Inspection·November 21, 2024

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 medical record review, observation, and staff interview, the facility failed to timely address concerns with a resident's feeding tube. This affected one (#39) of two residents reviewed for feeding tubes. The census was 94. Findings include: Review of Resident #39's medical record revealed an admission date of 08/23/24. Diagnoses listed included abnormal weight loss, Parkinson's disease, bipolar disorder, dementia, and dysphagia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment, had a feeding tube, and was receiving Hospice services. Review of nursing notes revealed on 11/02/24 at 9:08 P.M. Resident #39's feeding tube was clogged. After unclogging the feeding tube it was noticed that the feeding tube was dark almost black in color and had a foul odor. Feeding tube was flushed repeatedly and a new dressing place. A note was left for physician in the physician communication book. On 11/08/24 at 5:56 A.M., Resident #39's feeding tube was black and had a foul odor even after flushing. Feeding tube was not clogged and working properly. A note would be left for physician in the physician communication book. On 11/09/24 at 1:28 A.M., Resident #39's feeding tube was black and had a foul odor even after flushing. Attempted to be flushed again with no change in appearance. A note would be left for physician again. On 11/13/24 at 4:59 A.M., Resident #39's feeding tube was black and had a foul odor. A note would be left for physician and reported to oncoming nurse. Feeding tube was flushed and feed given as ordered. On 11/13/24 at 5:01 A.M., the Hospice on call physician was notified about Resident #39's feeding tube. Further review of Resident #39's medical record revealed no documentation of feeding tube concerns being addressed by physician, Nurse Practitioner (NP), or Hospice staff. Observation of Resident #39's feeding tube on 11/20/24 at 11:49 A.M. revealed it was black in color. Interview with Licensed Practical Nurse (LPN) #185 on 11/20/24 at 11:54 A.M. revealed Resident #39's feeding tube was black in color when he was admitted . Interview with the Director of Nursing (DON) on 11/21/24 at 9:42 A.M. confirmed concerns with Resident #39's feeding tube were not addressed by the facility physician, NP, or Hospice staff. 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 5 Event ID: 365422 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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)