Inspection·October 10, 2019

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. Based on observation, record review, staff interview, and review of facility policy, the facility failed to date and label an enteral tube feeding tubing bag and infusion tubing for one (#25) of one resident reviewed for tube feeding. The facility had two residents with tube feedings. The facility census was 28. Findings include: Review of Resident #25's medical record revealed an initial admission date of 02/25/19 and a re-admission date of 07/26/19. Diagnoses included hydrocephalus, personal history of sudden cardiac arrest, personal history of anaphylaxis, contracture of muscles, anoxic brain injury, muscle spasms, gastrostomy and tracheostomy. Review of Resident #25's physician order dated 06/11/19 revealed an order for continuous enteral feeding of Nestle Complete at the rate of 105 milliliters(ml) per hour. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/09/19, revealed Resident #25 was in a persistent vegetable state with no discernible consciousness. The MDS further revealed that Resident #25 had a feeding tube and required 51% or more of total calories provided by tube feed. Review of Resident #25's care plan dated 09/09/19 revealed the resident required tube feeding related to anoxic brain damage, personal history of anaphylaxis, comatose status and takes nothing by mouth. Interventions included dependent with tube feeding and water flushes. Observation of Resident #25 on 10/08/19 at 8:40 A.M. revealed a bag of Nestle Complete with a small amount of formula remaining in the bag. The bag had no date or time of when the formula was opened. The tube feeding was running through an external pump at the 105 ml/hr and the tubing to and from the pump was not dated for the time put into use. Interview with Registered Nurse (RN) # 122 on 10/08/19 at 8:57 A.M. confirmed Resident #25's tube feeding bag and tubing was not dated, but it should always be dated. RN #122 stated Resident #25 was on continuous tube feed and the tubing and bag were to be changed one time a shift. Review of the facility policy titled Enteral Feedings, dated December 2011, revealed that staff should document on the formula label with the initials, date and time the formula was hung/administered, and initial that the label was checked against the order. 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: 366466 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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)