Adventist Health Delano

Inspectors wroteBased on interview and record review the facility failed to conduct pre-hire reference checks on Certified Nursing Assistant (CNA) 1 who was providing care for one of three sampled residents (Resident 1). This failure had the potential to expose vulnerable residents to abuse and/or other negative effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, update, and implement a person-centered care plan (CP) for three of 15 sampled residents (Resident 39, Resident 17, and Resident 5). This failure had the potential for residents' immediate care needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) Two of two sampled residents (Resident 7 and Resident 2) had physician orders for foley catheter (a hollow tube inserted into the bladder to drain or collect urine) change and a feeding tube (a surgical opening fitted with a device to allow feedings to be) dressing change. These failures had the potential for Resident 7 and Resident 2 to have complications related to foley catheter and feeding tube care. 2) Blood pressure (physical force of circulating blood pushing against the walls of your arteries as your heart pumps through your body) was checked before administering the medication for one of four sampled residents (Resident 44). [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement infection prevention and control action database identified by the survey team (F690). This failure placed all facility residents at risk for a Urinary Tract Infection (UTI-infection in the urine).

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic (medication to treat mental disorders) medication consents were completed appropriately for two of four (Resident 17, and Resident 19) sampled residents. This failure had the potential for the residents to receive psychotropic medication without knowing all the risks and benefits.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P), tilted Advanced Healthcare Directive, Surrogate Decision Maker, for two of 15 sampled residents (Resident 44 and Resident 7) who were unable to sign an Advance Directive (AD - legal document indicating resident preference on end-of-life treatment decisions). This failure had the potential for Resident 44 and Resident 7 wishes not to be honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders prior to the application of bed alarm (a sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of three sampled residents (Resident 5). This failure had the potential to result in violation of residents' rights.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order for foley catheter (a flexible tube passed through the urethra and into the bladder to drain urine) change for one of two sampled resident (Resident 2). This failure had the potential to result in Resident 2 having a Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) with the possibility of sepsis (a life-threatening blood infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 44 and Resident 14) maintain a medication error rate of less than five percent (5%) during the medication pass observation. This failure resulted in a medication error rate of 16% consisting of four medication errors in a sample size of 25 opportunities for error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their intervention to turn and reposition one of three sampled residents (Resident 1) every two hours to prevent pressure ulcers (damage to the skin and underlying tissue from constant pressure, often on bony areas like the tailbone or heels, reducing blood flow, which can cause redness, blisters, and open sores, especially in people who can't move easily). This failure had the potential to cause further skin damage and/or prevent healing for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oral hygiene (the practice of keeping your mouth clean and disease-free) for one of three sampled residents (Resident 1). This failure had the potential to cause sickness and disease, tooth decay, bad breath, and decrease Resident 1's feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on abuse for one of three sampled residents (Resident 1) when the staff accused was not separated from providing resident care. This failure had the potential for other residents to be abused.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain vision for one of three sampled residents (Resident 1) when the facility failed to: 1. Administer Lumigan (prescription medicated eye drops that helps reduce intraocular pressure-the fluid pressure in the eyes. If the pressure is too high, it can cause irreversible vision loss) as ordered by the ophthalmologist (OPTH - medical doctors who specialize in all aspects of eye care). 2. Arrange the follow-up appointment with OPTH as ordered for continued eye assessment and care management. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure on, ADVERSE EVENT (an undesirable medical occurrence) REPORTING, for one of three sampled residents (Resident 1) when a medication error resulting in harm was not reported to the California Department of Public Health (CDPH). This failure had the potential for Resident 1 continually experience adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a qualified full-time Director of Activities (the staff responsible for facility's resident activities program), for 45 of 45 residents. This failure had the potential for residents' activities needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, FACILITY PROCEDURE: STORAGE OF FOODS/PHYSICAL ENVIRONMENT, when two of six canned garbanzo beans with dents (Can 1 and Can 2) were not removed from the dry storage room. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) in all 12 of 45 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff disinfected a glucometer (a device that measures the amount of sugar in the blood) with approved wipes for three of three sampled residents (Resident 17, and Resident 40). This failure had the potential to cause infection and spread of bacteria to residents. 2. Implement their policies and procedures titled FACILITY POLICY:ENHANCED BARREIR PRECAUTIONS IN SCU [Specialty Care Unit], and FACILITY POLICY: Infection Control in SCU for four of four sampled residents (Resident 37, Resident 32, Resident 12 and Resident 2) when: 2a. Correct Infection Control Precaution (ICP, actions taken to reduce potential of transmitting infections/germs) signage was not posted for two of four sampled residents (Resident 37, Resident 32, and Resident 12). [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and complete informed consent (a process in which residents are given important information about medical procedures and medications) for psychotropic medications (drugs that affect a person's mental state) for two of four sampled residents (Resident 21 and Resident 13). This failure had the potential for Resident 21 and Resident 13 to not be aware of the risks and benefits of taking psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to review and accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASRR - federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for one of one sampled resident (Resident 13). This failure had the potential for Resident 13 to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 followed the facility policy and procedure (P&P) titled MEDICATION ADMINISTRATION THROUGH A FEEDING TUBE, and professional standards for one of five sampled residents (Resident 4) with a Gastrostomy Tube (GTube-a device to allow feedings and medications to be administered directly to the stomach) when LVN 2 did not flush with water between medications. This failure had the potential for medications to clog or block the GTube resulting in Resident 4 not receiving the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly, as required by regulation, when the QAA committee met only three times from May 2024 to April 2025. This failure had the potential for the QAA committee to not identify and correct facility quality deficits placing all 45 residents at risk for poor care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided nail care. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 to develop an infection and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on restraint management for one of six sampled residents (Resident 1) when Resident 1's restraint was not monitored every two hours and the order for restraint was not renewed every three days. These failures had the potential to result in Resident 1 developing injuries and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor medication room temperatures for 34 out of 34 (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34) sampled residents. This failure had the potential to alter medication effectiveness (the ability of a medication to produce the desired effect).

