Health inspection·January 31, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm of a peg tube and the nursing facility was reportedly infusing the tube feeding at an accelerated rate. He had bleeding at his peg tube insertion site and abdominal complaints. He had complaints of nausea, while in the ER, and his abdomen was soft, non-tender, and round. He had bowel sounds present. His peg tube was not found to have had any drainage when checked in the ER. He was discharged back to the nursing facility. Residents Affected - Few A review of a nurse's progress note dated 01/16/24 at 12:26 A.M. by RN #100 revealed Resident #15 arrived back to facility with no new orders from the ER. The nurse contacted the on-call physicians service and received an order to hold the resident's tube feeding for the duration of the shift and continue to monitor for bleeding. They were to notify the in-house provider in the morning for further orders. The resident was assessed by the facility's nurse practitioner and gave orders to resume his enteral tube feeding at 55 ml/ hour on a continuous basis as was previously ordered when the resident had no further complaints of nausea. A review of Resident #15's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he did not have any communication issues and was cognitively intact. He was not known to display any behaviors and was not known to reject care. A review of Resident #15's care plans revealed the resident had a feeding tube and received tube feeding as his primary source of nutrition related to dysphagia. The care plan was initiated on 01/18/24. The care plan specified he was to receive Isosource 1.5 at 55 ml/ hour. The goal included the resident would tolerate tube feeding and be free from signs and symptoms of gastrointestinal distress. The interventions included the need to administer the tube feeding per the physician's orders. A review of the facility's investigation into the incident that occurred on 01/15/24 pertaining to Resident #15's enteral feeding revealed statements were obtained by the DON from RN #100, RN #140, and LPN #125. The statement from RN #100 obtained on 01/15/24 revealed the nurse had called the DON at 1:00 A.M. and notified her that at some point Resident #15's enteral feeding pump had started running at 295 ml/ hour. The nurse informed the DON that she had sent the resident to the ER due to nausea, vomiting, abdominal distention and other acute findings. He returned to the facility shortly after with no new orders. The nurse then contacted the facility's on-call physician's service and received an order to keep the resident NPO (nothing by mouth) and nothing by peg tube until he was evaluated by the facility's nurse practitioner (NP). She asked the nurse to provide her with some images of the enteral feeding pump via phone so she could see the settings and the amount that had been infused. She asked the nurse if she had received in report when the resident had been hooked up to the enteral feeding pump and was told by the nurse that she had not been made aware. Images of the enteral feeding pump that was sent to the DON as requested showed the pump settings read 295 ml/ hour and 290 ml volume infused. The nurse did state at some point before sending the resident out that she cleared the volume infused and she was unable to recall the amount that was listed when she cleared the pump. She also was not able to recall how much was left in the enteral feeding bag before discarding it after the resident was sent to the hospital. The nurse was unable to confirm if the 290 ml volume infused was the total volume he received while in the facility or not, as the nurse believed she may have cleared the enteral feeding pump, but could not be sure she did. The statement obtained from RN #140 by the DON on 01/16/24 revealed Resident #15 was set up with his tube feeding as ordered sometime around 5:30 P.M. to 5:45 P.M. She reported she was the one who had set up the enteral feeding pump system as ordered, but was unable to recall just exactly what the order was. She was able to recall that it was 50 something and that he also had water flush orders. She recalled his peg tube site had been bleeding slightly since his admission, but was not able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 2 of 4 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 provide any more information than that. Level of Harm - Minimal harm or potential for actual harm A statement obtained from LPN #125 by the DON on 01/16/24 confirmed Resident #15's enteral tube feeding was set up as ordered around 5:30 P.M. to 5:45 P. M by RN #140, who was in training with her. She too recalled the peg tube site had been bleeding slightly since his admission, but did not notice an increase in the amount of bleeding or any complaints of nausea or vomiting. She was unable to recall much more about the incident than that. Residents Affected - Few The facility's investigation did include the image of Resident #15's enteral feeding pump that had been sent to the DON by RN #100. The image showed the infusion rate was set at 295 ml/ hr and the volume delivered was indicated to be 290 ml. The image was a Xerox copy and had a hand written note on it that indicated it had been sent from RN #100. A review of the operator instructions for EntraFlo Nutrition Delivery System from Medline revealed there were directions on how to modify pump settings. The operating instructions for changing the rate or dose limit indicated the person making changes had to press run/ pause to stop the pump before being able to make any changes. They then had to select new flow/ infusion rate by pressing + or - buttons on the face of the pump. They then had to select new dose limit by pressing set dose limit and then press the + or - button within the next three seconds. They could press reset to clear volume delivered if desired and then