Harbor Post Acute Care Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1 did not pinch the face or pull the hair of one of three sampled residents (Resident 1) while providing care to her on 3/23/2026. Following the allegation of abuse Resident 1 was not protected from CNA 1 during the investigation of her allegations. These deficient practices resulted in Resident 1 being fearful of CNA 1 who was then allowed to participate in a meeting where Resident 1 was present to discuss her allegations of abuse. These deficient practices compromised the integrity of the investigation, did not provide protective measures to Resident 1 during the investigation, minimized the severity of the allegations, and placed Resident 1 at risk for continued abuse, intimidation, guilt and fear of retaliation.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH), when on 3/23/2026 one of three sampled resident's (Resident 1) Responsible Party (RP) notified the Administrator (ADM) that Certified Nurse Assistant (CNA) 1 pulled Resident 1's hair, pinched her face and placed a pillow over her head (3/22/2026) causing Resident 1 to be afraid of CNA 1. These deficient practices resulted in a delay in CDPH's investigation and had the potential for information pertinent to the allegations and investigation to be lost and/or forgotten.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Certified Nurse Assistant (CNA) 1 was not assigned to a resident (Resident 1) after Resident 1 requested not to receive care from CNA 1 for one of three sampled residents (Resident 1). This deficient practice had the potential to upset and cause emotional distress to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. 1 box of Boost (nutritional drink)supplement with 19 brick pack remaining were stored in the dry storage area with no date and label.2. 1 box of chocolate fat free ice cream with 26 cups remaining were stored in freezer #1 with no date and label.3. 1 box of [NAME] house honey wheat roll dough were stored in freezer #1 with no date and label.4. 1 box of liquid whole eggs pasteurized with 11 brick pack remaining were stored in refrigerator #1 with no date and label. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 101 out of 106 residents who received food from the kitchen.

Inspectors wroteBased on interview, and record review, the facility failed to:Ensure a comprehensive water management program was in place. Ensure the Infection Prevention Control Program (IPCP) including standards, polices, and procedures were current, based on national standards, and reviewed at least annually. Ensure gloves were worn while disinfecting the bedside table and prepping wound care supplies for one of one sampled resident (Resident 5). These deficient practices had the potential for staff to follow outdated policies, placing residents and staff at risk for cross contamination and transmission of diseases within the facility.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure beneficiary notices were accurately completed for two of 3 sampled residents (Resident 18 and Resident 30). This deficient practice had the potential to result in residents and/or their responsible parties not being notified of the cost of services per day after benefits expired.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Date Set ([MDS] - a resident assessment tool) was completed accurately for two of 24 sampled residents (Residents 7 and 22) by failing to: 1. Ensure Resident 7's Neurontin (a medication used primarily used as anticonvulsant and for treatment of certain types of nerve pain) were encoded as anti-convulsant in the MDS assessment under Section N (N0415(k) High-Risk Drug Classes) medication. 2. Ensure Resident 22 had accurate documentation in the MDS assessment to reflect the use of Depakote ([anti-convulsant]- medication that controls abnormal electrical activity in the brain). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Ensure care plan intervention was implemented to monitor signs and symptoms of urinary tract infection ([UTI] - an infection in the bladder/urinary tract) for one of four sampled residents (Resident 75) who had a foley catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice placed Resident 75 at risk for unidentified UTI that would lead potentially to life-threatening condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure medications were not left at the bedside for one of 24 sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1's not taking his prescribed medications that would lead to medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of one resident (Resident103) with resident-centered activities consistent with the resident's care plan. This deficient practice had the potential to result in Resident 103 expressing feelings of sadness and isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) had a low air loss mattress on the appropriate setting. This deficient practice had the potential for Resident 10 to develop a pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of two sampled residents (Resident 34) oxygen delivery equipment was labeled and changed in accordance with the current accepted professional standards of practice. 2. Ensure one of five sampled residents' (Resident 59) tubing for the nebulizer machine (medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) was changed every seven days per facility protocol. These deficient practices had the potential for Resident 34 and Resident 59 to experience complications such as infection associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to provide an effective pain management on one of one sampled resident (Resident 14) by failing to:1. Ensure Resident 14's pain level was assessed after administering pain medication. This deficient practice placed Resident 14 at risk for inadequate pain relief and delay of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of five sampled residents (Resident 1) by failing to:1. Communicate to dialysis center staff regarding Resident 1's change of condition. This deficient practice had the potential to result in a delay or lack of coordination of dialysis care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 3) received Furosemide ([diuretic]- medication used to remove excess fluid from the body) by the route ordered by the physician. This deficient practice had the potential for Resident 3 to have an adverse effect (bad outcome) after receiving the medication. