Inspection·November 18, 2023

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 reviews and interviews, the facility failed to implement nutritional interventions to monitor Resident #101's weights and thoroughly address weight loss timely. This affected one resident (Resident #101) of three residents reviewed. The census was 81. Residents Affected - Few Findings include: Review of the closed medical record for Resident #101 revealed an admission date of 08/01/23. Resident #101 passed away at the facility on 10/25/23. Resident #101's diagnoses included low body mass index, chronic obstructive pulmonary disease, hypertension, ataxic gait and major depression. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was cognitively intact. No weight loss was noted on the assessment and he required supervision for eating. Review of the progress notes revealed a Nutritional assessment dated [DATE] was completed by the Registered Dietitian (RD) #207. The assessment indicated Resident #101 would receive a regular diet, thin liquids, health shakes with all meals, and had a current body weight of 148 pounds, indicating underweight status. Resident #101 was at risk for malnutrition as evidence by weight being 76 percent (%) of ideal body weight, low body mass index (BMI), order for supplements, and diagnosis of depression. Nutritional interventions included continue general healthful diet to optimize intakes, nutritional monitoring to include monitoring weekly weights due to admission status. Review of the Plan of Care initiated on 08/10/23 for Low Body Weight revealed a plan for Resident #101 to have a gradual weight gain until they reach a health BMI or maintain current body weight within +/- 4 % of previous months weight would be desirable. Review of the Malnutrition Assessment, completed by RD #207, undated but signed by physician on 08/15/23 revealed the same information as the Nutritional assessment dated [DATE]. Review of email dated 09/26/23 from the Director of Nursing (DON) to RD #207 revealed Resident #101 had a weight loss of three pounds, the supplement was switched to nutritious juice and he was referred to speech therapy. Review of the Risk Meeting Minutes from 09/29/23 revealed Resident #101 was listed on the report for weight loss. Review of Resident #101's medical record revealed no evidence RD #207 assessed the resident for nutritional intervention after the identified weight loss on 09/29/23. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365665 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 365665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646 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)