Inspectors wroteBased on observation, interview, and record review, the facility has failed to implement their policy on hazardous (dangerous and involves risk to someone's health) materials for 25 of 34 sampled residents (Resident 1, Resident 3, Resident 9, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, and Resident 34). This failure had the potential to result in physical harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy on residents food storage for 11 of 34 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11). This failure had the potential for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide home medications for one of 34 sampled residents (Resident 12). This failure resulted in Resident 12 not being dispensed his home medications upon discharge and had the potential for negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure for abuse for one of three sampled residents (Resident 1) when: 1. An allegation of abuse was not reported within twenty-four hours to the California Department of Public Health (CDPH). 2. The investigation for the allegation of abuse was not completed within five days. 3. Two Certified Nursing Assistants (CNA 1 and CNA 2) with an allegation of abuse were not removed from working in the facility immediately and/or monitored while the investigation for the allegation of abuse towards Resident 1 was still being conducted. These failures had the potential for delayed investigation and continued abuse for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure podiatry (the medical field that specializes in the diagnosis, treatment, and study of disorders affecting the foot, ankle, and lower leg) care and treatment for one of three sampled residents (Resident 1). This failure resulted in Resident 1 requiring surgical intervention (a procedure performed on the body to treat a medical condition) and Intravenous (IV - given through the vein) antibiotics (medicines that treat bacterial infections [invasion and growth of germs in the body] by killing bacteria or preventing them from reproducing) for the infection to his left (first and second) foot and right (fourth) foot. 2. Administer IV antibiotics as ordered by the physician for one of three sampled residents (Resident 1) infection to his left (first and second) foot and right (fourth) foot. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify Family Member (FM) 1 regarding a change in condition for one of three sampled residents (Resident 1). This failure resulted in FM 1 not being aware of a change in condition for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow their grievance policy and procedure for one of three sampled residents (Resident 1). This failure resulted in grievances regarding Resident 1's provision of care to not be addressed.

Inspectors wroteBased on interview and record review, the facility failed to implement the Medical Doctor (MD) orders for one of six sampled residents (Resident 1). This failure had the potential for negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to staff appropriately to meet the needs of the residents for 12 of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, and Resident 12). This failure resulted in diminished ability to provide effective care to the residents, had potential to have negative impacts on other residents from lack of staffing and resulted in new skin wounds for two residents (Resident 10 and Resident 12).

