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. Page 1 of 4 365854 365854 11/29/2023 Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the undated policy titled, Resident Weight, stated the policy was to ensure staff were monitoring and obtained weights as indicated. The policy stated the staff were to record and monitor weights monthly or as indicated by the resident's condition. The policy stated residents at high nutritional risk would be weighed weekly. Review of the policy titled, Change of Condition, dated May 2020, stated the facility would immediately notify the resident, physician, or resident representative of a significant change in resident's physical, mental, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00148182. 365854 Page 2 of 4 365854 11/29/2023 Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320

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 reviews, staff and resident interviews, and policy review, the facility failed to ensure resident weights were obtained to monitor nutritional status. This affected two (#54 and #100) out of the three residents reviewed for weight loss. The facility census was 63. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #54 revealed an admission date of 06/14/22 with medical diagnoses of chronic respiratory failure, hypertension (HTN), hypothyroidism, and epilepsy. Review of the medical record for Resident #54 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #54 had moderate cognitive impairment and was dependent upon staff for bed mobility, dressing, toileting, and bathing, required extensive staff assistance for transfers, and set-up assistance with eating. Review of the MDS revealed no weight documented. Review of the medical record for Resident #54 revealed a nutritional risk care plan, dated 06/26/22, which indicated the facility would monitor Resident #54 for weight loss. Review of the medical record for Resident #54 revealed a weight of 189.4 pounds on 01/17/23 and 194.2 pounds on 06/01/23. Review of the medical record did not contain documentation to support the facility obtained weights or resident refused to be weighted from February 2023 to May 2023 or from July 2023 to November 2023. Review of the medical record for Resident #54 revealed a dietary progress note, dated 11/27/23 at 1:36 P.M., which stated last recorded weight was 06/01/23 and current weight was requested. Interview on 11/29/23 at 10:02 A.M. with Resident #54 stated staff do not weigh her regularly. Interview on 11/29/23 at 2:55 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #54 did not contain documentation to support the facility obtained monthly weights or Resident #54 refused to be weighed. DON confirmed Resident #54 weight was obtained on 11/29/23 and was 189.7 pounds. DON confirmed Resident #54 is at risk for weight loss and weights should be monitored. 2. 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), HTN, and dementia. Review of the medical record for Resident #100 revealed a significant change 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 a potential for decline in nutrition and hydration due to COPD, dysphagia, and dementia. The interventions included monitoring weights and diet as ordered. 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 365854 Page 3 of 4 365854 11/29/2023 Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Review of the undated policy titled, Resident Weight, stated the policy was to ensure staff were monitoring and obtained weights as indicated. The policy stated the staff were to record and monitor weights monthly or as indicated by the resident's condition. The policy stated residents at high nutritional risk would be weighed weekly. This deficiency represents non-compliance investigated under Complaint Number OH00148182. 365854 Page 4 of 4