Health inspection·May 23, 2024

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 policy review, the facility failed to notify the physician or nurse practitioner regarding significant weight loss and ensure the dietitian's recommendations for weight loss were addressed. This affected two (Residents #63 and #66) of three residents (#57, #63 and #66) who were identified as having an unplanned weight loss. The facility census was 79. Residents Affected - Few Findings include: 1. Record review revealed Resident #63 was admitted on [DATE] with diagnoses that included but were not limited to displaced intertrochanteric fracture of left femur, anxiety disorder, and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #63 had moderately impaired cognition and was independent for eating. Review of Resident #63's recorded weights revealed the following: 05/09/24 - 96.0 pounds (lbs). which was a 9.09 percent (%) weight change in less than 30 days and 18.64 % change over 180 days. 04/03/24 - 105.6 lbs. 03/21/24 - 107 lbs. which was a 6.14 % weight change in less than 30 days. 03/12/24 - 114.5 lbs. 11/21/23 - 118.0 lbs. Review of the nutritional documentation dated 02/11/24 and 02/23/24 revealed Registered Dietitian (RD) #206 made recommendations for an appetite stimulant. Further review of the medical record and review of physician's progress notes revealed that Resident #63's significant weight loss was not evaluated or addressed by the physician or nurse practitioner and the appetite stimulant that Registered Dietitian #206 recommended was not addressed. Interview on 05/23/24 at 11:21 A.M. with Registered Dietitian (RD) #206 revealed she recommended an appetite stimulant on 02/11/24 and 02/23/24 for Resident #63 but nursing did not communicate her recommendations to the physician or nurse practitioner. RD #206 stated she thought nursing informed the physician or nurse practitioner about weight loss. (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: 366463 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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)