Health inspection·February 20, 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 observation, interview, and record review, the facility failed to label and date Resident #92's continuous tube feed bag to ensure proper administration of enteral formula over extended periods of time. This affected one resident (Resident #92) out of four residents reviewed for tube feedings. Findings include: Review of medical record for Resident #92 revealed an admission date of 11/01/23 and her diagnoses included diabetes malignant neoplasm of esophagus, gastrostomy, and hypertension. Review of care plan last revised on 01/07/24 revealed Resident #92 required a feeding tube to maintain and/ or improve her nutritional status related to dysphagia, weight loss, and esophageal cancer. Interventions included tube feedings per dietitian and physician recommendations. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #92 had intact cognition and had a feeding tube. Review of February 2024 Physician Orders revealed Resident #92 had the following tube feeding order: Diabeta Source 65 milliliters (ml) per hour continuous every shift. Observation on 02/13/24 at 9:04 A.M. Resident #92 was lying in bed with an unlabeled and undated feeding tube bag connected running at 65 ml per hour. The bag had approximately 200 ml of formula left in the bag. Interview on 02/13/24 at 9:09 A.M. with Registered Nurse (RN)/ Minimum Data Set (MDS) #350 verified Resident #92 feeding bag was unlabeled and undated. She verified the bag did not contain the name of the formula on the bag, and/ or when the bag was hung including date and time. She proceeded to walk out of Resident #92's room to the medication cart and asked LPN #280 what tube feeding was hung and when it was last hung. LPN #280 revealed she had not been in Resident #92's room yet as her tube feeding was hung by the previous shift, and she was unsure when. Both RN/ MDS #350 and LPN #280 verified the tube feeding bag should have been dated of when it was hung and what product was inside the bag. Review of facility policy labeled, Enteral Tube Feeding- Bolus and Continuous dated 06/08/22 revealed the policy was to assure safe and effective administration of enteral feeding. The policy did not include any information regarding ensuring the tube feeding bag was labeled with the product it contained and/ or the date/ time when it was hung. 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: 366229 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 366229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Villa 7040 Hepburn Road Middleburg Heights, OH 44130 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)