Inspection·October 27, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for one of six residents reviewed. (Resident CL1) Findings include: Review of facility policy, Weights Policy revised February 1, 2020, revealed that a significant weight change is defined as 5% weight loss of more in one month; 7.5% or more in three months; and 10% or more in six months. Review of Resident CL1's admission Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated August 16, 2023 revealed that the resident was admitted to the facility on [DATE], and had the diagnoses including diabetes a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), renal disease (a condition characterized by a gradual loss of kidney function over time), and liver failure (when the liver has shut down or is shutting down). Review of Resident CL1's clinical records revealed Resident CL1 had a documented weight of 123.4 pounds on August 9, 2023, and a weight of 114.4 pounds on August 30, 2023; indicating a significant weight loss of 7% twenty-one days. Review of physician orders revealed an order dated August 16, 2023, for the following dietary supplements: Med Pass, two times a day for malnutrition, sandwich in the evening for protein malnutrition. and Magic Cup three times a day for weight management with all meals. Review of Resident CL1's Medication Administration Records for August and September of 2023 failed to reveal documented evidence hat the three prescribed nutrition supplements were provided to the resident. Further review failed to reveal documented evidence of supplement daily percent intakes of the prescribed nutritional supplements by Resident CL1. Further review of nursimg progress notes progress notes revealed no documented evidence regarding Resident CL1's acceptance or refusals of the prescribed supplements. Interview with the Registered Dietitian, Employee E3, on October 27, 2023, at 11:50 a.m. confirmed that there was no documented evidence of supplement percentage intakes to evaluate the nutrition interventions for Resident CL1. The dietitian stated that the nursing staff monitors supplement intakes by exception and confirmed that she had not observed the resident being offered and accepting of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395259 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Statesman Health & Rehabilitation Center 2629 Trenton Road Levittown, PA 19056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)