Health inspection·December 4, 2025

F 0693 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. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received tube feeding (a method of delivering liquid nutrition, fluids, and medication directly into the digestive system through a feeding tube when a person cannot eat or drink enough by mouth) in accordance with physician order, the comprehensive person-centered care plan, and the resident's goals when Resident 1's tube feeding rate was increased from 60 to 200 mL/hr (milliliters per hour, which is a unit of measurement for a flow or infusion rate). This failure resulted in Resident 1 transferring to a local acute care hospital and eventually passing away due to aspiration pneumonia (a lung infection. It happens when food, liquid, or vomit is breathed into the airways or lungs instead of being swallowed, leading to inflammation and a potential bacterial infection. Symptoms include cough, fever, shortness of breath, and chest pain).Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system (routine postoperative check-ups, wound care, suture removal, and other follow-up care related to digestive system surgery), pneumonitis due to inhalation of food and vomit (known as aspiration pneumonia), dysphagia (difficulty swallowing), and sepsis (a life-threatening blood infection). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/30/25 indicated, Resident 1 was cognitively intact and on feeding tube. Review of Resident 1's Discharge Summary from the hospital upon admission to the facility, dated 10/27/25, the Discharge Summary indicated, . Date of admission: [DATE] Date of discharge: [DATE] . Titrate (the process of gradually adjusting a medication or feeding dosage to achieve the optimal therapeutic effect with minimal side effects) tube feeds as needed . Condition on discharge: stable . Review of Resident 1's comprehensive care plan regarding tube feeding initiated on 10/28/25, the care plan indicated, . Goal . The resident will be free of aspiration . Review of Resident 1's Order Summary Report, active orders as of 11/12/25, the Order Summary Report indicated, Formula: Jevity 1.5 (a high-calorie, fiber-fortified liquid nutrition formula for people who cannot get enough nutrients from oral intake) via PEG(Percutaneous Endoscopic Gastrostomy) tube (a feeding tube inserted through the abdominal wall directly into the stomach) @ (at) 60 mL/hour x (times) 20 hours . (Start 1700 (5 PM), Stop 1300 (1 PM)). Fluid water flush 200 mL Q6H (every 6 hours) . Start Date 10/31/2025 . Review of Resident 1's nursing progress notes titled, Daily Skilled dated 11/10/25 at 12:23 PM, the progress notes indicated, . jevity 1.5 @ 60 ml x 20 hrs, tolerating feedings . no nausea . abdomen soft . Review of Resident 1's Nursing Progress Note dated 11/12/25 at 7:27 AM entered by Registered Nurse (RN) 1, the Nursing Progress Notes indicated, . Writer started medication pass at 715am (7:15 AM on 11/12/25). Upon checking resident's BP (blood pressure), resident was spitting up saliva (the clear, watery fluid in the mouth made by the salivary glands) and complained of severe nausea . Writer checked resident's Kangaroo pump (a brand Page 1 of 3 056394 056394 12/04/2025 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0693 Level of Harm - Actual harm Residents Affected - Few of medical device used for enteral feeding, delivering liquid nutrition, hydration, or medication directly into a resident's gastrointestinal tract via a feeding tube) and noticed that her feed was running at 200ml/hr rather than 60ml/hr as ordered. Writer stopped the feed and assessed the resident . Lung sounds (the noises made by the lungs during breathing) were clear . Resident was tachycardic (experiencing a fast heartbeat, defined as a resting heart rate greater than 100 beats per minute in adults) with pulse of 104 . Resident did not complain of any pain but was only experiencing nausea. Notified Medical Doctor (MD) of the situation . Review of Resident 1's Nursing Progress Note dated 11/12/25 at 2:36 PM, the Nursing Progress Notes indicated, . Resident requested cough medicine and Tylenol (a brand of medication) for her coughing. Upon assessing resident, resident seemed to sound more congested. Noted crackles (a sound like bubbling or popping which means abnormal lung sounds) bilaterally upon listening to lung sounds. Notified MD . MD assessed resident . MD ordered for resident to be sent out to ED for chest X-ray to rule out aspiration pneumonia . Transportation came to pick up resident and left around 1230pm (12:30 PM) . Review of Resident 1's Nursing Progress Note dated 11/12/25 at 3:06 PM, the nursing progress note indicated, . XXX (the hospital name) called to update that the resident was admitted . Dx (diagnosis): Aspiration PNA (pneumonia) and Sepsis (a life-threatening blood infection). During a concurrent record review and interview on 11/26/25 at 11:55 AM with Director of Nursing (DON), Resident 1's MEDICATION ADMINISTRATION RECORD (MAR) dated from 11/1/25 to 11/30/25 was reviewed. The MAR indicated, Resident 1 was on formula named Jevity 1.5 via PEG tube at 60 mL/hr for 20 hrs (Start at 5 PM and stop at 1 PM) with fluid water flush 200 mL every 6 hours. The MAR indicated, Licensed Vocational Nurse (LVN) 1 signed for Jevity in the evening on 11/11/25 from 3 PM to 10:59 PM and LVN 2 signed for Jevity at night from 11 PM on 11/11/25 to 6:59 AM on 11/12/25. DON stated, When a nurse signs the MAR, they are supposed to verify that the rate is accurate, when asked what signing the MAR meant. DON further stated, for this incident, when RN 1 checked the tube feeding pump at 7:15 AM on 11/12/25, RN 1 found out that the tube feeding pump was set to 200 mL/hr instead of the ordered rate of 60 mL/hr. During an interview on 11/26/25 at 3:09 PM with LVN 1 via phone, LVN 1 stated, he had hung a new bottle of Jevity for Resident 1 around 5:30 or 5:45 PM on 11/11/25. LVN 1 stated, he had not checked the feeding rate on the pump during his PM shift after hanging up the