Health inspection·January 28, 2026

F 0692 Provide enough food/fluids to maintain a resident's health. 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 one of three sampled residents (Resident 7), received hydration through the gastrostomy tube (GT - a tube inserted into a surgical opening to allow feedings to be administered directly to the stomach common for people with swallowing problems) as ordered by the physician.This failure resulted in Resident 7 receiving insufficient hydration.Findings:During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted on [DATE] with diagnoses that included cerebral palsy (group of conditions that affect movement and posture caused by damage to the brain before birth), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and dysphagia (difficulty swallowing). The AR also indicated Resident 7 had a GT.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 12/9/2025, the MDS indicated Resident 7 had severely impaired cognitive skills (ability to make daily decisions) and was dependent (helper does all the effort to complete activity) on others for all activities of daily living (ADLs- activities such as eating, bathing, dressing and toileting a person performs daily).During a review of Resident 7's Order Summary Report (OSR), the OSR indicated Resident 7 had a physician's order, dated 10/28/2025, to receive 60 milliliters (ml, unit of measure) of water every hour for 20 hours a day through Resident 7's GT for hydration for a total of 1200 ml of water per day.During an observation on 1/28/2026 at 12:50 pm in Resident 7's room, there was no enteral feeding pump (an electronic device that delivers liquid nutrition, fluids, and medication at a programmed rate) in the room to administer 60 ml of water every hour for 20 hours to Resident 7.During an interview on 1/28/2026 at 2:45 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 had never seen the physician's order for Resident 7 to receive 60 ml of water every hour for 20 hours a day. LVN 1 stated a physician's order for 60 ml of water to be given to a resident every hour would be administered through a feeding pump and Resident 7 had not had a feeding pump in the room for a long time.During an interview on 1/28/2026 at 3:25 pm with the Registered Dietician (RD), the RD stated Resident 7's current hydration order is to receive 60 ml of water every hour for 20 hours a day for a total of 1200 mL of water through the GT.During a concurrent interview and record review on 1/28/2026 at 3:35 pm with the Assistant Director of Nursing (ADON), Resident 7's physician's order for hydration, dated 10/28/2025, was reviewed. The ADON stated Resident 7's physician's order to receive 60 ml of water every hour for 20 hours per day through the GT for a total of 1200 mL of water was overlooked.During a concurrent interview and record review on 1/28/2026 at 4:48 pm with LVN 2, LVN 2 stated LVN 2 was not aware of the physician's order for Resident 7 to receive 60 mL of water per hour. LVN 2 stated LVN 2 had never seen a feeding pump for Resident 7 in Resident 7's room. LVN 2 reviewed Resident 7's Medication Administration Record (MAR- a report that serves as a legal record of the medications, nourishment, and hydration administered to a resident), dated 1/1/2026 to 1/31/2026, and the MAR indicated LVN 2 gave Resident 7 sixty (60) ml of water every hour when LVN 2 worked Residents Affected - Some Page 1 of 2 055141 055141 01/28/2026 Madera Post Acute Center 11900 Ramona Boulevard El Monte, CA 91732

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the 3 PM to the 11 PM shift on 1/4/2026, 1/5/2026, 1/6/2026, 1/9/2026, 1/10/2026, 1/11/2026, 1/12/2026, 1/15/2026, 1/16/2026, 1/17/2026, 1/18/2026, 1/21/2026, 1/22/2026, 1/23/2026, 1/24/2026, and on 1/27/2026. LVN 2 stated LVN 2 did not give Resident 7 water every hour and Resident 7's MAR was marked in error.During a review of the facility's Policy and Procedures (P&P) titled, Food and Nutrition Services - Hydration, dated January 2025, the P&P indicated to provide residents hydration based on the physician's treatment plan and resident condition. 055141 Page 2 of 2