Health inspection·January 29, 2026

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 interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received enteral nutrition (tube feeding - a delivery of liquid nutrition directly into the stomach through a percutaneous endoscopic gastrostomy (PEG - a feeding tube that is place through the stomach used for a person who cannot eat or swallow safely)) according to the physician's order, when Resident 1 did not receive the calculated amount of feeding for approximately two days. This failure had the potential to compromise Resident 1's nutritional status placing him at risk for weight loss, dehydration, and decline in condition.Findings: During a review of Resident 1's Face Sheet (FS- a document containing patient demographics) the FS indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Patient 1's History and Physical (H&P- a document containing demographic information), dated January 15, 2026, at 5:18 PM, the H&P indicated, Patient 1 was admitted to the facility with a tracheostomy (a surgically created opening in the neck where a tube is placed to help a person breathe) and PEG tube for further management and support. Patient 1 had a history of hypertension (high blood pressure), hyperlipidemia (a high amount of fat in the blood), multiple cerebral infarctions (blood flow to part of the brain is blocked, causing brain tissue to die from lack of oxygen). A review of Resident 1's Section B [hearing vision, speech] of the Minimum Data Set (MDS- A detailed checklist nursing facilities use to determine a resident's ability of moving around, memory, and medical problems) indicated, B0100 COMATOSE. Persistent vegetative state/ no discernible consciousness. yes. A review of Resident 1's Orders dated January 19, 2026, indicated, Tube Feeding continuous. [name of tube feeding] .Rate [how much to give] . 60 ml [milliliter-unit of measurement] / hr [hour].route [the way something goes into the body] .PEG tube. During an interview on January 29, 2026, at 1:39 PM, with Registered Nurse (RN 1), RN 1 stated, the Licensed Vocational Nurses or the Registered Nurses in charge of a resident can manage the tube feeding. RN 1 added, the tube feeding should be checked by the nursing staff at the start of the shift to ensure that it is being administered as ordered, during the shut off time (3:00 PM to 5:00 PM for day shift and 3:00 AM to 5:00 AM for night shift), and at the end of the shift, to be able to document the resident intake (amount of feeding the patient received). During an interview on January 29, 2026, at 1:48 PM, with the Clinical Coordinator (CC), the CC stated, tube feedings are monitored across the unit by doing rounds that consist of checking the right tube feeding, ensure it is labeled correctly, and that it is infusing (going into the body). The CC further stated the feeding and water is changed every 24 hours for infection control reasons. The CC stated if an issue is noticed with the pump used to infused the tube feeding, the nursing staff should stop the feeding immediately, label the pump, notify the interdisciplinary team (IDT- a group of health professionals who work together to manage a residents care which includes physician, nursing, social services, dietary), and seek further instruction. During an interview on January 29, 2026, at 2:34 PM, with Page 1 of 2 555443 555443 01/29/2026 HI-Desert Medical Center D/P Snf 6601 White Feather Rd Joshua Tree, CA 92252

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Registered Dietician (RD), the RD stated that on January 21, 2026, there was a care plan meeting set with Resident 1's daughter regarding a concern about a full tube feeding bottle was hanging at Resident 1's bedside dated January 19, 2026 and Resident 1 did not received tube feeding as physician's order. The RD verified with Resident 1's daughter and it was changed by the nursing staff. The RD stated an incident report was created at this time. A review of Resident 1's Current weights, dated January 14, 2026, through January 25, 2026, were reviewed as follows:January 14, 2026, Current weight: 87.2 kg [kilogram- unit of measurement]January 18, 2026, Current weight: 87.2 kgJanuary 25, 2026, Current weight: 85.4 kg (loss of 1.8 kg) During an interview on January 29, 2026, at 3:17 PM, with the Director of Nursing (DON), the DON stated, when the incomplete tube feeding was identified, the nurse notified the physician, and the decision was made to continue feeding at the same rate. During a concurrent interview and record review on January 29, 2026, at 4:35 PM, with RN 1, the Nursing narrative [NN], dated January 21, 2026, and January 22, 2026, were reviewed. The NN dated January 21, 2026, indicated .upon reconnecting the patient to their enteral feeding it was noted that only water was running through the system. upon inspecting the pump further it appeared was continually only flushing with water. A new bottle of [name of tube feeding] was hung and the pump was reset completely. The NN dated January 22, 2026, indicated . notified physician that the resident's tube feeding was not administered to resident for 48 hours, that only water was being infused via g-tube [PEG] for 48 hours. RN 1 stated, the nursing staff should have checked on the feeding to ensure that it was being administered. RN 1 stated it is important because nutrition is number 1, it can cause the blood sugar to go down, weight loss, and the residents should receive the nutrition they need. During a concurrent interview and record review on January 29, 2026, at 5:02 PM, with the DON, the facility's policy and procedure (P&P) titled, Guidelines for Management of Enteral and Parenteral Nutrition, dated September 19, 2016, was reviewed. The Guidelines for Management of Enteral and Parenteral Nutrition, dated September 19, 2016, indicated .Guidelines.initiate enteral formula (recommended by nutrition support specialist) at full strength at goal rate if no GI [gastrointestinal- related to the stomach and intestines] compromise. The DON stated that the policy was not followed and should have been because it is important to meet each resident's nutritional needs. 555443 Page 2 of 2