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 3's diagnoses included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and obesity. During a review of Resident 3's History and Physical (H&P), dated 1/30/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 27) had a Hemoglobin A1C ([HgA1C] - a blood test that measures the average blood sugar level over the past two to three months) completed every three months per physician's order. This deficient practice resulted in inadequate monitoring of Resident 27's diabetes ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 27's diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on interview and record review, the facility failed to recognize severe weight loss that was experienced by one of three sampled residents (Resident 1), when Resident 1 went from 92 pounds (lbs.), on 4/7/2025 to 72.75 lbs. on 5/5/2025 (a weight loss of 19.25 lbs. in less than a month). The facility failed to: 1. Ensure there were no discrepancies in the calculation of the percentage of food Resident 1 consumed between 4/14/2025 and 5/4/2025 when the Weekly Summary Nurse Progress Note indicated Resident 1's food intake was between 51% to 100% versus the Document Survey Report that indicated Resident 1's food intake was 38.9% to 71.4%. 2. Follow Resident 1's Care Plan interventions to monitor Resident 1's weight loss/gain of three lbs. in a week and five lbs. in one month. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer a medication, Tacrolimus (a drug that suppresses the immune system to prevent organ rejection), as ordered by a physician for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1, who was a lung transplant (a surgical procedure where one or both of a resident's diseased or damaged lungs were replaced with healthy lungs from a deceased donor) recipient, not receiving Tacrolimus and had the potential to cause harm/rejection to Resident 1's transplanted lung.

Inspectors wroteBased on observation, interview and record review, the facility failed the volume on their call lights was not turned down and audible. to ensure one of the facility's call light system was efficiently functioning. On 2/19/2025, the call light system in one of two nursing stations in the facility was not audible in Resident 3's care area and the facility's hallways. This deficient practice resulted in the facility's call light system not being audible in Resident 3's care areas and throughout the hallway. This deficient practice had the potential for the Resident 3's care needs to be neglected.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) who was transferred to a General Acute Care Hospital (GACH) on 1/21/2025 due to shortness of breath (SOB) was readmitted to the facility when the GACH cleared him to return to the facility on 1/31/2025. This deficient practice resulted in Resident 1 remaining at a GACH for 22 days beyond the date the GACH attempted to transfer him back to the facility. This deficient practice had the potential for Resident 1's continuity of care to be interrupted.

Inspectors wroteBased on interview and record review, the facility failed to immediately report a resident-to-resident altercation to the California Department of Public Health (CDPH), and the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours, for two of two sampled residents (Resident 1 and Resident 2). This deficient practice resulted in CDPH ' s inability to investigate the allegations of abuse timely and had the potential for other allegations of abuse to go unreported. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to investigate a resident-to-resident altercation between two of two sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from ongoing or further abuse. a. During a review of the Resident 1 ' s admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (a stroke caused by a ruptured blood vessel), hemiplegia (severe muscle weakness) and hemiparesis (muscle weakness) following cerebrovascular disease (group of disorders that affect blood supply to the brain) affecting the dominant right side, frontal lobe (responsible for functions ex: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow one of three residents ' (Resident 1) care plan, when Restorative Nursing Assistant 1 (RNA 1) transferred Resident 1 from the wheelchair to the bed by himself. This deficient practice has the potential for Resident 1 to experience a fall or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 106 out 108 total residents in the facility by not: A. Ensuring Foods were dated, labeled, and discarded before the used by date (expiration dates). B. Ensuring Dietary Aid (DA) 2 performed hand hygiene (washing hands) and changed gloves between tasks during tray line (Resident's trays are assembled and check for accuracy before food is delivered to them). C. Ensuring [NAME] 2 took off her wristwatch that was not covered with gloves during tray line. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for four of 24 sampled residents (Resident 26,27, and 213). The facility failed to: a. Ensure privacy curtain was drawn while providing care with Resident 26 and 27. b. Ensure Resident 213 indwelling urinary bag was covered completely with a privacy bag. These deficient practices had the potential to feel embarrassed and affect the self-esteem, self-worth, sense of independence and psychosocial well-being for Resident 26,27, and 213.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure call light was within reach for two of three sampled residents (Resident 12 and Resident 16). This deficient practice had the potential for Resident 12 and 16 not to receive necessary assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident Minimum Data Set ([MDS] a comprehensive assessment and care screening tool) assessment was transmitted within 14 days after completion for two of 14 sampled residents (Resident 69 and 83). This deficient practice had the potential to the delay in identifying resident care concerns needing individualized care plan, delay in providing residents interventions necessary to provide quality care and delay in the reimbursement process.

