Health inspection·December 12, 2025

F659 42 CFR §483.21(b)(3) Comprehensive Person-Centered Care Planning. The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

F725 42 CFR §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care...

F726 42 CFR §483.35 Nursing Services §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. §483.35(d) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

F800 42 CFR §483.60 Food and Nutrition Services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

F801 42 CFR §483.60(a) Staffing. The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care...

F802 42 CFR §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

F940 42 CFR §483.95 Training requirements. A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. 22 CCR §72339 Dietetic Service--Therapeutic Diets Therapeutic diets shall be provided for each patient as prescribed... 22 CCR §72313 Nursing Service-Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 22 CCR §72311 Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. Based on interview, medical record review, and facility's P&P (Policy and Procedure) review, the facility failed to provide the necessary enteral (passing through the intestine, either through the mouth or an artificial opening) care and services to one of four sampled residents (Resident 1) who had a GJ tube (gastrojejunostomy tube a feeding tube that goes through the stomach and into the jejunum (the middle part of the small intestine). It is used for long-term feeding when a resident cannot tolerate food or medication directly into the stomach, as it allows delivery past the stomach to bypass issues like slow stomach emptying, vomiting, or severe pain. A GJ tube has two ports: one for the stomach and another for the jejunum, which allows for feeding, medication, and sometimes decompression (venting air). The facility: 1. Failed to provide services that meet professional standards of quality, and to provide services by qualified persons in accordance with Resident 1's plan of care, when facility staff failed to properly identify and utilize his G port and his J port, resulting in incorrect administration of nutritional feed into the G port and medication into the J port, resulting in clogging of the J port and severe hypoglycemia necessitating hospitalization. 2. Failed to employ sufficient staff with specific competencies to provide nursing and related services to assure Resident 1's safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being when multiple staff members were unable to identify or ensure correct use of Resident 1's G and J ports. 3. Failed to ensure that Resident 1's medications were administered as prescribed when facility staff could not properly identify the G-tube, and staff failed to correctly deliver medications through the G tube. 4. Failed to provide Resident 1's therapeutic diet as prescribed when staff could not properly identify the J tube, and staff failed to correctly deliver Resident 1's enteral nutrition through the J tube. 5. Failed to implement Resident 1's plan of care when it failed to correctly provide Resident 1's therapeutic diet through the J tube and instead delivered it through the G tube, increasing risk for delayed gastric emptying, discomfort, and vomiting or aspiration. 6. Failed to implement Resident 1's plan of care when it failed to correctly administer Resident 1's medications through his G tube, increasing risk of erratic drug absorption and poor diabetes management. 7. Failed to timely notify the licensed attending physician of the sudden or marked adverse change of mechanical complication in the resident's condition when LVN 1, RN 1, RN 2 failed to properly notify the physician when uncertain about the correct tube ports, and the clogging of the J port. 8. The facility failed to ensure Resident 1's enteral feeding was given through the J tube port and medications were given through the G tube port as ordered by the physician. In addition, the facility staff failed to notify the physician when the staff were unable to accurately identify the G and J ports of the GJ tube and provide the in-service training on the care and management of a resident with a GJ tube. 9. The facility failed to ensure Resident 1 had a physician's order for Resident 1's G tube drainage bag maintenance and discontinuation. These failures resulted in Resident 1's required transfer to an acute care hospital for medical intervention and critical drop in Resident 1's blood sugar level that posed a serious risk for