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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for one of six residents reviewed (Resident 1). Residents Affected - Few Findings include: Review of facility policy, titled Weight Assessment and Intervention, last reviewed March 29, 2025, read, in part, Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Care planning for weight loss or impaired nutrition is a multidisciplinary effort. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy (the loss of muscle mass and strength), dysphagia (difficulty swallowing), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 1's physician orders revealed an order for Weekly weights X 4 weeks - new admission, every day shift every Wednesday for 4 Weeks, Document weight in PCC, with a start date of January 29, 2025, and a noted completed date of February 26, 2025. Review of Resident 1's clinical record revealed he weighed 193.4 pounds on January 29, 2025, and showed he had experienced a significant weight loss in one month to 178.2 pounds (7.8%) on February 26, 2025. Further review of Resident 1's clinical record failed to reveal weights were obtained and documented weekly as per physician order on February 12 and 19, 2025. Review of Resident 1's progress notes revealed Employee 1 (Registered Dietitian) wrote a progress note titled Brief Weight Note, about Resident 1 on February 26, 2025, that detailed, in part, Resident noted with significant weight loss in 30 days - which is unplanned/undesirable. Reweigh requested to confirm and pending. Full nutrition assessment to follow once weight change is confirmed. Discussed food preferences and possible interventions and resident agreeable to having fortified foods Page 1 of 2 395372 395372 04/08/2025 Capitol Rehabilitation and Healthcare Center 4000 Linglestown Road Harrisburg, PA 17112

F 0692 twice daily [and] will add fruit with breakfast. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's physician orders revealed an order for Weight STAT (without delay or immediately), with a start and completed date of March 3, 2025. Residents Affected - Few Review of Resident 1's March 3, 2025, weight measure revealed it was 177.4 pounds, which confirmed his significant weight loss. Review of Resident 1's care plan on April 7, 2025, failed to reveal his weight loss or nutrition interventions in response to his weight loss had been added to his care plan. During an interview with the Director of Nursing on April 8, 2025, at 1:46 PM, she revealed her expectation that weights should be obtained per physician's order, reweighs should be obtained the next day for confirmation, and care plans should be updated to reflect residents' weight loss and interventions. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services 395372 Page 2 of 2