Inspectors wroteBased on interview and record review, the facility failed to provide social services to three out of five sample residents (Resident 37, 93 and 94) by: a Failing to follow up on the advanced directive for Resident 37. b. Failed to follow up with dentures for Resident 93. c. Ensure Resident 94 was seen by a podiatrist (a provider who specializes in caring for the feet, ankles, and lower legs). This deficient practice had the potential to cause conflict with a resident's wishes regarding healthcare, delay the delivery of care and services, and affect the resident's psychosocial negatively. The failure of resident 94 not seen by podiatrist resulted in not having her toenail cut for six months and experience pain on her right 5th toe.

Inspectors wroteBased on observation and interviews, the facility failed to appropriately store medications that required refrigeration for two of two sampled residents (Resident 80 and 5). This deficient practice had the potential for loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to: A. ensure gowns were worn for two of 24 sampled residents (Resident 4 and Resident 213) when changing bed linen and touching the urinary catheter bag (a receptacle that serves as a container or collector for urine as it leaves the body and passes through the catheter tube). B. remove gloves from the dispensing box before administering medication to Resident 25. C. Ensure placing correct isolation signage and following proper Personal Protective Equipment ([PPE]- equipment used to prevent or minimize exposure to hazards) requirement for Resident 62. These failures resulted in compromised infection control measures to prevent infectious disease among residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for three of four sampled residents (Resident 12, 78, and 100) This failure had the potential to put Resident 12,78 and 100 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 24 sampled resident (Resident 90) was assessed for change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) or functional status which without immediate intervention, may result in complications or death) and physician informed when Resident 90 called 911 (a phone number used to contact emergency services) on [DATE], and [DATE]. This failure resulted in Resident 90 calling 911 and transferred to general acute care hospital (GACH) on [DATE] for abdominal pain and fecal impaction (large, hard mass of stool gets stuck in the rectum and cannot pass out). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 12) received continues oxygen therapy via nasal canula) a device that delivers extra oxygen through a tube and into your nose). This deficient practice had the potential to affect Resident 12's breathing and could cause desaturation (low blood oxygen concentration) from not receiving adequate amount of oxygen and a fire hazard.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of three sampled residents (Resident 24) by failing to ensure a resident did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 24. This deficient practice had the potential to result in the use of unnecessary psychotropic drugs for Resident 24 and can lead to side effects and adverse consequences such as a decline in quality of life and functional capacity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of a medication error rate of five percent or greater as evidenced by the identification of four medication errors out of 28 opportunities for errors, to yield a facility medication error rate of 10.71 percent for three of three randomly selected residents (Resident 90, 310, and 81). This deficient practice had the potential for increased pain, side effects, poor wound healing, and stomach irritation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three randomly selected residents (Resident 90, 310, and 81) by not administering Resident 90's lidocaine patch, by giving Resident 310 eyedrops in the wrong eye and by not giving Resident 81's calcium acetate with a meal. This deficient practice had the potential for Resident 90 experiencing increased pain, Resident 310 had the potential to develop side effects from receiving eyedrop in the wrong eye and Resident 81 experiencing stomach irritation from not receiving calcium acetate with meals.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 24 sampled residents (Resident 87) food preferences were honored and documented. This failure resulted in Resident 87's not receiving food items of Resident 87's choice and preference.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Social Service Policy & Procedure, Grievances which indicated that all facility grievance (complaint) investigations, should be initiated as soon as practicably possible, after the grievance is filed, for one of three sampled residents, Resident 1. This failure had the potential for an unaddressed and unresolved grievances and had the potential to affect the resident ' s quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light was in reach for one out of three sampled Residents (Resident 2). This deficient practice had the potential to result in a delay in or in an inability for Resident 2 to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention and control program was implemented by conducting facility-wide response testing of Coronavirus-19 (COVID-19: a highly contagious infection, caused by a virus that can easily spread from person to person) for one of 4 sampled residents (Resident 4) who had closed contact of confirmed COVID-19 case. This deficient practice had the potential to prevent early diagnosis of COVID-19 and possible continued spread of COVID-19 for all staff and residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. ensure one (1) out of eight (8) sample residents (Resident 15 ) are treated with respect and dignity by failing to knock and request permission before entering resident`s room ( Resident 15). b. to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for two (2) out of the eight (8) sampled residents (Resident 14 and 24). The facility staff was observed standing over the resident while assisting them during a meal. These deficient practices had the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review the facility failed to provide residents and or their responsible parties information on Advance Directives (an individual's wishes regarding medical treatment) for two of nine sampled residents (75 & 344). This deficient practice had the potential for violating Resident 75 and 344 choices for medical care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure that 11 multi dose medications had been discarded 90 days after date opened as per facility policy and procedure. