Health inspection·April 4, 2019

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 record review and interview the facility failed to ensure Resident #44's physician was notified timely of weight loss, failed to ensure timely assessments were completed and failed to ensure the timely implementation of interventions to address the resident's weight loss. This affected one resident (Resident #44) of four residents reviewed for nutrition. Residents Affected - Few Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, paranoid schizophrenia, bipolar disorder, chronic obstructive pulmonary disease, anxiety disorder, pneumonia and urinary tract infection. Record review revealed a plan of care, initiated 01/15/15 identified the potential for altered nutritional status related to obesity, schizophrenia, bipolar disorder and depression. The nutritional interventions included to assist resident at meals as necessary, encourage fluids, honor food preferences, monitor intake of meals and offer alternates. A nutritional intervention was added to the plan of care on 04/02/19 to give supplements as ordered. A physician order dated 11/09/17 revealed the resident was ordered a regular diet. A physician order dated 02/15/19 indicated the resident was ordered a Magic Cup (a nutritional supplement) three times a day with meals. Review of the current physician orders did not indicate that Resident #44 was on a planned weight loss program. The significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had an unplanned significant weight loss and required staff assistance for bed mobility, dressing, toilet use and hygiene and set up for eating. Review of the Comprehensive Medical Nutrition Therapy assessment dated [DATE] completed by Registered Dietitian (RD) #900 revealed Resident #44 was eating 25-50% of meals, she had been refusing meals due to behaviors, she refused to talk to RD #900 about recent decreased meal intakes and RD #900 would send Magic Cup supplement with meals as a trial. Review of the resident's weights from 09/05/18 to 03/06/19 revealed the following: On 09/09/18 the resident weighed 242.0 pounds (#), on 10/09/18 - 239.6#, on 11/04/18 - 244.8#, on 12/01/18 - 238.0#, on 02/12/19 - 221.5#, on 03/05/19 - 214.0# and on 03/06/19 - 215.6# The above weights revealed a 26 pound (10.7%) weight loss in six months (from 09/09/18 to 03/06/19 ), 22 pound (9.2%) weight loss in three months (from 12/01/18 to 03/06/19) and six pound (2.7%) weight loss in one month (02/12/19 to 03/06/19). As of 04/04/19 a monthly weight had not been recorded yet in the medical record for the month of April 2019. Review of the Medication Administration Records from 02/15/19 through 04/01/19 revealed poor to good acceptance of the Magic Cup supplement in February 2019, 35 refusals in March 2019 and seven refusals of nine administrations from 04/01/19 to 04/02/19. Review of the physician progress note, dated 03/26/19 at 3:51 P.M. authored by Physician #904 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365411 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Andover Village Retirement Community 486 S Main St Andover, OH 44003 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed the resident's weight was 214 pounds and there had been no recent weight loss. Physician #904 documented the resident was more depressed, deconditioned and he was recommending therapy. There was no evidence in the physician's note to indicate he had been notified of the significant weight loss for March 2019. Review of the quarterly Nutrition Significant Weight Loss Assessment, dated 04/01/19 completed by RD #900 revealed Resident #44 was consuming 26-50% of meals, her weight on 03/05/19 was 214 pounds, and RD #900 was unable to talk to the resident due to behaviors. RD #900 noted the physician had been updated on resident's poor intake and weight loss over three months but did not identify the amount of weight loss, that it was a significant weight loss due to behaviors or that she had been refusing the Magic Cup supplements. No additional nutrition interventions were initiated by RD #44 for the significant weight loss at this time. Review of the dietary progress note dated 04/02/19 at 1:36 P.M. by RD #900 revealed the facility nurse informed her that Resident #44 no longer wanted her Magic Cup supplement. An interview was conducted on 04/01/19 at 9:18 A.M. with Resident #44 who revealed she had been losing weight due to not liking the food and supplement served to her. The resident indicated no one on the staff had visited her recently to discuss her food preferences. She reported she did not eat in the dining room for personal reasons and chose to eat her meals in her room. During the interview Resident #44 was polite, appropriate and engaged in reciprocal conversation. An interview was conducted on 04/01/19 at 9:41 A.M. with Licensed Practical Nurse (LPN) #902 who revealed Resident #44 had been more depressed over the last month and had been losing weight due to not eating well. LPN #902 revealed the resident no longer wanted the Magic Cup supplement because she did not like the taste of it and often refused it over the last several months. An interview was conducted on 04/03/19 at 4:01 P.M. with Dietary Manager (DM) #901 who revealed she had just started at the facility in January 2019 and had not updated food preferences for Resident #44. DM# 901 revealed she had not discussed any supplement options with Resident #44 since the Magic Cup supplement that was ordered on 02/15/19 by RD #900. An interview was conducted on 04/03/19 at 6:01 P.M. with RD #900 who revealed she was not able to assess Resident #44's significant weight change for March 2019, because she was covering three facilities and did not have the time to do it. RD #900 verified she was aware of the 26 pound weight loss from 09/09/18 to 03/06/19 and the 22 pound weight loss from 12/01/18 to 03/06/19 but was unable to assess the change until 04/01/19. RD #900 verified she put no new nutritional interventions in place for Resident #44 at that time because Resident #44 did not want to talk to her and she did not want to be too pushy with her to try new supplements due to her prior refusals to speak with RD #900. Review of the facility policy titled Weight Management Monitoring, dated 10/10/13 revealed identified significant, unplanned weight loss should be assessed by the dietitian and reported to the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365411 If continuation sheet Page 3 of 3