bottle around 5:30 or 5:45 PM, when asked when he had last checked the feeding rate. LVN 1 stated, he did not check the pump settings with LVN 2 during the shift change around 11 PM. LVN 1 acknowledged, he was not sure Resident 1 was receiving the correct amount of tube feeding during his shift because he did not check the pump's feeding rate during his PM shift. LVN 1 stated, No, when asked if Resident 1 had experienced any symptoms of nausea or vomiting prior to this incident. LVN 1 acknowledged, there was a possibility that the wrong amount of tube feeding might be given to Resident 1 during his shift. LVN 1 stated, At least 30 minutes or 1 hour, when asked how often he should monitor the pump's feed rate. During an interview on 11/26/25 at 3:31 PM with RN 1, RN 1 stated, when making rounds on 11/12/25 at about 7:15 AM, Resident 1 had nausea and he realized the Jevity feeding rate on the pump was at 200 mL/hr which was different from what the doctor had ordered, so he stopped the pump immediately. RN 1 stated, Resident 1 told him that she felt nausea on the night of 11/11/25 but did not report it to LVN 2 (the night shift out going nurse) because Resident 1 thought it would go away. RN 1 stated, The nausea may have been caused from the (feeding) rate being too high which is a potential complication . RN 1 further stated, he did not check the tube feeding pump setting with LVN 2 during the shift change. During an interview on 11/26/25 at 4:13 PM with LVN 2 via phone, LVN 2 stated, No, ma'am, when asked if LVN 2 noticed that Resident 1 had been feeling nauseous on the night of 11/11/25. LVN 2 stated, she checked the tube feeding pump settings around 056394 Page 2 of 3 056394 12/04/2025 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0693 Level of Harm - Actual harm Residents Affected - Few 2 AM on 11/12/25 to replace the previous Jevity bottle with a new one as it was already empty when asked when she had last checked the feeding rate on the pump. LVN 2 stated, Maybe, I mis looked, when asked if she had checked the tube feeding rate on the pump for Resident 1 when she started working around 11 PM. LVN 2 stated, she overlooked at that time. LVN 2 stated, she was not sure what the pump's tube feeding settings were at that time. LVN 2 stated, I did not set it up. Honestly, I mis looked. LVN 2 stated, she just hung the new Jevity bottle without changing the setting of the pump around 2 AM on 11/12/25. LVN 2 stated, she should check feeding pump settings, stoma site, and residuals when asked what she should check when making rounds for residents receiving tube feedings. LVN 2 acknowledged that she missed checking the feeding pump settings for Resident 1. LVN 2 stated, I did not when asked if she checked the tube feeding rate on the pump after hanging the new Jevity bottle after 2 AM. LVN 2 further stated, At least 2 hours, when asked how often she should monitor the pump's feed rate. She stated, Honestly, I did not when asked if she checked it every 2 hours. During an interview on 11/26/25 at 4:50 PM with LVN 1 via phone, LVN 1 stated, I started to hang the new bottle at 5:30 PM or 5:45 PM, when asked again when he hung the new bottle on 11/11/25. LVN 1 stated, he was not one hundred percents sure if he had set the feeding rate of Jevity to 60 mL/hr at that time. During a concurrent interview and record review on 12/3/25 at 2:08 PM with LVN 3, the facility's policy and procedure (P&P) titled, Enteral Feeding Tube updated in May 2025 was reviewed. The P&P indicated, . 1) Upon admission or initiation, the licensed nurse obtains a specific provider order including the following: a) Type/Name of formula b) Amount to be administered . d) Flow rate . f) Water flushes . LVN 3 verified that initiation meant starting a new tube feeding orders, hanging up a new bottle, or checking in between shifts when asked. LVN 3 stated, while the P&P did not specify explicably about monitoring tube feeding pump settings during shifts, initiation included everything, including monitoring, when asked. During an interview on 12/4/25 at 10:53 AM with DON via phone, DON stated, It (the tube feeding pump) wasn't properly set. The rate was adjusted, when asked about the root cause of the incident. DON stated, the Jevity feeding was set as at 200 mL/hr and the water flushing was set to 60 mL. DON further stated, the Volume to be infused (total volume) on the tube feeding pump was not set, and that if it had been, the error could have been detected sooner. DON also stated, LVN 2 should have questioned to herself why she was hanging up the new bottle of Jevity at 2 AM on 11/12/25. Review of Resident 1's hospital notes from Hospital A titled, ED Provider Notes dated 11/12/25 indicated, . Arrival Time: 12:50 PM . pt (patient) sent from SNF (Skilled Nursing Facility, a healthcare facility that provides continuous skilled nursing and supportive care to residents who require a level of medical supervision on an extended basis) for eval of possible aspiration . with increased shortness of breath (difficulty catching breath). Per the patient the tube feeds were mistakenly increased from 60cc (measure of volume in the metric system, same as milliliter (mL)) qhr (every hour) to 200cc qhr for 12 hours and when morning nurse noticed . they found the error in rate. they worried she may have aspirated . with cough and hypoxia (a deficiency of oxygen reaching the body's tissues or organs, preventing them from functioning properly, often leading to serious damage or death, especially in the brain) . Review of Resident 1's hospital notes from Hospital A titled, Discharge Summary dated 11/20/25 indicated, . Death Summary Date of admission: [DATE] date of death : 11 /19/25 Reason for Hospital admission (Admitting Diagnosis): acute hypoxemic respiratory failure (critical condition where the lungs fail to oxygenate the blood adequately) . Etiology (the cause) likely aspiration pna (pneumonia) (TF rate was accidentally increased from 60 - > 200 cc / hr) . Patient passed peacefully on 11/19/25 . 056394 Page 3 of 3