Health inspection·March 26, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of three residents reviewed for nutrition (Residents 3 and 4). Residents Affected - Some Findings include: Review of facility policy Weight Policy revised December 2022 revealed that each resident will be weighed monthly. Any resident displaying a significant change in weight of greater than or equal to 5%, gain/loss in one month will be reported to the Registered Dietitian and reweighed. The Registered Dietitian will review the medical record of residents with significant weight changes (i.e. 5% loss/gain in one month, 7.5% loss/gain in 3 months, 10% loss/gain in 6 months). Dietary interventions will be recommended as needed. Review of Resident 3's clinical record revealed a weight of 227.3 pounds on December 29, 2023 and 227.3 pounds on January 10, 2024. Weight obtained on February 27, 2024, was 192.6 pounds (loss of 34.7 pounds or 15.3% in one month) with no reweigh obtained. Review of the weights and vitals summary revealed a weight of 188.4 pounds on March 11, 2024 (loss of 38.9 pounds or 17.1% in three months) with no reweigh obtained. Further review of the clinical record revealed no evidence that the Registered Dietitian reviewed the record due to the significant weight loss. Review of Resident 4's clinical record revealed a weight of 167.2 pounds on January 5, 2024 and 150.6 pounds on February 2, 2024 (loss of 16.9 pounds or 10.1% in one month) with no reweigh obtained. Further review of the clinical record revealed no evidence that the Registered Dietitian reviewed the record due to the significant weight loss. Interview with the Registered Dietitian on March 26, 2024, at 2:50 p.m. indicated that monthly weights are to obtained by the 9th of the month and then reweighs are requested. The Registered Dietitian confirmed that reweighs should have been obtained for Residents 3 and 4. 483.25 F692 Nutrition/Hydration Status Maintenance Previously cited 6/16/23 28 Pa. Code 211.5(f) Clinical Records Previously cited 2/28/24, 6/15/23 28 Pa. Code 211.10(c) Resident Care Policies Page 1 of 2 395740 395740 03/26/2024 West Chester Rehabilitation and Healthcare Center 800 West Miner Street West Chester, PA 19382

F 0692 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Level of Harm - Minimal harm or potential for actual harm Previously cited 2/28/24, 6/15/23 Residents Affected - Some 395740 Page 2 of 2