Health inspection·November 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 observation, interview, and record review, for one out of four residents (Resident 3), the facility failed to ensure the enteral feeding (liquid nutrition -a medical procedure that delivers nutrients, medications, and or fluids directly into the gastrointestinal [GI] tract) bottle/container was: 1. Labeled time when the feeding was hung up. 2. The enteral feeding was disposed/discarded after 48 hours as per facility's policy and procedures and the manufacturer's guidelines to prevent the growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins. These deficient practices had the potential to result in pathogen (germ) exposure to Resident 3 and placed the resident at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and unnecessary hospitalization. Findings: During a review of Resident 3's admission record indicated Resident 3 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included metabolic encephalopathy (a brain dysfunction that occurs when there's a chemical imbalance in the blood that affects the brain), type 2 diabetes (high level of sugar (glucose) in the blood, hypertension (high blood pressure), and protein-calorie malnutrition (inadequate intake of food (as a source of protein, calories, and other essential nutrients). During a review of Resident 3 Minimum Data Set (MDS - resident assessment tool) dated 10/9/2024, indicated Resident 3 cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 3 was totally dependent for all her functional care (eating, dressing, toileting hygiene .) During an observation of Resident 3's room on 11/20/2024, at 10:35 AM, Resident 3 ' s gastrointestinal tube (G-Tube - a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) enteral feeding bottle/container was dated 11/17/2023 with no infusion start time. During an interview on 11/20/2024 at 10:55 AM, Licensed Vocational Nurse 1 (LVN 1) stated, G-tube Page 1 of 4 055748 055748 11/22/2024 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feedings should be labeled with a date and time to ensure the feedings are changed timely and not administered past the correct duration and time. During an interview on 11/20/2024 with the Director of Nursing (DON), the DON stated that enteral feeding should be accurately labeled with a date and time prior to administrating to a resident. The DON further stated failing to accurately label the g-tube feeding with a date and time prior to administration could cause prolonged administration past duration deadline, which could lead to growth of pathogens that cause food borne illnesses such as stomach infection by consuming food that is past is use resulting in pathogen (germ) exposure resulting in unnecessary hospitalization and/or poor health outcomes. During a review of manufacturer ' s guidelines for the enteral feeding indicated, Use for a maximum of 48 hours after connection During a review of facility's policy and procedures titled Enteral Feedings-Safety Precaution dated, revised 11/2018 subtitled Preventing contamination indicated, maintain strict adherence to maximum hang times: Sterile formula in a closed system has a maximum hang time of 48 hours. 055748 Page 2 of 4 055748 11/22/2024 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 out of four residents received the correct therapeutic dose (of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician Residents Affected - Few This deficient practice placed Resident 4 at risk of oxygen poisoning (lung damage that happens from breathing in too much extra (supplemental) oxygen.) and had the potential to negatively impact the Resident 4 ' s health and well-being. Findings: During a review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, encephalopathy (a change in your brain function due to injury or disease), dysphagia (difficulty swallowing), depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) and chronic obstructive pulmonary disease (COPD- lung disease marked by permanent damage to tissues in the lungs) During a review of Resident 4s Minimum Data Set (MDS - resident assessment tool) dated 9/17/2024, indicated Resident 4 had moderately impaired cognition. The MDS also indicated Resident 4 required set-up and clean-up assistance with eating, partial moderate assistance with oral hygiene, upper body dressing, and personal hygiene and, was totally dependent for toileting hygiene, shower/bathing, lower body dressing and putting on footwear. Resident 4 was totally dependent for bed mobility sit to lying on side of the bed. The MDS also indicated the resident was non-ambulatory. During a review of Resident 4's Order Summary Report dated 11/20/2024 indicated physician's order for oxygen at two (2) liters per minute via nasal cannula continuously to keep oxygen saturation equal or greater than 94% for shortness of breath every shift for Residentt 4. During the initial tour on 11/20/2024 at 10:45am, Resident 4 was observed asleep in bed, an oxygen concentrator machine (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) was observed at bedside flowing at 5 liters (unit measure) per minute (duration) -l/min) flowing via the Resident ' s nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) Resident 4 ' s was observed resting comfortably in bed with no distress and unlabored breathing. During an observation and a concurrent interview on 11/20/2024 at 10:55 am Licensed Vocational Nurse 1 (LVN 1), stated Resident 4 has an order for continuous oxygen at 2L/min, a nasal cannula for shortness of breath (SOB), LVN 1 was unable to answer when asked why Resident 4 was receiving 5 L/min instead of the physician ' s order of 2L/min. During an interview on 11/20/2024 at 1:41 P.M., the Director of Nursing (DON) stated Resident 4 was at risk for oxygen overdose can cause the lungs to expand more and affect breathing due to over oxygenation which can cause the Resident to stop breathing and die. During a review of the facility's policy and procedures titled, Oxygen Administration, dated 10/2010 indicated the purpose of this procedure is to provide safe oxygen administration. Policy states, Verify that physicians order for oxygen and facility protocol for oxygen administration .unless 055748 Page 3 of 4 055748 11/22/2024 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0695 otherwise ordered, start the flow of oxygen at the rate of 2 to 3 l/min. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055748 Page 4 of 4