complications such as confusion, seizures, coma, or death. Findings: Review of the facility P&P titled Gastrostomy Tube Feeding via Continuous Pump dated 1/2017 showed it is the policy of the facility to provide nourishment via continuous pump to the residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician. Review of the facility's P&P titled Medication Administration dated 4/2017, under the section procedure showed to verify the tube placement by forcefully injecting 10-30 cc (cubic centimeter) of air into tube while listening with stethoscope to the abdomen for a loud bubbling sound (if no sound heard, notify supervisor immediately). Once placement of the tube is verified, check for residual amounts of feeding by drawing back on the plunger of the bolus syringe... allow each medication to flow down the tube by gravity and to give gentle boots with the plunger if the medication will not flow by gravity and repeat if necessary. On 10/23/25 at 1148 hours, a telephone interview was conducted with Resident Representative 1. Resident Representative 1 stated Resident 1's GJ tube was clogged in the facility then Resident 1 was transferred to the acute care hospital where they found his blood sugar dropped to the critical level of "36" where he could have died. Resident Representative 1 further stated the doctor from the acute care hospital told her Resident 1's J tube was clogged with large amount of medications. Closed medical record review for Resident 1 was initiated on 10/23/25. Resident 1 was admitted to the facility on 10/8/25, and discharged on 10/15/25. Review of Resident 1's H&P (History and Physical) examination dated 10/9/25, showed Resident 1 had no capacity to understand and make decisions. Review of the H&P further showed Resident 1 had diagnoses which included diabetes, gastroparesis and ventilator (a machine to assist with breathing) -dependent respiratory failure; and had a tracheostomy (a medical device inserted into the trachea (windpipe) to establish an airway and facilitate breathing) tube and GJ tube . Review of Resident 1's MDS (Minimum Data Set, a standardized assessment tool) assessment dated 10/12/25, showed Resident 1 was dependent on facility staff for his activities of daily living. Further review of the MDS showed Resident 1 had a feeding tube and received more than 51% calorie through the parenteral or tube feeding. Review of Resident 1's Order Summary Report showed the following physician's orders: - dated 10/8/25, (a) give Nepro (a feeding formula) at 55 ml/hour for 16 hours through the J tube via enteral pump to provide 880 ml/1584 calorie in 24 hours. To start at 1300 hours, and to stop at 0500 hours, or until dose limit is completed, (b) insulin Glargine (an insulin, hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels) subcutaneous (between the skin and muscle) solution 100 unit/ml, to administer 25 units subcutaneously at bedtime for diabetes mellitus, and (c) insulin lispro (rapid-acting insulin used to manage blood sugar levels in people with diabetes mellitus) injection solution 100 unit/ml, to inject as per sliding scale subcutaneously every six hours for diabetes mellitus if blood sugar: less than 70, to notify medical doctor, 70-149 mg/dl (milligrams per deciliter), to give 0 units; 150-200 mg/dl, to give 3 units; 201-250 mg/dl, to give 6 units; 251-300 mg/dl, to give 9 units; 301-350 mg/dl, to give 12 units; 351-400 mg/dl, to give 15 units; 401 mg/dl or more, to give 18 units and to notify the MD (Doctor of Medicine); - dated 10/9/25, J tube water flush 10 ml per hour via enteral pump to provide 160ml in 24 hours. To start at 1300 hours, and to stop at 0500 hours, or until dose limit is completed; and - dated 10/15/25, to transfer Resident 1 to the Acute Care Hospital for J tube replacement. Review of Resident 1's MAR (Medication Administration Record) for October 2025 showed Resident 1 received the insulin Glargine 25 units on 10/14/25 at 2100 hours, and insulin lispro 3 units on 10/15/25 at 0000 hours for the blood sugar of 152 mg/dl. In addition, the MAR showed Resident 1 had a blood sugar level of 84 on 10/15/25 at 0600 hours. Review of Resident 1's Nurses Progress Notes entry by RN (Registered Nurse) 3 dated 10/15/25 showed the following: - at 0720 hours, night shift reported Resident 1's J tube was clogged but the G tube was functional. Upon assessment Resident 1's J tube was clogged and resistance noted when flush. The note showed Resident 1 was awake, alert and responsive through mouth words, had no