The Cove At La Jolla

F-F550

Findings:

On 5/13/25 from 7:30 A.M. to 4:30 P.M., resident interviews were conducted during the initial tour of the facility. The following represents residents' statements about food during the initial tour:

Resident 8 stated I received cereal with no milk .the combinations are ridiculous like yesterday I got cold sausage with brussels sprouts .food is usually lukewarm, not enough food .I had two meals that I couldn't figure out what it was, it looked like fried mush, and I didn't' t eat it . the orange juice is terrible, doesn't taste like orange .

Resident 159 stated .The food is always cold, dry eggs, scrambled, and hard .

Resident 15 stated .Food barely adequate, not very good, always cold .Canned vegetables, lettuce not fresh. Portions too big to finish .

Resident 31 stated .Food not good, lunch and dinner are not up to expectations, always cold, not cooked very well, chicken is tough . I only eat breakfast .They don't season and tastes just plain .

Resident 17 stated .Food cold, unhealthy, bad flavor .

Resident 16 stated .Concerned with not sending requested sandwich for dialysis appointments .

Resident 10 stated .Food was terrible, no flavor, bad presentation .meal ticket it did not specify what he was receiving .

Resident 209 stated .Food content not good .seemed like food from prior day .

Resident 210 stated .Food was unidentifiable .

Resident 6 stated .The food was often cold .she did not always get what was on the menu .she was looking forward to getting sauerkraut, but they gave her carrots instead. She was tired of carrots because she got them every day .she was brought green beans, but could not have green beans because she was allergic .

Resident 24 stated .The food was terrible, it was cold, and had no flavor .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 On 5/14/25 at 10:02 A.M., a Resident Council Meeting was held with eight residents. Five of eight anonymous residents had food complaints. The complaints were as follows: Level of Harm - Minimal harm or potential for actual harm .Pancakes like rubber .

Residents Affected - Some .Food was bad .

.Sometimes good, sometimes not .

.She had lost weight .

.People do not like to eat same food for days .

.Have been trying to get menu for weeks .

.Did not know what to expect. At times did not know what they will receive .

.Menu was posted in hallway .Menu was tiny and pale .postings were too tall, difficult to read .

On 5/14/25 between 12 P.M. and 1:25 P.M. an observation of the tray line was conducted. The last tray was completed and sent out of the kitchen at 1:24 P.M. The last tray served to the last resident of the last unit was completed at 1:30 P.M.

On 5/14/25 At 1:30 P.M., a concurrent sampling of a test tray was conducted with the Dietary Manager (DM) and Registered Dietician (RD), on 5/14/25 at 1:30 P.M.

Temperatures and palatability were as follows:

Milk-43 F, Juice 46 F- not tasted

Pureed tray:

Pureed Meatloaf-127 F, warm, bland,needed seasoning

Mashed Potatoes- 140 F, warm, bland, needed seasoning

Pureed Spinach Au Gratin, 126 F, warm, bland, needed seasoning, no cheese flavor

Regular tray:

Meatloaf 135 F, warm, bland, needed seasoning

Spinach Au gratin, 126 F, warm, bland, needed seasoning, no cheese flavor

The RD stated that the facility standard for hot food was to be at least 120 F, and for beverages to be lower than 45 F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 On 5/16/25 at 10 A.M., an interview with the RD was conducted. The RD stated that the expectation for assessing residents' preferences and dislikes was to review the monthly menu with each resident, document Level of Harm - Minimal harm or resident's dislikes, and provide alternatives for foods that they disliked. The RD stated the importance of potential for actual harm providing palatable food to residents was to provide adequate nutrition for nourishment of the residents

during their stay and to promote healing. Residents Affected - Some

Record review of the facility policy titled FOOD PREFERENCE, dated 2023 indicated .Resident's food preferences will be adhered to within reason. Substitutes for dislike will be given from appropriate food groups. Condiments such as salt, pepper, and sugar are available at each meal unless contraindicated by

the diet order .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39448

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide residents with a diet free of food they were allergic to for one of 14 sampled residents (6).

This failure placed Resident 6 at an increased risk of allergic reaction.

Findings:

Per the facility's Admission Record, Resident 6 was admitted to the facility on [DATE REDACTED].

Per the facility's Allergy Report, dated 5/15/25, Resident 6 had an allergy to Broccoli, documented on 1/19/25.

On 5/15/25 AT 9:40 A.M., an interview was conducted with Resident 6. Resident 6 stated, a Certified Nursing Assistant (CNA) brought her broccoli on 5/14/25 at dinnertime.

On 5/15/25 at 1:38 P.M., an interview was conducted with CNA 4. CNA 4 stated, when she brought the dinner meal tray to Resident 6 on 5/14/25, Resident 6 complained to her that there was Broccoli on her plate. CNA 4 further stated, she was supposed to check the meal tray to see if it matched her diet, but she missed that one.

