Health inspection·April 9, 2025

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 observation, resident and staff interviews, record review, and review of facility policy, the facility failed to ensure residents who had recent weight loss received their nutritional supplements and weighed according to physician orders. This affected one (Resident #18) of three residents reviewed for weight loss. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed a re-entry date on 02/05/25. Diagnoses included pneumonia, respiratory failure, sepsis, pressure ulcers, dysphagia, chronic kidney disease, metabolic encephalopathy, and iron deficiency anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact, weighed 133 pounds (lbs), was on a physician prescribed weight gain, and on a therapeutic diet. Review of the physician orders for Resident #18 revealed she had an active orders for weights to be obtained monthly on the fifth (dated 10/19/24); Ensure Clear (high calorie nutritional supplement) once daily in morning (dated 12/27/24), and a regular diet. On 03/31/25, Magic Cups (high calorie nutritional supplement) daily with lunch. On 02/27/25, LiquaCel (protein supplement) 30 milliliters (ml) once daily Review of the weights for Resident #18 revealed her recorded weight dropped from 132.9 lbs on 01/26/25 to 123 lbs on 02/25/25, constituting a 7.4% weight loss within 30 days. A follow-up weight was completed on 02/28/25 but was issued as invalid. A follow-up weight was not obtained until 03/05/25 at 124 lbs, eight days after the 02/25/25 weight was recorded. Additionally, no further weights were recorded after 03/05/25, including the weight which should have occurred on 04/05/25 per physician orders. Interview and observation on 04/08/25 at 12:11 P.M. with Resident #18 stated she had lost significant weight, going from approximately 160 lbs to 123 lbs as of 03/05/25. She reported she did not know what a Magic Cup was, and stated she did not receive one for lunch and had never received one for lunch in the past. Resident #18's meal ticket was on her bedside table and it was noted the Magic Cup supplement was listed as a required part of her lunch meal. However, upon observation of the lunch tray, the Magic Cup was not present. Interview on 04/08/25 at 1:02 P.M. with Dietary Manager #124 confirmed the facility had a stock of Magic Cups available in the freezer and had them available prior to lunch. Page 1 of 2 366475 366475 04/09/2025 Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/08/25 at 1:27 P.M. with Registered Dietitian (RD) #205 confirmed that although the 03/05/25 weight showed a one pound increase (to 124 lbs), no further monitoring was conducted, and the facility considered this slight gain as resolution of the issue. RD #205 verified Resident #18 was not weighed for 04/05/25 as physician ordered and there has been no weight obtained yet for April 2025. Interview on 04/08/25 at 2:34 P.M. with Registered Nurse (RN) #114 stated Resident #18 frequently refuses her Ensure and LiquaCel, but in regards to the Magic Cup, the kitchen should provide that on her meal tray. Review of the facility policy titled Clinical Services - Weight Monitoring with a revised date of 05/10/24 revealed it mandates the daily and monthly review of residents' weights and requires clinical leaders to review and correct any missing or inaccurate weights. Furthermore, the Standard Operating Procedure (SOP) directs the facility to refer any residents experiencing a five percent or greater weight change to a Registered Dietitian (RD) or Nutrition and Dietetics Technician, Registered (NDTR) for evaluation. This deficiency represents non-compliance investigated under Complaint Number OH00163634. 366475 Page 2 of 2