Health inspection·January 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify the physician as ordered. This affected one (#28) resident of three reviewed for change in condition. The facility census was 73. Findings include: Medical record review for Resident #28 revealed an admission date of 10/29/23. Diagnoses included Alzheimer's disease, dementia with anxiety, chronic obstructive pulmonary disease, severe protein calorie malnutrition, heart failure, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed the resident was assessed with an intact cognition. Resident #28 required supervision for bed mobility, transfers, toileting and eating. Resident #28 weight was documented as 186 pounds. Review of the plan of care for Resident #28 dated 11/03/23 revealed the resident was at risk for malnutrition and dehydration related to chronic disease, advanced age, and potential for weight and intake decline related to disease progression. Interventions include to administer medication as ordered, provide diet as ordered and obtain weight at a minimum of monthly. Report significant changes of five percent or more in a month to the physician and the dietician. Review of the physician orders for Resident #28 revealed an order dated 12/12/23 for weekly weights every Tuesday, and to notify the physician if weight gain was greater than five pounds for congestive heart failure. Review of the electronic health record for Resident #28 revealed the resident weighed 186 pounds (lbs.) on 11/02/23, 190.4 lbs. on 11/29/23, 189.3 lbs. on 12/05/23, 190.2 pounds on 01/02/24 at 4:13 A.M., and 206.6 lbs. on 01/02/24 at 2:51 P.M. Review of the progress notes and medical record for Resident #28 dated 01/01/24 through 01/18/24 was silent for any physician notification of a weight gain greater than five pounds after 01/02/24. Interview on 01/11/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #1 verified Resident #28's medical record did not contain any documentation that the physician was notified of the significant weight gain and should have been. Interview on 01/11/23 at 3:30 P.M. with Director of Nursing (DON) #17 verified Resident #28's Page 1 of 3 365558 365558 01/18/2024 The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011

F 0580 Level of Harm - Minimal harm or potential for actual harm medical record did not contain any documentation that the physician was notified of the significant weight gain and should have been. Request for policy related to the collection or weights or physician orders was requested during the survey and not provided for review. Residents Affected - Few Review of the facility policy titled, Notification of Change, dated 12/12/22, revealed the facility must inform the guest/resident, consult with the guest's/residents physician when there is a change in status. This deficiency represents non-compliance investigated under Complaint Number OH00149058. 365558 Page 2 of 3 365558 01/18/2024 The Laurels of Hamilton 2923 Hamilton Mason Road Hamilton, OH 45011

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 medical record review and staff interview, the facility failed to follow physicians orders for obtaining weights. This affected one (#28) resident of three reviewed for weight monitoring. The facility census was 73. Residents Affected - Few Findings include: Medical record review for Resident #28 revealed an admission date of 10/29/23. Diagnoses included Alzheimer's disease, dementia with anxiety, chronic obstructive pulmonary disease, severe protein calorie malnutrition, heart failure, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed the resident was assessed with an intact cognition. Resident #28 required supervision for bed mobility, transfers, toileting and eating. Resident #28 weight was documented as 186 pounds. Review of the plan of care for Resident #28 dated 11/03/23 revealed the resident was at risk for malnutrition and dehydration related to chronic disease, advanced age, and potential for weight and intake decline related to disease progression. Interventions include to administer medication as ordered, provide diet as ordered and obtain weight at a minimum of monthly. Report significant changes of five percent or more in a month to the physician and the dietician. Review of the physician orders for Resident #28 revealed an order for a mechanical soft diet dated 01/17/24, and order dated 12/13/23 for the diuretic Lasix oral tablet 20 milligram (mg) to give one tablet by mouth two times a day for edema and hold for systolic blood pressure less than 100 millimeters of mercury (mmHg), an order dated 12/12/23 for weekly weights every Tuesday and to notify the physician for weight gain greater than five pounds for congestive heart failure, and an ordered dated 12/05/23 to apply compression stockings or ACE wraps to the resident's bilateral lower extremities daily and remove at bedtime once daily for edema. Review of the electronic health record for Resident #28 revealed the resident weighed 186 pounds (lbs.) on 11/02/23, 190.4 lbs. on 11/29/23, 189.3 lbs. on 12/05/23, 190.2 pounds on 01/02/24 at 4:13 A.M., and 206.6 lbs. on 01/02/24 at 2:51 P.M. Review of the medical record and nursing progress notes for Resident #28 dated 01/01/24 through 01/18/24 was silent for any additional weights obtained during this time frame. Interview on 01/11/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #1 verified Resident #28's medical record did not contain weekly weights and it should have after it was ordered on 12/12/23. Interview on 01/11/23 at 3:30 P.M. with Director of Nursing (DON) #17 verified weekly weights were not obtained for Resident #28 per the physician order dated 12/12/23. Request for policy related to the collection or weights or physician orders was requested during the survey and not provided for review. This deficiency represents non-compliance investigated under Complaint Number OH00149058. 365558 Page 3 of 3