Health inspection·April 8, 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 review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to complete a comprehensive nutritional assessment and monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement appropriate interventions to address weight loss for two of three residents reviewed for nutritional status and weight loss (Residents CR1 and A1). Residents Affected - Some Findings included: A review of a facility policy entitled Nutritional Assessment last revised October 2024, revealed that the Registered Dietitian (RD), in conjunction with nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: usual body weight, current height and weight, a description of the resident's usual intakes, history of reduced appetite or progressive weight loss or gain prior to the resident's admission, current clinical conditions and recent events that may have affected a resident's nutritional status, general appearance - a description of the resident's overall appearance, usual meal and snack patterns, food preferences and dislikes (including flavors, textures, and forms), preferred portion size. Additionally, the assessment will include a review of prescribed medications that may affect nutrient absorption, appetite, level of consciousness, and/or gastrointestinal function, a review of laboratory results to assess fluid and electrolyte balance, an estimation of calorie, protein, and fluid needs, and an assessment of whether the resident's current intake is adequate to meet his or her nutritional needs. Further review of a facility policy entitled Weight Assessment and Intervention last revised by March 2022, indicated that in one month any unplanned/undesired significant weight chance of 5% or more since the last weight assessment is significant and greater than 5% is severe and any undesirable weight change is evaluated by the dietitian, physician, and multidisciplinary team to develop interventions to stabilize/improve the residents' weight. A review of Resident CR1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), weakness, and dependance on supplemental oxygen. Page 1 of 4 395345 395345 04/08/2025 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of the resident's weight documentation revealed that on March 7, 2025, the resident weighed 123 pounds with a height of 65 inches, resulting in a Body Mass Index (BMI) of 20.6 (a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements) of 20.6 within ideal body weight. Residents Affected - Some Further review of Resident CR1's weight record revealed the following weights: March 12, 2025, at 11:51 AM - 121.8-lbs. March 20, 2025, at 12:37 PM - 110.9-lbs., This represented a weight loss of 10.9 pounds or 8.9% in one week, and a total loss of 12.1 pounds or 9.8% since admission, which constituted severe and significant weight loss. No additional weights were recorded in Resident CR1's clinical record. A review of Resident CR1's Survey Documentation Report (a report that summarizes the recoded tasks performed by nurse aides) dated March 2025, revealed the resident's average meal intakes for breakfast, lunch, and dinner was approximately 31.4 percent. Review of the resident's Survey Documentation Report for March 2025 showed an average meal intake of approximately 31.4% across breakfast, lunch, and dinner. Progress notes dated March 25, 2025, at 11:01 AM, indicated the resident was transferred to the hospital due to altered mental status and hematuria (blood in urine). Hospital records dated March 25, 2025, at 4:41 PM, documented that the resident appeared extremely malnourished, exhibited signs of severe dehydration (loss of fluid in the body) and hypotension (low blood pressure), and was subsequently placed on hospice care. Further review of the clinical record revealed no documentation that a comprehensive nutritional assessment was completed by the RD upon admission, nor was there evidence that the resident's attending physician or responsible party (RP) had been notified of the resident's poor intake or progressive weight loss. An interview conducted with the facility's RD, in the presence of the Nursing Home Administrator (NHA), on April 8, 2025, at 10:45 AM, confirmed that a comprehensive nutritional assessment should have been completed within 72 hours of admission but was not completed for Resident CR1. The RD also confirmed that no interventions were initiated to address the resident's poor intake or significant weight loss. The NHA reported the prior RD had worked at the facility through February 28, 2025, and that a Certified Dietary Manager (CDM) provided temporary coverage from March 1 through March 9, 2025. The NHA acknowledged that a CDM is not qualified to complete comprehensive nutrition assessments and confirmed the facility did not employ a qualified nutrition professional during that period to fulfill this responsibility. A review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Barrett's esophagus ( a condition in which tissue that is similar to the tissue lining in the intestines changes or replaces the lining of the esophagus which is the tube that transports food from the mouth to the stomach) without dysplasia (a precancerous condition), malignant neoplasm (cancerous tumors) and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). A review of the resident's comprehensive person-centered plan of care initiated December 7, 2023, and revised November 5, 2024, indicated that the resident was at risk for nutritional deficits due to diagnoses and required a therapeutic diet. Interventions included periodic weight monitoring, 395345 Page 2 of 4 395345 04/08/2025 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evaluation and notification of significant weight changes to the RD, physician, and family, provision of nutritional supplements as ordered, and the use of meals and snacks tailored to the resident's preferences and functional needs. A review of the resident's quarterly Nutrition Risk Assessment/Full - V4 assessment completed by the facility's RD dated January 29, 2025, at 11:51 AM, documented the resident needed increased nutrient needs related to cancer diagnosis, assist with meals to promote po (oral) intake, need verbal cues, and continue to use finger foods as available. Also, the RD noted to continue to monitor monthly weights per protocol with a goal to maintain weight stability, tolerate diet, adequate hydration, meet estimated needs, and skin integrity and adjust diet regimen prn (as needed). A review of Resident A1's weight record revealed the following recorded weights: January 6, 2025, at 1:56 PM, weight was 156.4 -lbs. February 1, 2025, at 11:45 AM, weight was 156.8 - lbs. March 3, 2025, at 3:11 PM, weight was 143.3 - lbs. March 4, 2025, 2:06 PM, weight was 145.2 - lbs. April 1, 2025, at 2:05 PM, weight was 146.4 - lbs. Further review of Resident A1's weight record revealed that he had a significant weight loss of 11.6 - lbs. or 7.4% in 30-day (February 1, 2025, through March 4, 2025). A review of a weight change note completed by the RD eighteen (18) days post weight loss on March 17, 2025, at 11:33 AM, indicated that weights were reviewed and identified a significant loss of 7.6% in 30 days. History of colon cancer and Barrett's esophagus. Diet order regular/regular texture/thin liquids with intake for meals is 50-100% and occasional intakes less than 50%. Lactose intolerance noted. Most recent labs from March 12, 2025, reviewed and medications reviewed. Comfort measures noted with weight stability desired. The RD's note confirmed the weight loss and stated the resident's physician and RP had been notified and that the plan was to continue monitoring and follow up with the interdisciplinary team. However, there was no evidence that additional or revised nutritional strategies were developed and implemented at the time of the initial weight loss. During an observation of the third-floor dining room on April 8, 2025, at 12:10 PM, Resident A1 was observed eating rice and meatballs with his hands. The resident scooped food with his hands, and food was observed falling before reaching his mouth. Interview with the Director of Nursing (DON) on April 8, 2025, at 1:00 PM, revealed that Resident A1 prefers to feed himself and often declines staff assistance. The DON confirmed the resident would benefit from the use of finger foods but acknowledged this intervention, which was part of the resident's care plan, was not being consistently implemented. Further interview with the DON confirmed that the facility failed to identify the resident's significant weight loss in a timely manner and failed to initiate nutritional interventions to address the weight loss or reinforce the use of care-planned accommodations, such as finger foods, to support the resident's independence and nutritional intake. 395345 Page 3 of 4 395345 04/08/2025 Maple Ridge Rehabilitation & Healthcare Center 615 Wyoming Avenue Kingston, PA 18704

F 0692 28 Pa Code 211.10 (c) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services Residents Affected - Some 395345 Page 4 of 4