every meal; honor food preferences as able; staff to assist with meals as needed; offer fluids throughout the day; encourage oral intake; weigh as prescribed and monitor weights. During an observation conducted on 04/15/25 at 12:09 PM Resident #23 was in the dining room, lunch tray was set on the table and the MDS coordinator assisted the resident, however, the consistency of the food was not pureed and was not the correct lunch tray for Resident #23. At 12:18 PM an observation of Resident 23's tray with correct consistency and appeared to have double portions. Resident #23 was observed opening his mouth wide and eating 100% of his lunch. At this time an interview was conducted with the MDS coordinator, who stated Resident #23 has a good appetite and eats 100% of his meals most of the time. During a second dining observation on 04/16/25 at 12:24 PM, Resident #23 was in the dining room for lunch and was assisted by a Certified Nursing Assistant (CNA) and was eating well. The meal ticket was reviewed and stated double portions. A review of Resident #23's weight log showed that the following weights were recorded: on 10/28/24 upon admission he was at 134.90 pounds, on 02/04/25 he was at 127.00 pounds (7.9 pounds weight loss), and on 04/01/25 he had an additional 6-pound weight loss. This showed a 10.30 percent weight loss from 10/28/24 to 04/01/25. During an interview conducted on 04/16/25 at 10:58 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 4 years. She stated the facility does not have a restorative CNA and the CNA assigned to the resident would do the monthly weights. Staff A stated the CNA then would document the weights in the computer and the nurses and the dietitian have access to see the residents' weights. She also stated that weights are done monthly at the beginning of the 106013 Page 2 of 4 106013 04/17/2025 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few month unless there's a physician's order for a specific timeline to obtain the resident's weight. Staff A stated she would report any weight changes to the Assisting Director of Nursing (ADON) and then the dietitian will come in and follow up with the resident. Record review of the dietitian nutrition note dated 10/29/24 showed Resident #23's Ideal Body Weight (IBW) was 69 kg (152.1 pounds) and current body weight (BW) was 61 kg (134.90 pounds) with recommendation to continue to follow up per protocol. At this time, no Body Mass Index (BMI) was calculated and no documentation that Resident #23 was at risk for weight loss. Record review of the dietitian nutrition follow up note dated 01/23/25 stated Resident #23 is tolerating puree diet well and staff has reported about 100 percent intake of meals. In addition, she reviewed the weights from 10/28/24 to 01/04/25, however, the dietitian only looked at the weight for 12/04/24 and 01/03/25 and noted Resident #23 has had a small weight decline (2.3 percent weight loss x 1 month), which is not significant. The interventions were to continue to monitor oral intake, body weight and skin integrity, with a goal for weight stabilization. Further review of the chart revealed no nutritional interventions or supplements were ordered at this time. Record review of the dietitian note dated 04/13/25 for Resident #23 evaluation due to recent weight loss of 3.4 percent in a month. She reviewed the last 3 months of Resident #23's weight history and noted the weight loss as not significant. She mentioned Resident #23 is currently on supplements including Vitamin E, Vitamin D3, Calcium with minerals, Vitamin C, and Vitamin B12. She also noted that Resident #23 is considered at risk for weight loss and overall decline due to current medical status. The interventions were to continue monitoring closely, weight trends, and skin integrity. No additional interventions were ordered to address the weight loss. In addition, the dietitian did not review the complete weight history (10/28/24 to 04/01/25). At this time Resident #23 had a weight loss trend of 13.9 pounds since admission which indicated a 10.30 percent weight loss from 10/28/24 to 04/01/25. An interview conducted on 04/16/25 at 12:35 PM with the General Manager for Dining, who stated staff members such as nursing, dietitian and even herself can add a food preference to the residents' chart. She stated these preferences are part of the meal ticket and printed on the Dining Details report daily. She reviewed Resident #23's preferences and noted the double portions preference was entered by the ADON on 11/12/24. During an interview conducted on 04/16/25 at 12:59 PM with the Clinical Dietitian, who stated she has been at the facility since September 2024 and works Part-time at least 20 hours a week. She stated she would receive an email with new admissions, and she usually completes the nutritional assessment within 3 days. For the Long-Term Care (LTC) residents, she conducts assessments quarterly, unless she is requested by family, or if the resident is losing weight. She noted that weight loss is considered if the resident has lost 5 percent in a month, 7.5 percent in 3 months and 10 percent in 6 months. She stated that during her assessments she utilizes her clinical knowledge, low BMI, any wounds the resident may have or if poor intake to assess the resident for risk of weight loss. She noted that a normal BMI is 18.5-25 and under 18.5 is considered excessive weight loss. She stated the facility does offer fortified foods, for breakfast is oatmeal, and the other meal is mashed potatoes to add more calories for the residents who are underweight. She then stated that the residents in this community are usually underweight. She also stated if a resident is losing weight, she would immediately put interventions in place such as Ensure or Glucerna (for diabetic residents) supplements, then fortified foods, the last resort is an appetite stimulant (with a physician's order) and continue evaluation. In addition, she stated she receives the monthly weight changes report via email. The 106013 Page 3 of 4 106013 04/17/2025 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few report will include residents that are losing weight and percentage change in 30 days, 90 days and 180 days. At this time, the dietitian was asked to review Resident #23's weight history from admission date and was asked to calculate the weight loss and if it is significant. The dietitian stated, yes it looks significant, let me look at the weights again. She then stated, I missed that. I did not look back to 6 months, only until 02/01/25. She then stated that she was not aware Resident #23 was getting double portions for his meals. A side-by-side review of the clinical monthly weight changes report she received revealed that Resident #23 has a significant weight loss and again she stated, I missed that. Furthermore, the Clinical Dietitian also acknowledged that the current BMI for Resident #23 is 18.4 which indicates that Resident #23 is underweight by 0.1. An interview was conducted on 04/016/25 at 3:00 PM with the ADON and the Director of Nursing (DON). The ADON stated she spoke with Resident #23's son on 11/12/24 and she added double portions as preferences as per the son. In addition, the care plan would note this food preference change and the dietitian was notified. They both stated that the interdisciplinary team (ADON, DON, Social Services, MDS, Activity Manager) holds weekly high-risk rounds, the dietitian does not attend these meetings however, she receives email updates with the monthly weight changes report. ADON also stated that they identified a weight loss for Resident #23 and immediately notified the Clinical Dietitian by email on 04/08/25. Then the High-Risk meeting was conducted on 04/10/25. She acknowledged that the dietitian documentation was done on 04/14/25 and she did not address the significant weight loss. ADON also stated she is the one to update the care plans, however, the dietitian did not advise any recommendations for her to update the nutrition care plan. At this time both ADON and DON acknowledged all findings. 106013 Page 4 of 4