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse for one of 13 sampled residents (Resident 13), when the alleged abuser Licensed Vocational Nurse (LVN) 1 was not removed from the working schedule and/or monitored until cleared from the abuse allegation. This failure had the potential to place Resident 13 at risk for further abuse and had the potential to place other residents at risk for abuse and serious harm.

Inspectors wroteBased on interview and record review, the facility failed to complete an investigation for one of 13 sampled residents (Resident 13) allegation of abuse within five (5) working days. This failure had the potential for the abuse allegation to not be thoroughly investigated and could result in further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide enough direct care staff to ensure the daily needs were met for four of four sampled residents (Resident 21, Resident 18, Resident 34, and Resident 31) when: 1. Resident 21, Resident 18, Resident 34, and Resident 31 were not turned every two hours. This failure had the potential for Resident 21, Resident 18, Resident 34, and Resident 31 to develop pressure injuries (damage that can occur as a result of being in the same position for extended periods of time). 2. Resident 21's call light was not answered timely. This failure had the potential for Resident 21 to feel devalued and helpless. 3. Resident 21 face and hands were not cleaned before meals without asking. This failure had the potential for Resident 21 to feel helpless and neglected. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 41 of 41 licensed nurses were competent to: 1. Care and manage the nephrostomy (tube placed directly into the kidney to drain urine) tube for one of one sampled resident (Resident 18). This failure had the potential for the urine to flow backwards into Resident 18's kidney and may have contributed to multiple infections. 2. Administer medications through a gastrostomy (G-tube, tube inserted into stomach for nutrition and medication) tube for two of two sampled residents (Resident 25 and Resident 17). This failure had the potential for medication reactions, blockage of the G-tube, and insufficient water provided to Resident 25 and Resident 17.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective Quality Assurance Performance Improvement Program (QAPI- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes). This failure had the potential to result in facility issues not identified, recognized, addressed, and corrected appropriately.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Conduct infection control surveillance that included collection of data, analysis, tracking and trending, and follow up of outcomes of infections for 46 of 46 residents. 2. Ensure the Infection Preventionist (IP) and Director of Infection Prevention (DIP) performed their duties to complete infection control surveillance for 46 of 46 residents. 3. Store and label oxygen tubing to prevent contamination for one of three sampled residents (Resident 201). 4. Ensure nephrostomy (tube placed directly into the kidney to drain urine) was secured and maintained in a clean environment to prevent infections for one of one sampled resident (Resident 18). 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS - assessment tool) quarterly (every three months) assessments were completed for five of nine sampled residents (Resident 1, Resident 19, Resident 21, Resident 34 and Resident 13). This failure had the potential for the delay in the development and implementation of Resident 1, Resident 19, Resident 21, Resident 34 and Resident 13's individualized care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality were followed when: 1. One of one sampled resident's (Resident 18) nephrostomy tube (tube placed directly into the kidney to drain urine) was not secured and maintained in a clean environment. This failure had the potential for Resident 18's nephrostomy tube to be displaced and urine to flow back into the kidney and the potential for infection. 2. Multiple medications were crushed and administered together through a (G-tube, inserted through the belly, directly into the stomach) for two of four sampled residents (Resident 25 and Resident 17). This failure had the potential to cause a blockage in the G-tube and violated Resident 25 and Resident 17's right to refuse a medication. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Injury or Skin/Wound Conditions- Assessment, Prevention and Management when staff did not turn and reposition one of seven sampled residents (Resident 15) every two hours. This failure had the potential to result in impaired healing or worsening of a pressure injury (PI-localized damage to the skin and/or underlying tissue as a result of prolonged pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide Restorative Nursing Assistant (RNA) program (provided by RNA to help maintain or improve mobility for the residents) for five of 35 sampled residents (Resident 31, Resident 354, Resident 19, Resident 1, and Resident 27). 2. Ensure the Director of Nursing (DON) implemented the RNA program. These failures had the potential for reduced mobility and range of motion (ROM - limit to which a part of the body can be moved around a joint) for Resident 31, Resident 354, Resident 19, Resident 1, and Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and sanitary food handling practices for: 1. One of three sampled freezers (Freezer #6) 2. One of three sampled refrigerators (Refrigerator #5) when food items were not dated after opening. These failures had the potential to result in decreased palatability (tastiness) and foodborne illnesses for residents.

