Health inspection·September 26, 2022

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 review, staff interview, and review of the facility's policy, the facility failed to timely and routinely assess a resident who had significant weight loss two months in a row. This affected one (Resident #60) of three residents reviewed for nutrition. The facility identified eight residents with unplanned significant weight loss/gain. The facility census was 75. Residents Affected - Few Findings include: Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, hypertension, dementia, and depression. Review of Resident #60's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/09/22, revealed the resident was cognitively impaired and required supervision and setup assistance for eating. Review of Resident #60's nutritional assessment and plan of care, dated 05/09/22, revealed the resident's weight had been stable since admission. Resident #60 was prone to fluid or electrolyte concerns, inadequate intake, and received medications which could cause appetite changes, gastrointestinal distress, and/or other nutrition-related side effects. Interventions included offering substitutes for uneaten foods, snacks per resident preference and choice to meet nutritional and quality of life needs, and offering supplements as ordered. Review of Resident #60's weight record revealed Resident #60 weighed the following: 189.8 lbs. on 05/04/22, 168.5 lbs. on 08/18/22, and 157.6 lbs. on 09/15/22. On 08/18/22, Resident had a 21.3 lbs. weight loss and a 11.2 significant weight loss in three months. On 09/15/22, Resident #60 had a 10.9 lbs. weight loss and a 6.5% significant weight loss in one month and a 32.2 lbs. weight loss in four months and was a 17% significant weight loss. Further review of Resident #60's medical record revealed Resident #60's significant weight loss was not addressed by the Registered Dietitian (RD) or Physician from 08/18/22 through 09/19/22. Resident #60 was last assessed by the RD on 05/09/22. Review of Resident #60's physician orders, dated 09/20/22, revealed an order for a supplement after meals as indicated. Interview on 09/21/22 at 2:22 P.M. with RD #326 revealed RD #326 was not aware of Resident #60 sustaining any significant weight loss while residing in the facility. RD #326 reported she was typically notified of significant weight loss when quarterly MDS assessments were completed and reported there was no formal process for monitoring weights in between quarterly assessments. RD #326 verified (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: 366166 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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)