complaints of pain and discomfort, abdomen was soft, non-tender, no nausea and vomiting. The notes further showed the staff notified the nurse practitioner; - at 0930 hours, the staff received orders from the nurse practitioner to transfer Resident 1 to an acute care hospital; - at 0945 hours, the MD ordered to transfer Resident 1 to the acute care hospital for J tube replacement; - at 1120 hours, Resident 1 was transferred to the acute care hospital; and - at 1530 hours, the contact was made with the acute care hospital via telephone and the facility staff confirmed Resident 1 had been admitted with diagnoses of jejunostomy malfunction and hypoglycemia (low blood sugar). Review of Resident 1's Recent Laboratory results from the acute care hospital dated 10/15/25 at 1239 hours, showed the blood glucose level of 36 mg/dl. Review of Resident 1's ED (Emergency Department) Notes dated 10/15/25 at 1249 hours, showed the staff attempted to flush Resident 1's J tube with 20 ml of water and unable to flush "completely clogged." Review of Resident 1's Order from the acute care hospital dated 10/16/25 at 0840 hours, showed an order for IR (Interventional Radiology) Jejunal Feeding Tube Replacement. The order further showed the reason for exam was Resident1 had a clogged GJ J-tube, the G tube was functional but J tube was clogged. On 10/24/25 at 0944 hours, a telephone interview was conducted with LVN (Licensed Vocational Nurse) 1. LVN 1 stated Resident 1 had a GJ tube with two ports. LVN 1 stated one port was a J tube for the enteral feeding and the other port was a G tube to be used to administer the medications. LVN 1 stated on 10/14/25 at around 2100 to 2200 hours, when she went to administer Resident1's medication, Resident 1's enteral feeding was running through one port and she assumed the other port was the G tube for medication administration. LVN 1 stated when she attempted to pass the medication through the port, she felt a resistance so she reported to RN 2. LVN 1 stated RN 2 attempted to administer the medication through the same port and was able to administer the medication even though she felt some resistance. When asked if LVN 1 was able to identify the correct J and G tube ports of Resident 1's GJ tube, LVN 1 stated the G and J tube ports were not labeled, so she was not able to identify and verify if the feeding was running through the J tube port. LVN 1 stated she did not change the port where Resident 1's enteral feeding was running from. LVN 1 stated when she reported to RN (Registered Nurse) 2, RN 2 also attempted to administer the medication through the same port she had attempted and RN 2 also was not able to verify the correct port. When asked what she could have done to identify and verify if the Resident was receiving the enteral feeding through the correct port, LVN 1 stated she should have called the doctor. LVN 1 further stated she did not call to verify with the doctor if the Resident was receiving the enteral feeding through the correct port. When asked if she received an in-service training before being assigned and care for Resident 1 who had a GJ tube, LVN 1 stated "no." On 10/24/25 at 1123 hours, a telephone interview was conducted with RN 2. RN 2 stated Resident 1 was admitted with a GJ tube and had G tube drainage bag attached to one port and the enteral feeding was running on the other port. RN 2 stated on 10/14/25, she was notified by LVN 1 of Resident 1's tube being "blocked" and LVN 1 could not give the medication. RN 2 stated she went to check Resident 1 and observed Resident 1 was not connected to the G tube drainage bag and one port was connected to the enteral feeding. RN 2 stated when she attempted to administer the medication through the other port, she confirmed the tube was hard to flush but was able to administer the medication. When asked if she was able to correctly identify the two ports of Resident 1's GJ tube, RN 2 stated the two ports of the GJ tube were not labeled and she could not identify the ports. RN 2 stated Resident 1 should receive the enteral feeding through the J tube and she assumed the port connected to the enteral feeding was the J tube, so she attempted to administer the medication through the other port which was blocked. RN 2 stated she did not change the port where the enteral feeding was running from. RN 2 stated she could not verify if Resident 1 was receiving the enteral feeding from the J tube. When asked why Resident 1 required the J tube feeding, RN 2 stated because Resident1 had gastroparesis an