Inspectors wroteBased on observation and interview, the facility failed to create a policy and procedure (P&P) to ensure safe food handling/storage guidelines were being followed for food brought to residents by family/visitors from outside of the facility. This failure had the potential to result in foodborne illness for residents.

Inspectors wroteBased on interview and record review, the facility failed to perform the antibiotic stewardship program (a program that promotes the appropriate use of antibiotics) for three of three sampled residents (Resident 19, Resident 20, and Resident 27) when the surveillance data collection form and infection surveillance log was not completed. This failure had the potential to result in unmonitored and unnecessary use of antibiotics for Resident 19, Resident 20, and Resident 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Tracheostomy [surgical opening in the neck] Tube and inner Cannula [flexible tube] Changing, for one of one sampled resident (Resident 24) did not have a spare tracheostomy tube at the bedside. This failure had the potential to result in a delay in care in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 48) on a psychotropic (used to treat mental health disorders) medication, behavior was monitored consistently. This failure had the potential for staff to not be able to identify when changes occurred in Resident 48's mood/behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 45) was provided with gradual dose reduction (GDR - reduce dose gradually over time) of an anti-depressant medication (medication used to reduce depressed mood). This failure had the potential for Resident 45 to continue taking a medication unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label and date an Intravenous (IV, in the vein) solution (fluid) and tubing (carries fluid from bag to the vein) for one of three sampled residents (Resident 13). This failure had the potential of medication being administered to the wrong resident and the potential for Resident 13 to acquire an infection due to increased time of use. 2. Date the glucose (sugar) Quality Control (QC) testing strips vial (small container) upon opening on one of four sampled medication carts (Cart 3).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 1) with a means to call for assistance when needed. This failure had the potential for Resident 1's needs to not be met, had the potential for feelings of low self-esteem and had the potential for serious harm and other negative consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) titled Procedure: Braden Scale and Prevention of Skin Breakdown and PROCEDURE: TURNING SCHEDULE for one of three sampled residents (Resident 3) when: 1. Resident 3's heel with redness and discoloration was on a flat pillow. 2. There was no documentation of repositioning for more than 4 hours for Resident 3. These failures had the potential for Resident 3 developing pressure injuries and other negative health consequences.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on Team Conferences after a change of condition for seven of eight sampled residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8). This failure resulted in the reason for the change of condition to be unknown, had the potential for the skin conditions to worsen, and had the potential for lapse in continuity of care, and had the potential for harm.

Inspectors wroteBased on interview and record review, the facility failed to accommodate and meet the needs of six of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 6, Resident 7). This failure had the potential for negative outcomes up to and including harm.

Inspectors wroteBased on interview and record review, the facility failed to document resident information and follow up assessments after a change of condition for seven of eight sampled residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8). This failure had the potential for worsening skin conditions to go unnoticed, prolong healing, lack in continuity of care and other negative consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were: 1. Answered timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). 2. Within reach for one of four sampled residents (Resident 1) These failures had the potential for unmet care needs and negatively impact Resident 1, Resident 2, and Resident 3's safety and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent sufficient staffing to meet the needs for two of four sampled residents (Resident 1 and Resident 2). This failure resulted in unmet care needs, and negatively impacted the safety, physical, mental, and psychosocial well-being for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to report two separate allegations of abuse, for one of four sample residents (Resident 1). These failures resulted in delayed investigation of abuse for Resident 1 and had the potential for Resident 1 to be at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for TEAM CONFERENCES for six of six sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5 and Resident 6) when: 1. Resident 5 and Resident 6 had new onset pressure ulcers (wounds caused by prolonged pressure). 2. Resident 1, Resident 2, Resident 3 and Resident 4 had fall incidents. These failures resulted in Care Plans (CP - helps nurses and other care team members organize aspects of patient care according to a timeline) not being updated and had the potential for the cause of the falls and pressure ulcers to not be identified, had the potential for increased risk of pressure injury and falls for all residents and had the potential for lack of appropriate prevention/care to be implemented resulting in negative consequences.