Health inspection·December 22, 2023

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 observation, record review and interview, the facility failed to ensure the abdominal binder used to secure Resident #99's percutaneous endoscopic gastrostomy (PEG) tube was in place at all times. This finding affected one (Resident #99) of three residents reviewed for care. Findings include: Review of Resident #99's hospital documentation dated 06/15/23 revealed the resident was admitted for a urinary tract infection (UTI) and presented from the facility for a PEG tube (tube through the stomach for fluids and nutrition) removal which was replaced in the emergency room (pre admission to the skilled nursing facility). Review of Resident #99's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, altered mental status and vascular dementia. Review of Resident #99's hospital documentation dated 07/13/23 revealed the resident underwent replacement of a PEG tube on 07/12/23. An abdominal binder was ordered to prevent further PEG tube dislodgement in the future. Review of Resident #99's physician orders revealed an order dated 08/08/23 for an abdominal binder to be in place to protect the PEG tube every shift. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #99's nursing progress note dated 12/21/23 at 2:00 A.M. authored by Licensed Practical Nurse (LPN) #804 indicated the resident's PEG tube fell out and was lying next to her. An order was obtained to send the resident to the hospital for a PEG tube replacement. Review of Resident #99's hospital discharge paperwork dated 12/21/23 revealed the PEG tube was reinserted. Observation on 12/22/23 of Resident #99's PEG tube binder revealed the binder was secured and in place. Telephone interview on 12/22/23 at 10:24 A.M. with LPN #804 with the Administrator and Director of Page 1 of 2 366010 366010 12/22/2023 The Pinnacle Rehabilitation and Nursing Center 330 Southwest Ave Tallmadge, OH 44278

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing (DON) present revealed she found Resident #99's PEG tube out and lying on the bed. LPN #804 stated the resident did not have a PEG tube binder in place the time of the observation and she was unaware of where the binder went. Review of the Enteral Nutrition policy revised 01/14 indicated if the resident had a feeding tube placed prior to admission or returning to the facility, the Physician and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00148986. 366010 Page 2 of 2