Health inspection·July 16, 2025

F 0656 Level of Harm - Potential for minimal harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop an individualized plan of care and implement the care needs to minimize the risk of dislodging the GT for one of three sampled residents (Resident 1) who was at high risk for dislodging the GT. Resident 1 had multiple documented incidents of the GT being dislodged. This failure resulted in not providing appropriate, consistent, and individualized care to Resident 1. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the comprehensive person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of the residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition. Medical record review for Resident 1 was initiated on 7/16/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's medical record showed a Change of Condition completed on 5/30, 6/7, 9/24, 11/1, and 11/26/24; and 4/29 and 7/11/25, regarding the dislodged resident's GT. Review of Resident 1's plan of care failed to show a care plan problem to address the resident's GT being dislodged and interventions to prevent Resident 1's GT from being dislodged. On 7/16/25 at 1458 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON verified the above findings and stated a plan of care to prevent the dislodgement of the GT should have been developed for Resident 1. Page 1 of 2 056010 056010 07/16/2025 Seal Beach Health and Rehabilitation Center 3000 N Gate Road Seal Beach, CA 90740

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, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate care and services to prevent the occurrences of complications with a GT. The facility failed to conduct an assessment and document in the resident's medical record regarding the possible causes of Resident 1's GT being dislodged on multiple occasions. In addition, the facility failed to ensure interventions were updated or modified to prevent further dislodgement of Resident 1's GT. These failures posed the risk of developing complications related to the GT, which had the potential to negatively impact Resident 1's well-being. Findings: Review of the facility's P&P titled Enteral Tube Feeding via Gravity Bag revised 11/2018 showed it is the purpose of this procedure to provide nourishment to the resident who is unable to obtain nourishment orally. Medical record review for Resident 1 was initiated on 7/16/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 7/16/25, showed a physician's order dated 6/7/24, for Enteral feeding every shift: Fibersource 1.2 (enteral feeding formula) at 60ml/hr x 20 hours to provide 1200 ml/1440 kcal. On at 2 PM and off at 10 AM or until total volume ordered infused. May use Jevity 1.2 (enteral feeding formula) at the same rate/ml/kcal if Fibersouce HN on backorder Review of Resident 1's Progress Notes showed dislodgement of Resident 1's GT on seven separate dates including 5/30, 6/7, 9/24, 11/1, and 11/26/24; and 4/29 and 7/11/25, which required medical interventions and replacement of the GT. Review of the Change of Condition for each occurrence failed to show documentation of the investigation or possible causes of dislodgement of the GT, except for the incident on 9/24/24. On 7/16/25 at 1140 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 wore an abdominal binder because Resident 1 pulled at her GT. CNA 1 stated in her opinion, Resident 1 should be showered with the abdominal binder on and then replaced with a dry one after the shower to keep the GT secure. On 7/16/25 at 1158 hours, an interview was conducted with LVN 1. LVN 1 stated the only intervention the facility had implemented besides the abdominal binder, to prevent Resident 1 from pulling out the GT was a sign on the wall above Resident 1's bed to keep Resident 1's right arm outside of the sheets to prevent the GT from being grabbed and pulled. LVN 1 also stated there were times when Resident 1's GT had been pulled out by staff during repositioning. On 7/16/25 at 1243 hours, an interview was conducted with CNA 2. CNA 2 stated when Resident 1 needed a shower, the licensed nurse was notified to disconnect the GT and remove the abdominal binder. The licensed nurse left the room and notified the shower team Resident 1 was ready to be transported. CNA 2 stated the licensed nurse did not wait in the room for Resident 1 to be picked up, so there was a period of time where Resident 1 was left alone with the abdominal binder off. CNA 2 also stated the shower team was rarely given a report on high-risk residents prior to picking them up for their showers. On 7/16/25 @ 1458 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON verified there have been multiple incidents where Resident 1 pulled out the GT. The ADON stated there was never an investigation completed to determine the cause of Resident 1's GT getting dislodged other than the statements from the staff. Additionally, the ADON verified there was no documentation of possible causes in the Change of Condition, except for the incident on 9/24/24, and there have been no IDT meetings held to determine the possible causes of the frequent GT dislodgement for Resident 1. Cross reference F656 056010 Page 2 of 2