Health inspection·July 8, 2021

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. Based on record review, staff interview, and policy review, the facility failed to notify the responsible party when a resident experienced a significant weight loss. This affected one (#32) of two residents reviewed for notification of change. The facility census was 38. Findings include: Review of the medical record of Resident #32 revealed an admission date of 02/19/21. Diagnoses included essential hypertension, muscle weakness, and cognitive communication deficit. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/17/21, revealed the resident had impaired cognition. Review of Resident #32's weights revealed: on 02/21/21, she weighed 144 pounds; on 03/01/21 at 140 pounds; on 04/06/21 at 127 pounds; on 04/19/21 at 125 pounds; and on 05/01/21 at 127 pounds. This revealed a 17 pound weight loss and a 11.8 percent significant weight loss in less than three months. Review of the progress notes dated 04/2020 through 06/01/2020 revealed no indication of family notification of weight loss. Interview on 07/08/21 at 9:54 A.M. with Registered Dietitian (RD) #350 stated she does not personally notify the responsible party of a resident's weight loss and the nurse does the notification when they call to notify of the new orders associated with the weight loss. RD #350 further verified the medical record of Resident #32 lacked evidence of notification of responsible party of weight loss. Interview on 07/08/21 at 11:48 A.M. with Licensed Practical Nurse (LPN) #287 stated the nurses notify the responsible party of weight loss when they call to notify of the new orders associated with the weight loss. LPN #287 further stated the notification was documented in the progress notes when the notification was completed. Review of the facility's undated policy titled, Notification and Reporting of Changes in Health Status, Illness, Injury, and Death of a Resident, revealed the appropriate associates will promptly inform the resident representative of a significant change in the resident's status, such as a deterioration in health and document the notification in the medical record. 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 3 Event ID: 366319 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 366319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes 9840 Montgomery Road Cincinnati, OH 45242 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)