Health inspection·November 29, 2023

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 interviews, and policy reviews, the facility failed to notify the physician of a resident's significant weight loss. This affected one (#100) resident out of the three residents reviewed for weight loss. The facility census was 63. Findings included: Review of the medical record for Resident #100 revealed an admission date of 05/17/23 with medical diagnoses of chronic obstructive pulmonary disease (COPD), hypertension and dementia. Review of the medical record for Resident #100 revealed a significant change Minimum Data Set (MDS), dated [DATE], which indicated Resident #100 had severe cognitive impairment and required supervision with eating and supervision with dressing, transfers, and toileting. The MDS revealed no weight was documented and no weight loss noted. Review of the medical record for Resident #100 revealed no documentation to support her weight was obtained upon admission [DATE]. Further review revealed a weight on 07/01/23 at 117.2 pounds, on 10/02/23 at 103.8 pounds, and on 11/03/23 at 92.2 pounds. Review of the medical record did not contain documentation to support Resident #100 refused to be weighed or any other weights were obtained. Review of the medical record for Resident #100 revealed a nutrition note, dated 10/16/23 at 3:19 P.M. which indicated Resident #100 weight was 103.8 pounds and had a 7.5% decline in weight in three months which triggered a significant weight loss. The note stated a supplement would be recommended to help maintain weight. The note did not contain documentation to support the physician was notified of the weight loss. Further review of the medical record revealed a nutrition note, dated 11/13/23 at 3:22 P.M. which stated Resident #100's weight was 92.2 pounds and had a 5.0% decline in one month which triggered a significant weight loss. The note recommended to reweigh the resident to confirmed weight loss and update weight. The note did not contain documentation to support the physician was notified of the significant weight loss. Interview on 11/29/23 at 1:12 P.M. with Dietician #400 stated Resident #100 was considered a nutritional risk resident and should have been weighed weekly after significant weight loss documented on 10/16/23. Dietician #400 confirmed the medical record for Resident #100 did not contain documentation to support the facility notified the physician of the significant weight loss or that the facility obtained weights as per policy to monitor Resident #100's nutritional status. Dietician #400 stated Resident #100 has had a gradual decline due to her dementia and nutritional supplements were implemented to help maintain her weight. (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 4 Event ID: 365854 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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)