Health inspection·April 16, 2025

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, the facility failed to ensure residents receiving enteral feeding (EF-also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one of three sampled residents (Resident 3) by failing to secure and cover the feeding tube tip with a cap when the feeding tube was disconnected from Resident 3. This failure had the potential to result in gastrointestinal (GI-relating to stomach and intestines) infection to Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE], and readmitted on [DATE], with diagnoses of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia (difficulty swallowing), tracheostomy (a surgical opening in the neck fitted with a device to allow oxygen to reach the lungs), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). During a review of Resident 3's History and Physical (H&P), dated 10/19/2024, the H&P indicated, Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 2/12/2025, the MDS indicated Resident 3 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 3 received tube feedings (a method of delivering liquid nutrition directly into the digestive system through a tube) while a resident in the facility. During a review of Resident 3's Care Plan (CP), titled Resident is on gastrostomy tube (GT-a medical device that provides direct access to the stomach to deliver food, liquids, and medications) feeding, last revised on 3/12/2025, the CP indicated Resident 3 was at risk for aspiration (when food or liquid accidentally enters the airway and lungs), dehydration (when the body does not have enough water), weight fluctuation, weight gain, and infection at GT site. The CP goal indicated Resident 3 will minimize risk of infection at GT site daily. Page 1 of 2 056159 056159 04/16/2025 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 3's Order Summary Report, the report indicated the following physician's order dated 2/17/2025: - Fibersource HN 1.2 (a nutritionally complete liquid formula with fiber designed for people with normal or increased need for calories (a unit of measurement to quantify the energy content of food and drinks) and proteins, providing 1.2 caloriesper per milliliter (ml-a unit of measurement), 54 grams (gr-a unit of measurement) of protein, and 15.2 gr. of fiber per liter (L-a unit of measurement)) at 85 ml per hour for 20 hours via pump to provide 1700ml per 2040 kilocalories (kcal-a unit of measurement) per day. Off at 8 a.m. and on at 12 p.m. During a concurrent observation and interview on 4/16/25 at 10:35a.m. with Registered Nurse (RN) 1 in Resident 3's room, Resident 3's tube feeding of of Fibersource HN 1.2 bag dated 4/16/2024 was off and disconnected from the resident with the tubing tip on the floor, without a cover, exposed to the environment. RN 1 stated the tip of the tube should have been covered with the tube feeding cap and secured on the pump when not connected to the resident to prevent infection. During an interview on 4/16/25 at 1:47p.m. with the Director of Nursing (DON), the DON stated Resident 3's feeding tube should have been covered with a tube feeding cap and secured on the pump to prevent infection ton to the resident. During a review of facility-provided policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, last reviewed on 2/27/2025, the P&P indicated, The facility will remain current in and follow accepted best practices in enteral nutrition. 056159 Page 2 of 2