Resident #60 weighed 162.7 pounds on September 15. By October 21, she had dropped to 138.6 pounds. The facility recorded no other weights during that period.
Her wounds weren't healing either. During an October 22 interview, the resident expressed frustration about her condition and denied ever refusing dressing changes. The next day, she and her spouse told inspectors they were concerned the dramatic weight loss was preventing her wounds from healing.
They were right to worry.
Wound Physician #110 acknowledged during an October 23 interview that the resident's wounds had not healed. He identified the biggest barrier to recovery: "her nutrition."
But the facility had known about the nutrition problem for weeks without acting on it.
Registered Dietitian #140 had sent an email on September 9 to the administrator, director of nursing, and assistant director of nursing recommending that Resident #60 start nutritional supplements to promote wound healing. The same day, staff updated her care plan to include "prosource" supplements.
The recommendation never reached her doctor.
When inspectors interviewed the dietitian on October 23, she said she had just discovered the resident's significant weight loss that day. Her first plan was to ask the facility to reweigh the resident to make sure the dramatic change wasn't a documentation error. Second, she wanted to interview the resident about taking supplements.
The administrator confirmed during an October 23 interview that the dietitian had sent the September 9 email with the supplement recommendation. But the director of nursing and assistant director of nursing who received that message "were no longer with the organization," the administrator explained. The recommendation "was not passed on to the resident's physician."
Primary Care Physician #155 confirmed she never received the dietitian's September 9 recommendation. She told inspectors she "definitely would have ordered a supplement" if the dietitian had made the recommendation. The doctor said they would have closely monitored the resident's response because of her kidney disease.
The facility's own policy required staff to follow through on exactly this type of situation. The pressure injury policy, updated May 1, specified that intervention and preventive measures included "dietician referrals and administering vitamins and minerals and protein supplements in accordance with physician orders."
For five weeks, Resident #60's weight plummeted while her wounds failed to heal. The dietitian had identified the solution on September 9. The doctor was ready to prescribe it. But the communication breakdown meant the resident continued declining while the supplement recommendation sat in an email that nobody forwarded.
The resident's spouse watched her lose nearly 25 pounds and correctly connected the weight loss to her healing problems. The wound physician confirmed malnutrition was sabotaging her recovery. The dietitian had the answer weeks earlier.
Nobody connected the dots until federal inspectors arrived in October and started asking questions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altercare of Canal Winchester Post-acute Rc from 2025-11-17 including all violations, facility responses, and corrective action plans.
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