Health inspection·July 1, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address the hydration (the process of replenishing the water content in the body) needs of one of three sampled residents (Resident 1) who was dependent on hydration and nutrition via gastrostomy tube (G-Tube is a tube inserted through the belly that brings nutrition and hydration directly to the stomach), and who had an order for nothing by mouth (NPO) when there was no physician's order for hydration/water flushes, the physician was not notified of the Registered Dietician's (RD) recommendations for hydration, RD did not follow up timely to ensure the recommendations for hydration was carried out, and the facility did not follow their policy and procedure (P&P) on Intake and Output Recording to monitor and record intake and output of residents with feeding tube. These failures had the potential to result in insufficient fluids to maintain proper hydration for Resident 1. Residents Affected - Few Findings: During a review of Resident 1's History and Physical Examination (HPE), dated 5/21/25, the HPE indicated, PEG [percutaneous endoscopic gastrostomy tube is a feeding tube inserted through the abdominal wall into the stomach, allowing for direct feeding into the stomach] Tube in place During a review of Resident 1's Dehydration Risk Screener (DRC-assessment for dehydration risk), dated 5/21/25, the DRC indicated, Score: 10, Score of 10 or higher indicates a resident is at risk for dehydration. During a review of Resident 1's Interdisciplinary Team Care Conference (IDTCC), dated 5/22/25, the IDTCC indicated, Resident [1] admitted to facility 5/21/25, on G-tube feeding. She [Resident 1] requires maximum total assistance with ADL's [activities of daily living-basic tasks that individuals perform to maintain their daily life and care for themselves]. Nutritional/Diet Order: NPO [nothing by mouth]. During a review of Resident 1's Order Summary Report (OSR), dated 5/22/25, the OSR indicated, Diagnoses: Encounter for attention to Gastrostomy, Dietary: NPO [nothing by mouth]. The OSR had no physician's order for water hydration. During a review of Resident 1's Medication Administration Record (MAR), dated 5/2025, the MAR indicated there was no order of water hydration/flushes. During a concurrent interview and record review on 6/26/25 at 2:23 p.m. with Director of Nursing (DON), DON reviewed Resident 1's clinical record. DON stated there was no documented water hydration given to Resident 1 during Resident 1's five day stay in the facility on 5/21/25 until 5/26/25. DON Page 1 of 3 555229 555229 07/01/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0692 stated there was no documentation of a physician's order for water hydration. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's admission Record (AR), dated 5/28/25, the AR indicated, Resident 1 was a [AGE] year-old female resident admitted on [DATE] with diagnoses of Cerebral Infarction (a condition where a part of the brain tissue dies due to a lack of blood flow), Gastrostomy tube, Dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (lung disease), Mild Protein-Calorie Malnutrition (lacking nutrition in the body), and need for assistance with personal care. Residents Affected - Few During a concurrent interview and record review on 6/30/25 at 2:12 p.m. with DON, DON reviewed Resident 1's clinical record. After reviewing the clinical record, DON stated the licensed nurses did not document the intake (how much fluid entered the resident's body) and did not document output (amount of something produced, excreted, or released by the body, e.g. urine). DON stated for residents with feeding tube, the intake and output (I&O) should be monitored and recorded. During an interview on 6/30/25 at 2:18 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she completed the admission assessment and clinical record for Resident 1 upon Resident 1's admission to the facility on 5/21/25. LVN 1 stated she failed to obtain a physician's order for water flushes/hydration. During a review of Resident 1's Nutrition Risk Assessment (NRA), dated 5/22/25, the NRA indicated, Rec: [recommendation] Flush order 150 cc [cubic centimeter/milliliter] q [every] 6 hours = 600 cc [for 24 hours]. During an interview on 6/30/25 at 2:18 p.m. with LVN 1, LVN 1 stated she communicated with Certified Dietary Manager (CDM) but did not document the Registered Dietician (RD) recommendation. LVN 1 stated, I think we [staff] just missed it [RD recommendation for water hydration]. I did not document about the flush [water hydration recommendation]. During an interview on 7/1/25 at 3:32 p.m. with CDM, CDM stated when Resident 1 was admitted , the DON approached him and asked him to call the RD because Resident 1 did not have a physician's order for water flushes/hydration. CDM stated he called the RD, and RD recommended giving the resident 150 milliliters (ml) of water every six hours. CDM stated he verbally informed LVN 1 of the RD's recommendation. CDM stated he did not document the RD recommendation in Resident 1's clinical record. During an interview on 7/2/25 at 9:35 a.m. with RD, RD stated she documented Resident 1's nutrition risk assessment on 5/22/25 (next day from admission) and recommended 150 cc water flushes every six hours. RD stated she was supposed to follow up if her recommendation was followed up with the physician in two to three days from admission for feeding tube dependent residents. RD stated she did not follow up on Resident 1 in two to three days due to the third day being Sunday and the fourth day (5/26/25) when Resident 1 was sent to the acute care hospital was a holiday. RD stated, Unfortunately, I did not follow up if my recommendations were followed. During a review of Resident 1's Change in Condition Evaluation (CCE), dated 5/26/25 (five days later from admission date), the CCE indicated, Signs and Symptoms Identified: SOB [shortness of breath] with gurgling sounds with high pulse rate [sic]. Pulse: 123 [normal pulse is 60-100]. During a review of the Hospital's ED (Emergency Department) Physician's Notes (EDPN), dated 5/26/25, the EDPN indicated, Diagnosis: Sepsis (life threatening infection), Hypernatremia (too much sodium in blood caused by dehydration), and Severe Dehydration. Plan: Free water deficit [not enough water 555229 Page 2 of 3 555229 07/01/2025 Valley Healthcare Center 1205 8th Street Bakersfield, CA 93304

F 0692 in the body] is 2.4 L [liters]. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Intake and Output [I&O] Recording dated 11/1/17, the P&P indicated, I&O may be instituted per an Attending Physician's order or by a Licensed Nurse for any resident with the following: A. Enteral (providing nutrition by delivering nutrients directly into the stomach through a tube) feedings. Residents receiving enteral feedings will be placed on I&O for the length of time needed to evaluate tolerance of the feeding. Residents Affected - Few During a review of the facility's P&P titled, Nutrition/Hydration Management dated 11/1/17, the P&P indicated, The DNS [Director of Nursing Services] is responsible for ensuring that residents are assessed for nutrition/hydration on admission. The concept of nutrition management is an interdisciplinary process. The key components of this system are: C. Implementing the nutrition and hydration program. During a review of the facility's P&P titled, Tube Feeding/TPN dated 11/1/17, the P&P indicated, The physician order and information communicated to the dietary department should include: B. Amount of formula and fluid. 555229 Page 3 of 3