F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
interviews and record reviews, the facility failed to ensure care for gastrostomy tubes was provided in
accordance with professional standards for one (#2) of three residents sampled for gastrostomy tubes.
Findings included:
A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with a
diagnosis of intestinal obstruction. Resident #2 was discharged from the facility on 8/24/2024.
A review of Resident #2's physician orders revealed the following orders:
- An order dated 8/11/2024 indicating Resident #2's gastrostomy tube (GT) site may be left open to air if
clean and no drainage and to monitor for skin integrity and changes every shift.
- An order dated 8/14/2024 to evaluate for displacement of the GT every shift by observing for abdominal
distension, nausea, vomiting, and pain. If displacement is suspected, clamp GT and call the physician.
A review of Resident #2's Treatment Administration Record (TAR) for August 2024 revealed the following:
- Monitoring of Resident #2's GT site for drainage, cleanliness, and skin integrity changes was not
completed for the Day (7 AM to 3 PM) shift on 8/15, 8/16, 8/17, 8/19, 8/22, 8/23, or 8/24/2024 and was not
completed on the Evening (3 PM to 11 PM) shift on 8/18/2024.
- Evaluation of Resident #2's GT for displacement and observation of signs of abdominal distension,
nausea, vomiting, and pain was not completed for the Day (7 AM to 3 PM) shift on 8/15, 8/16, 8/17, 8/19,
8/22, 8/23, or 8/24/2024 and was not completed on the Evening (3 PM to 11 PM) shift on 8/18/2024.
An interview was conducted on 10/28/2024 at 3:37 PM with Staff A, Registered Nurse (RN) and Unit
Manager (UM) and the facility's Director of Nursing (DON). The DON stated when a resident with a GT was
admitted to the facility a set of batch orders were put into the resident's order set by the admitting nurse.
Staff A, RN UM stated GT's were normally left open to air unless there was drainage present around the
GT site. The DON stated if a resident with a GT had an order in place to assess the GT site every shift for
drainage, the order should be signed off as directed in the physician order
(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:
105176
Printed: 05/28/2026
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
105176
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Winter Haven Health and Rehabilitation Center
202 Ave O NE
Winter Haven, FL 33880
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)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
to signify the assessment was completed. If drainage was identified during the assessment, the nurse
should notify the resident's physician and follow the physician orders.
A follow up interview was conducted on 10/28/2024 at 4:35 PM with the DON. The DON reviewed the
missing documentation in Resident #2's TAR related to monitoring the GT site for drainage and evaluation
of the resident's GT every shift. The DON was not able to state why the orders were not signed off as
completed in Resident #2's TAR but stated the resident's nurse might have interpreted the order differently
and might have thought the order did not need to be signed off if the resident's GT site had no drainage
that day. The DON stated it would not be acceptable for nursing staff to not sign off orders related to wound
care or medication administration. A request for a policy related to the maintenance of gastrostomy tubes
was made to the DON following the interview. The DON stated the facility did not have a policy related to
the maintenance of gastrostomy tubes and staff were to follow the physician orders.
Event ID:
Facility ID:
105176
If continuation sheet
Page 2 of 2
