Health inspection·July 16, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate care and services to prevent the occurrences of complications with a GT. The facility failed to conduct an assessment and document in the resident's medical record regarding the possible causes of Resident 1's GT being dislodged on multiple occasions. In addition, the facility failed to ensure interventions were updated or modified to prevent further dislodgement of Resident 1's GT. These failures posed the risk of developing complications related to the GT, which had the potential to negatively impact Resident 1's well-being. Findings: Review of the facility's P&P titled Enteral Tube Feeding via Gravity Bag revised 11/2018 showed it is the purpose of this procedure to provide nourishment to the resident who is unable to obtain nourishment orally. Medical record review for Resident 1 was initiated on 7/16/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 7/16/25, showed a physician's order dated 6/7/24, for Enteral feeding every shift: Fibersource 1.2 (enteral feeding formula) at 60ml/hr x 20 hours to provide 1200 ml/1440 kcal. On at 2 PM and off at 10 AM or until total volume ordered infused. May use Jevity 1.2 (enteral feeding formula) at the same rate/ml/kcal if Fibersouce HN on backorder Review of Resident 1's Progress Notes showed dislodgement of Resident 1's GT on seven separate dates including 5/30, 6/7, 9/24, 11/1, and 11/26/24; and 4/29 and 7/11/25, which required medical interventions and replacement of the GT. Review of the Change of Condition for each occurrence failed to show documentation of the investigation or possible causes of dislodgement of the GT, except for the incident on 9/24/24. On 7/16/25 at 1140 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 wore an abdominal binder because Resident 1 pulled at her GT. CNA 1 stated in her opinion, Resident 1 should be showered with the abdominal binder on and then replaced with a dry one after the shower to keep the GT secure. On 7/16/25 at 1158 hours, an interview was conducted with LVN 1. LVN 1 stated the only intervention the facility had implemented besides the abdominal binder, to prevent Resident 1 from pulling out the GT was a sign on the wall above Resident 1's bed to keep Resident 1's right arm outside of the sheets to prevent the GT from being grabbed and pulled. LVN 1 also stated there were times when Resident 1's GT had been pulled out by staff during repositioning. On 7/16/25 at 1243 hours, an interview was conducted with CNA 2. CNA 2 stated when Resident 1 needed a shower, the licensed nurse was notified to disconnect the GT and remove the abdominal binder. The licensed nurse left the room and notified the shower team Resident 1 was ready to be transported. CNA 2 stated the licensed nurse did not wait in the room for Resident 1 to be picked up, so there was a period of time where Resident 1 was left alone with the abdominal binder off. CNA 2 also stated the shower team was rarely given a report on high-risk residents prior to picking them up for their showers. On 7/16/25 @ 1458 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON verified there have been multiple incidents where Resident 1 pulled out the GT. The ADON stated there was never an investigation completed to determine the cause of Resident 1's GT getting dislodged other than the statements from the staff. Additionally, the ADON verified there was no documentation of possible causes in the Change of Condition, except for the incident on 9/24/24, and there have been no IDT meetings held to determine the possible causes of the frequent GT dislodgement for Resident 1. Cross reference F656 Event ID: Facility ID: 056010 If continuation sheet Page 2 of 2