press the run/ pause button to restart the pump. On 01/31/24 at 2:08 P.M., an interview with State Tested Nursing Assistant (STNA) #200 revealed she had worked the afternoon shift on 01/15/24 when Resident #15 was admitted . She was assigned to his unit and assisted him with care. She recalled being in his room around 6:00 P.M. to assist the resident with changing his gown as he had blood on it due to bleeding around his peg tube site. She notified RN #100, who intervened and assisted the resident with changing his dressing around the peg tube site. She was in his room again around 8:30 P.M. when the resident was complaining of feeling sick. She described him as being pale and was having difficulty keeping his eyes open. She reported the resident's complaints to RN #100 again and RN #100 had her go to the resident's room to see what his enteral feeding pump was running at. She remembered the pump read 295 on the left side of the pump and had a one on the right side of it. She was not sure what the numbers meant but relayed it back to RN #100, who was checking to see what the pump should have been set at. RN #100 commented that the enteral feeding pump was running six times the amount that the resident should have been getting. The nurse then checked the resident and sent him out to the hospital after she was unable to reach the resident's family. She was not able to give any specific times when things occurred after the 8:30 P.M. time she mentioned, but stated the resident was still in the facility when her shift ended at 10:00 P.M. She had not talked to the DON or any other administrative staff as part of the facility's investigation into the incident. On 01/31/24 at 5:05 P.M., an interview with Resident #15 revealed he did not recall much about what occurred on 01/15/24 as he indicated he was a little out of it after his transfer from Columbus. He did recall there being an issue with the amount of enteral feeding he received but thought it was from the hospital he came from infusing it at a higher rate than he should have received. He was not aware that the enteral feeding was not set up until after he arrived at the facility. He was asked if it would have been possible that he may have changed the settings on the pump by pushing the buttons on the front of it. He denied that he knew anything at all about the pump and would not know how to even work it. On 01/31/24 at 5:15 P.M., an interview with the DON confirmed there had been a problem with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 3 of 4 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 366128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Cambridge Inc. 66731 Old Twenty-One Road Cambridge, OH 43725 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 Resident #15's enteral tube feeding on 01/15/24. She had been notified of the issue by RN #100 on 01/16/24 around 1:00 A.M. She investigated it like a medication error and it was difficult for her to ascertain exactly what happened. From what she could determine, Resident #15's enteral feeding was set up by the day shift nurses (RN #140 and LPN #125)They claimed they had set it up and it was running as ordered at the time their shift had ended around 6:00 P.M. RN #100 reported she had found the enteral feeding pump infusing at 295 ml/ hour instead of the 55 ml/ hr it was ordered at. RN #100 was not able to say how long it had infused at that rate as she did not look at the pump early in her shift when she was assessing the resident when it was reported he had bleeding from his peg tube site. It was not until after 8:30 P.M. that RN #100 had found the pump infusing at 295 ml/ hour. RN #100 was also not able to tell her how much had been infused since it had been initiated as the nurse was unsure if she had cleared the infused volume amount when responding to the pump's sounding alarm. The nurse had told her that she did not touch the pump but then stated she may have reset the infused volume, which would have required her to touch the pump. The nurse was also unable to tell her what the amount was that was remaining in the enteral feeding bag when she had discarded it after the resident had went to the hospital and the feeding was put on hold. She indicated RN #100 was worked up about the resident's bleeding he was having from his peg tube site. She felt the nurse was not responding to the situation in the manner she should have as she did not check to see what rate the feeding was being infused at when she was in the room assessing the problems with his peg tube site. She confirmed she had the nurse take a picture of the pump to send her to show what the infusion rate was set at. She confirmed it was reading 295 ml/ hr, more than what was ordered for the resident to receive. The nurse was telling her that over a 1,000 ml of enteral feeding had been infused but she told the nurse that would not have been possible unless she added more to the enteral feeding bag, which the nurse did not. She suspected the resident received about the approximate amount he should have based on the volume infused amount that was showing considering the flow rate and what time the other nurses reported the feeding had been initiated. She was not able to determine how long the resident received the accelerated amount of enteral tube feeding that was showing on the pump. As a result of that incident, she changed the way in which the nurses took report at shift change. They were now required to do a standing report in the room of any resident on an enteral feeding to verify the amount infusing was what was ordered by the physician. She also had RN #100 do a competency to ensure she knew how to properly operate the enteral feeding pump. This deficiency represents non-compliance investigated under Complaint Number OH00150213. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366128 If continuation sheet Page 4 of 4