On 5/15/25 at 1:52 P.M., an interview was conducted with Licensed Nurse (LN) 5. LN 5 stated, she checked

the meal trays for accuracy before the CNAs delivered them to the residents. LN 5 further stated, she checked Resident 6's dinner tray on 5/14/25, but she did not remember seeing broccoli on her tray.

On 5/16/25 at 9:59 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, there should have been three staff checking to ensure Resident 6's diet was followed. The DON further stated, the broccoli should have been identified by the kitchen staff, the LN who checked the tray, and the CNA who delivered the tray.

Per the facility's policy, titled Food Preferences, dated 2023, .Resident's food preferences will be adhered to within reason .

Per the facility's policy titled, Resident allergies, Preferences and Substitutes, reviewed 10/24, Resident food trays will be checked by the Dietary department and verified by Nursing, to ensure accuracy, prior to delivery.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43518

Residents Affected - Some Based on observation, interview and record review the facility failed to ensure that one kitchen staff wore a beard restraint during breakfast tray line.

This failure had the potential to contaminate all residents' food with staff's facial hair and promote foodborne illness.

Findings:

On 5/13/25 at 7:45 A.M., an observation of the breakfast tray line and an interview with the Dietary Supervisor (DS) was conducted. The DS was observed with an uncovered beard and mustache plating breakfast food. The DS stated that the policy was that he could serve food without a beard restraint if the beard and mustache were trimmed and groomed. The Registered Dietician(RD) was asked to review policy for facial hair for kitchen staff.

Record review of the facility policy titled DRESS CODE, dated 2023, indicated that .8. If applicable, beards and mustaches (any facial hair) must wear beard restraint .

On 5/16/25 at 10 A.M., an interview with the Registered Dietician (RD) was conducted. The RD stated that

the expectation was for any staff with facial hair needed to cover it with beard restraint. The RD stated that

the importance of covering facial hair was to prevent contamination of residents' food from staff facial hair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 555545

F-F656

Findings:

Resident 209 was admitted to the facility on [DATE REDACTED] with diagnoses including obstructive sleep apnea (OSA-

a problem in which breathing pauses during sleep due to blocked airways) according to the facility's Admission Record.

An observation and interview was conducted on 5/13/25 at 11:42 A.M. with Resident 209. Resident 209 had

a white machine on the bedside drawer. Resident 209 stated the machine was a BIPAP [Bilevel positive airway pressure machine used as breathing support and administered through a face mask or nasal mask] machine. Resident 209 stated she cleaned the machine and added water to the machine when needed.

An interview and joint record review was conducted on 5/14/25 at 8:57 A.M. with Licensed Nurse (LN) 2. LN 2 reviewed Resident 209's electronic medical record (EMR). LN 2 stated there was no physician's order for a BIPAP or a CPAP machine.

During an interview on 5/15/25 at 2:03 P.M. with LN 4, LN 4 stated she was aware that Resident 209 had a CPAP machine. LN 4 stated she needed to check with the Director of Nursing (DON) regarding the facility's policy for CPAP machine cleaning.

During an interview on 5/15/25 at 2:23 P.M. with LN 3, LN 3 stated she did not know how to clean a CPAP machine.

During an interview and joint record review on 5/15/25 at 3:27 P.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated

the hospital history and physical, dated 5/10/25 indicated Resident 209 used a CPAP machine. The MDSN stated there was no physician's order for the CPAP machine until 5/14/25.

An interview on 5/16/25 at 8:26 A.M. with the Director of Nursing (DON) was conducted. The DON stated there should have been a physician's order for the CPAP machine to ensure that Resident 209's condition was treated, education was provided to Resident 209 and for staff to know how to clean the machine for infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 A review of the facility's undated policy and procedure (P&P) titled, CPAP/BIPAP Monitoring and Management was conducted. The P&P indicated, It is the policy of this facility that: 1. BIPAP/CPAP devices Level of Harm - Minimal harm or be administered as ordered by the physician for conditions such as .Sleep Apnea .Interventions are potential for actual harm implemented to minimize risks associated with BIPAP/CPAP.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 43518 potential for actual harm Based on observation, interview, and record review the facility failed to ensure that palatable food was Residents Affected - Some served to fifteen of fifty-one sampled residents.

This failure had the potential to prevent residents from eating their meals and not receiving their daily nutrition.

Cross reference

F-F695

This failure had the potential for Resident 209 to not receive appropriate care, treatment, and interventions for the use of a continuous positive airway pressure machine (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep).

