Pine Ridge Skilled Nursing And Rehab
Inspection Findings
F-Tag F0693
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 medical record review, hospital record review, staff interview, and review of the facility, the facility failed to implement resident tube feeding orders upon admission. This affected one (Resident #19) of three residents reviewed for hospitalization. The facility identified one (Resident #19) with orders for tube feeding.
The facility census was 46 residents.Findings include: Review of the medical record for Resident #19 revealed an admission date of 05/14/25 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition. Resident #19 transferred to the hospital on [DATE REDACTED], was readmitted to the facility on [DATE REDACTED], was transferred again to the hospital on [DATE REDACTED], and was readmitted to the facility on [DATE REDACTED] Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 09/06/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the hospital continuity of care record for Resident #19 dated 08/22/25 revealed an order for Nutren 2.0 tube feeding 10 milliliters (ml) per hour with goal rate of 35 ml per hour. Review of the physician's orders for Resident #19 revealed no order for tube feeding initiated on 08/22/25 for the resident. Review of the Medication Administration Record (MAR) for Resident #19 dated 08/22/25 to 08/25/25 revealed it did not include documentation of tube feeding administration for
the resident. Review of the care plan for Resident #19 dated 08/28/25 revealed the resident was at a moderate nutritional risk related to the need for enteral feedings. Interventions included to provide enteral feedings per the order. Interview on 09/19/25 at 10:52 A.M. with the Director of Nursing (DON) verified the tube feeding orders were not entered into Resident #19's medical record upon her return from the hospital.
The DON stated the facility did not provide the tube feeding for Resident #19 from 08/22/25 to 08/25/25 because they did not have the formula that was ordered available in the facility. Review of the facility policy titled Enteral Nutrition dated November 2018 revealed nutritional support through enteral nutrition should be provided to residents as ordered. The staff could use products from a basic formulary until specialized products can be delivered. This deficiency represents noncompliance investigated under Complaint Number 2601904.
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
Event ID:
PINE RIDGE SKILLED NURSING AND REHAB in MORROW, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MORROW, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PINE RIDGE SKILLED NURSING AND REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.