Health inspection·August 5, 2024

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding thickened liquids, dated April 11, 2024, indicated that the definition for thickened liquids are liquids where the consistency has been altered to facilitate safe, oral intake. They are ordered as part of treatment for a disease or clinical condition, such as dysphagia (a medical term for difficulty swallowing) due to stroke, cancer, multiple sclerosis (a chronic disease of the central nervous system) or other neuromuscular disease. Thickened liquids are provided only when ordered by a physician/practitioner, or when ordered by a dietitian or speech-language pathologist who has been delegated to write diet orders, to the extent allowed by state law. The facility utilizes standard liquid categories. Category 0: Thin; Category 1: Slightly thick (naturally thick); Category 2 Mildly thick (nectar thick); Category 3: Moderately thick (honey thick), and Category 4: Extremely thick (spoon thick). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 19, 2024, revealed that the resident was usually understood, could usually understand, had a diagnosis which included dysphagia, and was on a mechanically altered diet (foods that are easy to swallow because they are blended, chopped, ground, or mashed so that they are easy to chew and swallow). A care plan for the resident, dated May 31, 2024, revealed that the resident has a swallowing problem. Staff were to provide the resident's diet as ordered, and she was to have nectar thick liquids (have slightly more body than thin liquids, but still can pour easily). Physician's orders for Resident 1, dated April 5, 2024, included an order for the resident to receive 237 milliliters (ml) of Ensure Plus (a nutritional supplement) three times a day. Physician's orders for Resident 1, dated May 31, 2024, included an order for the resident to receive a liberal geriatric diet (tailored to a person's preferences and health needs) with chopped meats and nectar/mildly thick consistency for her liquids. A nursing note for Resident 1, dated June 19, 2024, at 12:11 p.m. revealed that the resident went to a luncheon off the unit and was given thin water instead of a thickened drink. The resident's lungs were clear and her temperature. range was within normal limits. The resident had no coughing or signs of respiratory distress. Page 1 of 2 395944 395944 08/05/2024 Chambers Pointe Health Care Center 1425 Philadelphia Avenue Chambersburg, PA 17201

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations of Resident 1 during the supper meal on August 5, 2024, at 4:59 p.m. revealed that the resident was sitting at a table in the Evergreen Unit main dining room eating her supper. The resident had a hot dog that was cut up in small pieces on a hot dog bun, baked beans, enriched pudding (nutrients that were lost during processing are added back in), a small glass containing a red-colored nectar thick juice, and a container of Ensure Plus with a straw in the container. The resident picked up the container of Ensure Plus and took sips through the straw throughout the meal. Interview with the Nursing Home Administrator on August 5, 2024, at 5:27 p.m. confirmed that the nursing note for Resident 1 on June 19, 2024, indicated that the resident received the incorrect consistency for her liquids. Interview with Dietitian 1 on August 5, 2024, at 6:25 p.m. revealed that there was only one Ensure product that he is aware that would be considered nectar thick at room temperature, and that would be Ensure Max Chocolate. He indicated that Chocolate Ensure Plus would be considered Category 1 at room temperature, which would be considered slightly thick. He indicated that Resident 1 would require Category 2 level for her liquid consistency. Interview with Registered Nurse 2 on August 5, 2024, at 6:40 p.m. confirmed that she did not add any thickener to Resident 1's Ensure Plus prior to giving it to the resident. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395944 Page 2 of 2