Health inspection·October 22, 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 record review, family interview, and staff interview, the facility failed to ensure a resident, who was known to have multiple dislodgements of his Percutaneous Endoscopic Gastrostomy (Peg) tube, had an abdominal binder in place as ordered to prevent any accidental dislodgements. This affected one resident (#4) of three residents reviewed for feeding tubes. Findings include: Review of Resident #4's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of a traumatic brain injury due to a fall, cognitive communication deficit, hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting the left non-dominant side, dysphagia, and gastrostomy status (surgical placement of a tube through the abdominal wall into the stomach for the purposes of providing nutritional supplements). Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. He was not noted to have displayed any behaviors, nor was he known to reject care during the seven day assessment period. He had a functional limitation in his range of motion on one side of his upper and lower extremities. He was coded on the MDS as having the use of a feeding tube and received 51% or more of his calories through his feeding tube. Review of Resident #4's active care plans revealed he had a care plan in place for having the use of a tube feeding for the primary source of nutrition due to dysphagia. The interventions included the need for an abdominal binder to be in place related to frequent tube displacements. The intervention had been in place since 09/30/24. Review of Resident #4's progress notes revealed a nurse's note dated 09/26/24 at 1:00 P.M. that indicated the nurse entered the resident's room to administer his afternoon meds. His Peg-tube was noted to be dislodged and was lying on the resident's abdomen with the balloon deflated. The nurse attempted to reinsert a new Peg-tube unsuccessfully. The physician was notified and a new order was obtained to send the resident to the emergency room to replace his Peg-tube. He returned to the facility on [DATE] at 4:31 P.M., after his Peg-tube had been replaced. Review of Resident #4's progress notes revealed a nurse's note dated 09/28/24 at 2:35 P.M. that indicated the nurse went into the resident's room to administer medication to resident and flush his Peg-tube. The nurse noticed that the Peg-tube was not secured in place and was found out of placement. The physician was contacted and gave an order to transfer the resident to the emergency room. The resident returned to the facility on [DATE] at 9:00 P.M. with a new Peg-tube placed and an abdominal (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 4 Event ID: 366429 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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)