Health 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. Page 1 of 2 365665 365665 11/18/2023 Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the weights revealed Resident #101 weighed 148 pounds on 08/02/23, 148 pounds on 08/14/23, 148 pounds on 08/18/23, 139 pounds on 09/26/23 (6% weight loss since admission and 08/18/23 weight) and 136 pounds on 10/09/23. A progress note dated 10/13/23 revealed Resident #101 weighed 133 pounds. Weekly weights were not completed the week of 08/06/23 and 08/21/23. Interviews on 11/18/23 from 9:30 A.M. through 3:21 P.M. with Licensed Practical Nurse (LPN) #201, LPN #202, Registered Nurse (RN) #200 and State Tested Nursing Assistant (STNA) #203 revealed new admissions should be weighed weekly for four weeks unless ordered otherwise. They stated they refer to the RD #207 if any concerns with weight loss. Interview on 11/18/23 at 9:50 A.M. with the DON revealed the facility did weight losses differently. She stated she managed them and notified the doctor and obtained orders. She stated she followed-up with RD #207 and the certified nurse practitioner (CNP) via email and at the weekly risk meeting. An additional interview at 1:36 P.M. with DON revealed she first noted Resident #101's weight loss on 09/26/23 and notified the CNP and RD #207. She stated the resident was started on a supplement. The DON stated RD #207 should have been involved more and documented more about his weight loss. Interview on 11/18/23 at 1:14 P.M. with RD #207 revealed she saw him on admission on [DATE]. She verified there were no other progress notes from her in the medical record. She stated she was not sure how she did not see him again. She stated his face looked familiar and remembered they discussed him in the weekly Risk Meeting. She stated the DON would communicate any needs and showed the above-mentioned email from the DON on 09/26/23. Review of the facility policy titled Weight Assessment and Prevention Policy, revised on September 2008 revealed new residents should be weighed weekly for four weeks. Any weight change of 5% or more will be immediately reported to the dietitian in writing and the dietitian will respond within 24 hours. This deficiency represents non-compliance investigated under Complaint Number OH00147312. 365665 Page 2 of 2