Inspection·February 6, 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 observations, staff interviews, policy review, and record review, the facility failed to ensure Resident #100 received timely care and services related to the resident's nasograstic tube not functioning properly. This affected one (Resident #100) of three residents reviewed to tube feeds. The facility census was 58. Findings include: Review of the medical record for Resident #100 revealed an admission date on 01/11/24 and discharged on 01/18/24. Diagnoses included acute gastric ulcer with hemorrhage, protein calorie malnutrition, anemia, and atrial flutter. Review of the physician orders revealed an order for Isosource 1.5 calorie oral liquid by nasal gastric (NG) tube at 60 milliliters per minutes (ml/hr.) Check NG every shift. Review of the Nurse Practitioner (NP) #310 progress note dated 01/15/24 revealed Resident #100 was seen by NP #310. There was no documentation of the order for the portable kidney, ureter, and bladder (KUB) x-ray completed on 01/15/24. No concerns were noted in the NP's progress note and it did not state the KUB x-ray was ordered nor did it mention to hold tube feed or medications. Review of the progress note dated 01/15/24 at 10:50 A.M. revealed NP #310 ordered an x-ray to check peg tube placement. There was no order to hold the tube feed or medications. Review of the KUB x-ray dated 01/15/24 revealed the feeding tube tip was at the gastroesophageal (GE) junction. Impression recommended advancing the feeding tube by five centimeters (cm) and repeating the exam to confirm position of the tip of the NG tube right of midline. The results were faxed to the facility was 01/15/24 at 7:15 P.M. However, NP #310 reviewed the results two days later on 01/17/24 and new orders were to hold tube feed and immediately (stat) chest x-ray. Review of Resident #100's portable chest x-ray dated 01/17/24 revealed the results were left lower lung infiltrate. Review of the NP #310's progress note dated 01/17/24 revealed nursing had stated that NG tube was not flushing easy, encountering resistance and medications very difficult to administer. Tube feed was placed on hold and a stat KUB x-ray was obtained. The results showed that the tip of the NG tube was at GE junction with recommendation to advance five cm and confirm placement. A stat chest x-ray was obtained to roll out aspiration. The chest x-ray showed left lower lobe infiltration. Resident #100 was sent to hospital to have NG tube placement and evaluation. (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 3 Event ID: 365563 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 365563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumnwood Nursing & Rehab Center 275 East Sunset Drive Rittman, OH 44270 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)