Health inspection·August 21, 2023

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 facility policy review, the facility failed to appropriately monitor all residents who had significant weight decline. This affected one (Resident #60) of three residents reviewed for nutrition. Census was 53. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Her diagnoses were degenerative disease of nervous system, congestive heart failure, cerebellar ataxia, hyperlipidemia, diabetes mellitus, anemia, osteoarthritis, polyneuropathy, primary open-angle glaucoma, bursitis, anxiety disorder, overactive bladder, major depressive disorder, shoulder lesion, non-toxic goiter, dementia, thyrotoxicosis, weakness, acquired absence of left breast and nipple, transient cerebral ischemic attack, respiratory failure, and hypokalemia. Review of her Minimum Data Set (MDS) assessment, dated 05/15/23, revealed she was cognitively intact. Review of Resident #60's weights, dated February 2023 to August 2023, revealed she lost a total of 45.5 pounds in six months, which equated to 23.7 percent of her body weight. Review of Resident #60 meal intake records, dated 07/12/23 to 08/02/23, revealed there should have been 66 meals documented. There were 37 missing meals in the logs. Also, she refused three meals; two on 07/31/23 and one on 08/01/23. Review of Resident #60 nutritional notes, dated May 2023 to August 2023, revealed notes that indicated meal intakes were variable and even stating that meal intakes were poor. There were nutritional supplements orders to try to combat the weight loss, but there was no documentation to support a recommendation for meal intakes to be documented more thoroughly. Review of Resident #60's current care plan revealed she was deemed to be a nutritional risk. Her interventions included offering foods that she prefers and review weights, labs, skin, and intakes routinely. Interview with Diet Technician #163 on 08/10/23 at 12:20 P.M. and 2:40 P.M. confirmed the meal intake documentation is not complete. She stated Resident #60 would refuse meals often, which contributed to her weight loss. She confirmed Resident #60 lost the desire to live, which was something she would say to the staff often. She confirmed Resident #60's care plan did not reflect the poor intakes and refusals of meals, and how the facility was going to combat that. She confirmed it would be (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 2 Event ID: 366424 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 366424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein New Albany 6690 Liberation Way New Albany, OH 43054 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)