Health inspection·March 13, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet a resident's needs identified in the comprehensive assessment for one of seven residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included diabetes and an altered mental state. The Minimum Data Set Care Area Assessment summary dated January 20, 2024, noted that the resident was at risk for impaired nutrition and that it was to be addressed in the care plan. There was no evidence that interventions to address Resident 1's nutritional needs were included in the current care plan. In an interview on March 13, 2024, at 2:21 p.m., the Nursing Home Administrator confirmed that the identified care area was not addressed in the resident's care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 2 395477 395477 03/13/2024 Laureldale Skilled Nursing and Rehabilitation Cent 2125 Elizabeth Avenue Laureldale, PA 19605

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 timely assess nutritional status for two of seven sampled residents. (Residents 1, 6) Residents Affected - Few Findings include: Review of the facility policy entitled, Weights and Heights, dated August 1, 2023, revealed that residents were to be weighed upon admission and then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. Review of the facility policy entitled, Change in Condition dated August 1, 2023, revealed that a facility must immediately inform the resident, the physician, and responsible party (RP) of a significant change in the resident's physical status (deterioration in health). Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included diabetes and altered mental state. Review of the Minimum Data Set (MDS) assessment, dated February 7, 2024, revealed the resident had cognitive impairment. Review of the weight record revealed that the resident weighed 147 pounds on January 12, 2024. There was no further weights recorded until March 5, 2024, when he weighed 128.65 pounds, a significant (12.5 percent) loss of 18.35 pounds. Documentation revealed that the resident was only eating about 25 percent of his meals from February 27, to March 8, 2024. There was no evidence to support that the facility had assessed or addressed the significant weight loss and/or had immediately notified the physician and responsible party of Resident 1's change in condition. Clinical record review revealed that Resident 6 had diagnoses that included spastic paraplegia and anemia. Review of the MDS assessment, dated February 2, 2024, revealed the resident had no memory impairment. Review of the weight record revealed the resident weighed 122.4 pounds on January 5, 2024. There was no further weights recorded until March 8, 2024, when the resident weighed 110 pounds, a significant (10.13 percent) loss of 12.4 pounds. There was no evidence to support that the facility had assessed or addressed the significant weight loss and/or had immediately notified the physician and responsible party of Resident 6's change in condition. In an interview on March 13, 2024, at 2:21 p.m., the Nursing Home Administrator stated there was no documented evidence that staff obtained the weights according to the facility policy or that staff immediately notified the physician and RP of the significant weight losses. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395477 Page 2 of 2