Health inspection·April 15, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's medical record were clear and complete when licensed nurses (LN) did not consistently sign the Medication Administration Record (MAR) when the tube feeding (TF) formula was administered, and a TF order did not have a rate (the speed of the TF delivered to the stomach) order for 1 of 3 sampled residents (Resident 4). As a result, Resident 4's medical record was incomplete, which compromised the ability to track and verify the amount of TF formula administered. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses that included gastrostomy ( a surgical procedure to create an opening in the abdomen and into the stomach to allow for the insertion of a feeding tube) status. A review of Resident 4's medical record was conducted on 4/15/25. Per the hospital discharge record dated 2/26/25, under Order Instructions for preparing TF formula, give one pouch for the formula to be warmed in a warm water bath, poured into a TF bag, and diluted with 120 milliliters (ml) of sterile water. Once this was done. Hang the bag and set the TF rate at 60 ml per hour continuously. Resident 4 should receive three pouches of TF formula per day. Per the Facility Physician's Order Summary Report dated 2/27/25, Resident 4 had an order of every 24 hours 1 pouch of [name of the formula] has to be warmed in warmed water bath, poured into a TF bag, and diluted with 120 ml of warm sterile water. Once this is done, can hang bag and set TF rate. The TF rate and the total number of pouches were not written in the Order Summary. Per the Medication Administration Record, dated 2/27/25 through 3/4/25, Resident 4 had an order of every 24 hours 1 pouch of [name of the formula] has to be warmed in warmed water bath, poured into a TF bag, and diluted with 120 ml of warm sterile water. Once this is done, can hang bag and set TF rate. The TF rate and the total number of pouches were not recorded, and only one licensed nurse signed the MAR each day. On 4/15/25 at 3 P.M., an interview and joint record review was conducted with LN 2. LN 2 stated the licensed nurses had to administer the TF formula once every eight hours. LN 2 stated that he administered the TF formula to Resident 4 without signing the MAR. LN 2 stated he should have signed the Page 1 of 2 056062 056062 04/15/2025 Amaya Springs Health Care Center 8625 Lamar Street Spring Valley, CA 91977

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MAR every time the TF was administered to Resident 4, so there would be a record of the number of pouches given per day, and there would be a record of the work he had done. LN 2 also stated that the MAR and the order summary should have a complete order that included the TF rate. LN 2 stated he could not be sure what Resident 4's TF rate was when the TF was administered to Resident 4. On 4/15/25 at 4:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the TF order in the MAR, and the order summary should include the TF rate. In addition, the DON stated that the LNs should have signed the MAR every time they started (began/provided) a new pouch, to ensure that the resident was provided three pouches per day. Per the facility's policy and procedure, dated 1/1/12, titled Enteral Feeding, .Calculate [the] amount of formula to be given per shift .document administration of enteral feeding . 056062 Page 2 of 2