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. Ensure that six (6) insulin (medicine to lower blood sugar) for a resident had been discarded 28 days after date opened (Resident 1,15,19, and 29). This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. ensure dietary staff performed proper hand hygiene during tray line. b. ensure the food thermometers were sanitized after removing from one food item and inserting into another food item. c. ensure all food items stored in the kitchen dry storage room were labeled and dated. This deficient practice placed the facility residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: After exit it was determined C and D were moved to F812 a. ensure staff properly used personal protective equipment (PPE) in yellow zone rooms. b. ensure staff performed proper hand hygiene while performing wound care treatment for Resident 45. c. facility failed to ensure licensed staff practiced hand hygiene after disinfecting a blood pressure cuff and stethoscope and after cleaning a blood glucose monitor (machine used to check blood sugar level) before donning (applying) gloves and touching one of one Resident's (17) fingers to perform a blood glucose test. d. facility failed to date and label one of one resident's (52) humidifier (used to add moisture to the oxygen) and oxygen tubing, per facility policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a pest-free environment and an effective pest control program to ensure the facility was free of fruit flies in the kitchen. This deficient practice had the potential to spread disease and cause food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of six alert residents (Residents 37, 52, and 65) in the Resident Council Meeting were informed of their rights to receive information from State Long-Term Care Ombudsman (agencies acting as client advocates), and to be informed of how to contact the agencies and to communicate with them when needed. This deficient practice had a potential to negatively impact residents' rights to be informed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six alert residents (Resident 37 and 52) in the Resident Council Meeting were informed of their rights on how to file a grievance. This deficient practice had a potential to negatively impact residents' rights to be informed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents have the right to be free from neglect, physical, verbal, and mental abuse for one of eight (8) sampled residents (Residents 57). This deficient practice had Resident 57 feeling attacked, humiliated, and degraded.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline individualized care plan to reflect the assessment and meet the immediate needs that included interventions to address activities, or regular room visits, and ongoing programs to support the resident in their choice of activities for one of one sampled resident (Resident 89). This deficient practice had the potential to decrease the physical and cognitive ability and hinder the emotional health of Resident 89.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan regarding Resident 's 16 continuous removal of her nasal cannula (device used to deliver supplemental oxygen) with the interdisciplinary team. This deficient practice had a potential to result in respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide shower according to pre-determined schedule for one of two sampled residents (Resident 89), who was totally dependent on staff for ADL's. This deficient practice resulted in Resident 89 not receiving a shower for one month and had the potential to negatively impact Resident 89's self-esteem.

Inspectors wroteBased on interviews and record review, the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for one of one residents (34) with dementia. This deficient practice had the potential to prevent Resident 34 from maintaining his/her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to accurately document the time a controlled medication was removed from the narcotic drawer of the medication cart and failed to document immediately after the medication was given to one of one Residents (51). Licensed staff documented removing Vimpat (a schedule V controlled medication, which has a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics; used to treat seizure disorders) from Resident 51's medication bubble pack in the controlled medication/narcotic drawer of the medication cart at 5 p.m. on 11/4/2021 but did not document in the electronic medical record until 8:17 p.m. on 11/4/2021. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. As evidenced by the identification of two out of 31 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 6.45% for two of five residents (Residents 17 and 8) observed during the medication administration facility task. a. For Resident 17, the facility failed to follow the physician's order to administer Novolog Insulin Aspart (medication to treat abnormal blood sugar) before meals and did not administer the medication according to manufacturer's recommendations. b. For Resident 8, the facility failed to administer Metformin HCL (for diabetes [disease in which blood glucose/blood sugar levels are too high]) within the correct timeframe as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure a water pitcher was not provided at the bedside for one of one sampled resident (Resident 22) as ordered by the physician. This deficient practice had a potential for Resident 22 to choke and aspirate.