Health inspection·July 25, 2024

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 clinical records and staff interviews, it was determined that the facility failed to monitor residents' weight for three of three residents reviewed. (Resident R1, Closed Record Resident CR1 and CR2) Residents Affected - Some Findings include: Review of the facility policy Resident Weight Policy, dated 7/1/24, indicated weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 7/14/24, indicated diagnoses of hip fracture (broken hip bone), rib fracture (broken rib bone), and s/p motor vehicle accident. Review of Resident R1's physician orders dated 7/8/24, indicated to obtain weight upon admission, then weekly for four weeks. Review of Resident R1's care plan dated 7/15/24, indicated to weigh resident per protocol. Review of Resident R1's weight record on 7/25/24, at 12:39 p.m. indicated one weight of 173 pounds on 7/8/24. The weight record did not include any other weights. Review of the clinical record revealed that Closed Record Resident CR1 was admitted to the facility on [DATE]. Review of Resident CR1's MDS dated [DATE], indicated the diagnoses of hip fracture, high blood pressure, and Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident CR1's physician order dated 5/25/24, indicated to obtain weight upon admission, then weekly for four weeks. Review of Resident CR1's care plan dated 5/30/24, indicated resident is at nutrition risk related to poor intake, dysphagia (difficulty swallowing), and dementia. Page 1 of 2 395603 395603 07/25/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident CR1's weight record on 7/25/24, at 12:45 p.m. indicated two weights dated 5/25/24, of 160 pounds, and weight dated 6/8/24, of 134.4 pounds. A weight loss of 25.6 pounds in two weeks. The weight record did not include any other weights. Review of Resident CR1's Medical Nutritional Therapy Observation dated 5/30/24, indicated: nutritional monitoring of intake, weights, skin status and lab data. Review of Resident CR1's Medical Nutritional Therapy Observation dated 6/8/24, was blank. Review of Resident CR1's progress note dated 6/4/24, indicated resident is only eating 15-30% (percent) of her meals and will be placed on supervised feed list, and have a trial of weighted utensils (adaptive silverware). Review of Resident CR1's Skilled Note dated 6/8/24, indicated no nutrition problems. Review of Resident CR1's Skilled Notes indicated the next entry on 6/10/24, which indicated no nutrition problems and no evidence that the physician was notified of the weight loss. Review of the clinical record revealed that Closed Record Resident CR2 was admitted to the facility on [DATE]. Review of Resident CR2's MDS dated [DATE], indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression. Review of Resident CR2's physician order dated 6/8/24, indicated to obtain weight upon admission, then weekly for four weeks. Review of Resident CR2's care plan dated 6/15/24, indicated resident is at nutrition risk related to history of anxiety and depression. Monitor weight per protocol. Review of Resident CR2's weight record on 7/25/24, at 1:00 p.m. indicated two weights dated 6/8/24, of not taken, and weight dated 6/15/24, of 161.2 pounds. The weight record did not include any other weights. Interview on 7/25/24, at 1:15 p.m. Dietary Manager Employee E1 indicated he was not in place at the time of the missed weights, lack of nutritional assessment, intervention, and notification of the physician and that he would address any concerns as soon as he became aware of them. Interview on 7/25/24, at 1:30 p.m. the Director of Nursing confirmed the weights not completed for Resident R1, CR1, and CR2 and that the facility failed to monitor residents' weight for three of three residents reviewed. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 395603 Page 2 of 2