Health inspection·August 27, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on record review, facility policy review, and interview, the facility failed to ensure dietary recommendations were timely implemented and the physician was updated timely on a resident's severe weight loss. Actual harm occurred to Resident #1 when nutrition recommendations were not implemented, and the physician was not updated resulting in the resident sustaining an avoidable 16.6% severe weight loss in one month. This affected one (Resident #1) of three residents reviewed for nutrition.Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/02/25 with diagnoses including atherosclerotic heart disease, dementia, ventricular tachycardia, chronic kidney disease, congestive heart failure (CHF), and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/30/25, revealed Resident #1 had moderately impaired cognition. Resident #1 required staff assistance with eating and had a weight loss of five percent (%) or greater within last month.Review of the physician order dated 06/10/25 revealed an order for oral med pass (high calorie nutritional supplement) 120 milliliters (ml) two times per day (BID). The order was discontinued on 07/17/25.Review of the dietary progress note dated 06/18/25 at 1:32 P.M. revealed current weight was 200.8 pounds (lbs). The resident's weight monitored daily for congestive heart failure management; history of edema; diuretic treatment with Torsemide 10 milligrams (mg) every day. Regular diet with no added salt. Meal intakes are between 76-100% acceptance. Weight loss related to history of edema and fluid changes. Current diet and supplements were meeting estimated needs. No new recommendations.The nursing progress note dated 07/15/25 at 8:31 A.M. revealed Resident #1 returned from the hospital with a new order for Keflex (antibiotic) 500 milligrams(mg) by mouth four times per day for 10 days prophylactically due to increased white blood cell count and left ventricular assist device (LVAD).Review of Resident #1's weight log revealed on 07/14/25, weight was 197.5 lbs. and weight on 07/16/25 was 183.8 lbs.; this was a 13.7 lb. severe weight loss. There was no evidence of physician notification.The dietary progress note dated 07/18/25 at 1:41 P.M. revealed Resident #1's current weight was 183.8 lbs. which indicated an 11.8% severe weight loss compared to weight of 208.3 lbs. on 06/16/25. Accuracy of weight was questioned due to weight being down 13.7 lbs. in two days. Meal intakes 51-100%. No noted chewing or swallowing impairment. Med Pass was discontinued on 07/17/25 following Resident #1 being sent to the emergency department (ED) on 07/15/25 related to shortness of breath and altered mental status. The resident returned with an antibiotic order. Recommendation for a re-weight and to restart oral med pass four ounces (120 ml) BID. This nutrition recommendation was not initiated until 12 days later 07/30/25.Resident #1's weight log revealed on 07/27/25, weight was 182.0 lbs. and weight on 07/28/25 was 173.2 lbs.; this was an 8.8 lb. loss. in two days and 10.6 lbs. weight loss in two weeks, a 6.1% severe weight loss. There was no evidence of physician notification.Review of the physician order dated 07/30/25 revealed the order for four ounces of oral med pass BID for supplement.Review of the July 2025 Medication Administration Record (MAR) revealed Resident #1 did not receive oral med pass four ounces BID from 07/18/25 through 07/29/25. On 07/30/25, Resident #1 began receiving four Residents Affected - Few Page 1 of 2 365699 365699 08/27/2025 Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906

F 0692 Level of Harm - Actual harm Residents Affected - Few ounces of med pass BID for supplementation.The dietary progress noted dated 08/06/25 at 4:12 P.M. revealed current weight was 166.2 lbs. and was a 16.6% severe weight change since 07/05/25. Weight was down an additional 4.4 lbs. since 07/30/25. Meal intakes vary. Remeron started on 08/05/25 and Torsemide discontinued. Resident #1 more lethargic with labs ordered. Four ounce med pass daily started on 07/30/25 with good acceptance. Recommendation to increase med pass four ounces to three times per day. The nursing progress noted dated 08/07/25 revealed Resident #1 was taken to emergency room (ER) due to lethargy, refusing to eat, drink, or take medications. Physician notified and order given to transfer to ER. Family notified.Interview on 08/26/25 at 3:26 P.M. with Registered Dietician (RD) #320 revealed she had noted Resident #1's med pass had been discontinued on 07/17/25 following a return from the ER and not restarted until 07/30/25. RD #320 stated she didn't know why the med pass had been discontinued but this was during the time of the transition of the previous Director of Nursing (DON) and current DON and she did notify nursing of the discrepancy. Resident #1 stated the resident's weight loss was initially attributed to fluctuations due to CHF and diuretic therapy, but the last couple of weeks the resident stated he didn't feel like eating and an appetite stimulant (Remeron) was added, and the med pass was increased to three times daily.Interview on 08/26/25 at 3:48 P.M. with the DON revealed Resident #1's med pass was discontinued on 07/17/25 and she isn't sure why. The DON confirmed the med pass should not have been discontinued and verified it was re-started on 07/30/25.Interview on 08/27/25 at 8:21 A.M. with the DON confirmed there was no documentation which indicated the physician was notified of the weight loss on 07/16/25 or 07/28/25.Review of the facility policy titled Resident Condition Changes dated 04/01/23 revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition. A change in condition includes but is not limited to, a change in physical or mental status, refusal of medications or treatment, a need to alter treatment, an accident, need to transfer or discharge, development of wounds or other new condition, inability to provide an ordered medication or treatment, lab or radiology results. The nurse will notify the resident's responsible party of condition change.This deficiency represents non-compliance investigated under Master Complaint Number 2600641 and Complaint Number 2595112. 365699 Page 2 of 2