Findings:

Resident 209 was admitted to the facility on [DATE REDACTED] with diagnoses including obstructive sleep apnea (OSA-

a problem in which breathing pauses during sleep due to blocked airways) according to the facility's Admission Record.

An observation and interview was conducted on 5/13/25 at 11:42 A.M. with Resident 209. Resident 209 had

a white machine on the bedside drawer. Resident 209 stated the machine was a BIPAP [Bilevel positive airway pressure machine used as breathing support and administered through a face mask or nasal mask] machine. Resident 209 stated she cleaned the machine and added water to the machine when needed.

An interview and joint record review was conducted on 5/14/25 at 8:57 A.M. with Licensed Nurse (LN) 2. LN 2 reviewed Resident 209's electronic medical record (EMR). LN 2 stated there was no care plan for a BIPAP or CPAP machine.

During an interview and joint record review on 5/15/25 at 3:27 P.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated

the hospital history and physical, dated 5/10/25 indicated Resident 209 used a CPAP machine. The MDSN stated there was no care plan for the CPAP machine until 5/14/25.

An interview on 5/16/25 at 8:26 A.M. with the Director of Nursing (DON) was conducted. The DON stated there should have been a care plan for the CPAP machine to ensure that Resident 209's condition was treated, education was provided to Resident 209 and for staff to know how to clean the machine for infection control.

A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 10/2024 was conducted. The P&P indicated, .the interdisciplinary team (IDT)[team members with various areas of expertise who work together toward the goals of their residents] shall develop a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, mental and psychological need.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39448

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure fall mats were placed appropriately for one of 14 sampled residents (40), and ensure loose flooring was identified for three of three hallways.

These failures placed residents at increased risk of injury.

Findings:

1. Per the facility's Admission Record, Resident 40 was admitted to the facility on [DATE REDACTED] with diagnosis of difficulty walking.

Per the facility's undated Care Plan Report, Resident 40 was at risk for falls related to impaired mobility, weakness, and a history of falls. The Care Plan Report had an intervention to add floor mats to both sides of Resident 40's bed to prevent injury due to a previous fall on 4/30/25.

On 5/15/25 at 2:59 P.M., an observation of Resident 40 and interview was conducted with Licensed Nurse (LN) 5. There was a floor mat one side of Resident 40's bed, and the floor mat on the other side of his bed was stood up against the wall. LN 5 stated, staff moved the floor mat out of the way while transferring Resident 40, but it looked like they forgot to put the fall mat back down after the transfer. LN 5 further stated,

the floor mat would not have been effective while placed up against the wall instead of being on the floor.

On 5/16/25 at 10 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, Resident 40's floor mat should have been returned to the floor next to his bed.

Per the facility's policy titled, Fall Management System, revised June 2018, It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls.

43518

2. On 5/15/25 at 11:14 A.M., a concurrent observation of facility flooring and interview with the Director of Environmental Services (DES) was conducted. The DES confirmed flooring was loose . The DES stated that

the flooring was water damaged and bubbling up in many of the hallways.

The following areas had water damage with loose flooring:

1. The beginning of the center hallway; four areas with three inch diameter bubbles extended upward from

the floor, directly under the hand railing,

2. Near room [ROOM NUMBER], beneath the handrail, three areas of one inch bubbles extended upward from the floor, adjacent to a recently repaired area,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 3. Near room [ROOM NUMBER] in the hallway, two areas with one inch bubbles extended upward from the floor Level of Harm - Minimal harm or potential for actual harm 4. Near room [ROOM NUMBER] one area with a three inch bubble, the floor was separated at the seam creating a two-inch-high area where flooring was warping upward, beneath the hand railing. Residents Affected - Some

The DES stated that the loose flooring could have been a tripping hazard for residents, staff, and visitors.

On 5/16/25 at 10 A.M. an interview was conducted with the Administrator (ADM). The ADM stated that the expectation was that hallways should have been free from any tripping hazards. The ADM stated that the importance of a safe environment was for the comfort and safety of the residents, staff, and the visitors of the facility.

Review of the facility policy titled PHYSICAL ENVIRONMENT, undated, indicated .It is the policy of this facility that the facility must provide a safe, functional, sanitary, comfortable, and home-like environment for residents, staff and public through monthly environmental rounds .The following should be included in Monthly Environmental Rounds .8. Hallways free of potential environmental hazards .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 12 555545 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555545 B. Wing 05/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46235 potential for actual harm Based on observation, interview and record review, the facility failed to provide respiratory care services for Residents Affected - Few one of one resident who used a continuous positive airway pressure machine (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) when Resident 209 used a CPAP machine but did not have a physician's order. In addition, Licensed nurses did not know how to clean

the CPAP machine.

This failure had the potential for Resident 209 to receive inappropriate care and treatment to address Resident 209's respiratory problems.

Cross reference