Health inspection·October 16, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #2's gastric tube was properly assessed, monitored, and cared for. This affected one resident (Resident #2) out three residents reviewed for feeding tubes. Review of medical record for Resident #2 revealed an admission date of 08/28/25 with diagnosis included but not limited to, chronic respiratory failure, other artificial openings of gastrointestinal tract status, type 2 diabetes mellitus with diabetic neuropathy, severe protein-calorie malnutrition, gastrostomy infection, end stage renal disease, dependence on renal dialysis, dependence on respirator, and tracheostomy status.Review of the care plan dated 09/02/25 and last revised 09/11/25 revealed Resident #2 was at nutrition risk related to gastric tube related to chronic respiratory failure on ventilator, tracheostomy, and end stage renal disease (ESRD) on dialysis. Goal to include Resident #2 will be free of complications related to presence of feeding tube daily. Intervention to include provide tube site care per physician order and facility policy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. Resident #2 was dependent for activities of daily living (ADL) care.Review of the care plan dated 09/02/25 and last revised 09/11/25 revealed Resident #2 was at nutrition risk related to gastric tube related to chronic respiratory failure on ventilator, tracheostomy, and end stage renal disease (ESRD) on dialysis. Goal to include Resident #2 will be free of complications related to presence of feeding tube daily. Intervention to include provide tube site care per physician order and facility policy. There was no evidence of readmission on [DATE] care plan for feeding tube care.Review of the progress note dated 10/07/25 at 7:29 A.M revealed Resident 2 had two episodes of emesis, the physician was notified and ordered to send the resident to hospital for evaluation.Review of the progress note dated 10/12/25 at 6:00 P.M. revealed Resident #2 was readmitted to facility. Review of Resident #2's readmission/admission assessment dated [DATE] at 5:03 A.M. revealed the readmission/admission assessment was started and mostly incomplete. The gastrointestinal system section had nothing completed, including information on the residents gastric tube as of 10/16/25.Review of Resident #2's medical record including physician orders, progress notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for 10/12/25 through 10/14/25 revealed no evidence for care of the feeding tube site, including monitoring of the site, and drainage: quantity, odor, and appearance.Observation and interview on 10/14/25 at 10:45 A.M. of Resident #2 ' s J-tube on her left side revealed what looked like an ostomy bag with tube feeding coming out of site in bag which was dark brown drainage with what appeared to be granules. Resident #2 reported the peg site was from the hospital that way.Review of the physician orders for 10/15/25 revealed an order was initiated three days after readmission to change jejunostomy tube (J-tube) bag/pouch and set up as needed (PRN), every hour PRN and change J-tube ostomy bag and set up every 3 days. J-tube was a small tube inserted into the jejunum, the second part of the small intestine to provide nutrition when a person cannot eat by Residents Affected - Few Page 1 of 2 366487 366487 10/16/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0684 Level of Harm - Minimal harm or potential for actual harm mouth. Review of the MARS and TARS for 10/15/25 revealed orders three days after admission to monitor J-Tube site and peri skin every shift. Special instructions to monitor for redness, tenderness, itching, burning, and/or swelling. Report changes to provider and document in a note.Interview on 10/15/25 at 6:36 A.M. with Director of Nursing (DON) confirmed there were no orders for Resident #2 for dressing changes for her J-tube site until 10/15/25. Residents Affected - Few 366487 Page 2 of 2