Delta View Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-5), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from physical abuse when Resident 1 and Resident 2 were left without staff supervision and Resident 2 hit Resident 1 on the back of the head two times. This failure had the potential to result in physical, mental and emotional harm for Resident 1. During a review of Resident 1's admission Record, printed 4/6/26, the Record indicated Resident 1 was admitted to the facility in 2025 with a diagnosis of, Cognitive Communication Deficit. During a review of Resident 2's admission Record, printed 4/28/26, the Record indicated Resident 2 was admitted to the facility in 2024 with a diagnosis of, Other Cerebral Infarct (brain tissue death due to lack of oxygen). During an interview on 4/28/26, at 1:03 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assist one out of six residents (Resident 6) with impaired vision and prescription glasses in obtaining timely optometry care. This failure had the potential to cause Resident 6 frustration, decreased independence in managing daily activities, and increased fall risk. During a review of Resident 6's admission Record, printed 4/29/26, the Record indicated Resident 6 was admitted to the facility in 2020 with a diagnosis of, Dementia in other diseases (cognitive decline and memory loss occurring as a symptom of a primary, underlying condition). During an interview on 4/27/26, at 2:31 p.m., with Resident 6's Responsible Party (RP) 1, RP 1 stated Resident 6 has not had an eye exam and could not see with their glasses. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain an effective infection prevention and control program, including an infection surveillance system (an ongoing, systematic, and active monitoring of infections, as well as the practices used to prevent them) to prevent transmission of communicable disease (an infectious illness that can spread from one person to another), during an Respiratory Syncytial Virus (RSV, a respiratory infection that infects the lungs and breathing passages) infection for two of six sampled residents (Resident 1 and Resident 2) when:1. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a copy of requested medical records to the legal representative for one of four sampled residents, (Resident 1), until 22 working days from the date facility received the written request. During record review of Resident 1's admission Record printed on 9/18/25 the record indicated Resident 1 was admitted to the facility on [DATE] and was discharged to an acute care hospital on 5/1/25. During concurrent interview and record review on 8/7/25 at 12:10 p.m. with the Director of Medical Records (DMR), medical record request for Resident 1 dated 5/22/25 and facility's document titled Records Release log dated May 2020 to August 2025 were reviewed. The medical record request indicated that Resident 1's legal representative requested the following medical records: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to process a record request for Nurse Staff Data for one of four sampled residents, (Resident 1), when Resident 1's representative requested the above information. Nurse staffing data includes facility name, current date, total number of and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses, Licensed Vocational Nurses, Certified Nursing Assistants and resident census. This failure to provide requested Nurse Staff Data resulted in the requested data not being available to Resident 1's representative. During a record review of admission Record printed on 9/18/25, indicated Resident 1 was admitted to the facility on [DATE] and was discharged to an acute care hospital on 5/1/25. [...]

Inspectors wroteBased on interview and record review the facility failed to be in compliance with the state regulation when they did not provide copies of facility's Policies and Procedures, (P&P), regulatorily required to govern the facility to one of four sampled residents, (Resident 1)'s legal representative upon written request. During a record review of admission Record printed on 9/18/25, indicated Resident 1 was admitted to the facility on [DATE] and was discharged to an acute care hospital on 5/1/25. During a concurrent interview and record review on 8/7/25 at 12:10 p.m. with the Director of Medical Records, (DMR), facility's document titled Release of Record log dated May 2025 to August 2025 and Resident 1's legal representative's record request dated 5/28/25 were reviewed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 14, Resident 96 and Resident 5) Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), were accurate when: 1. Resident 14 MDS section A was not coded accurately to reflect Preadmission Screening and Resident Review (PASRR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) PASRR Level II evaluation. Resident 14 MDS section GG was not coded accurately to reflect lower extremities range of motion status. 2. Resident 96, ARD for discharge assessment was coded inaccurately. 3. Resident 5 MDS Section N, was coded inaccurately for antidepressant, antibiotic, anticoagulant and anticonvulsant. These failure had the potential for residents to not receive appropriate care.

Inspectors wroteBased on observation, interview and record review, for one (Resident 3) of two sampled residents, the facility failed to implement its Care Planning - Interdisciplinary Team policy and procedure when there was no care plan developed to address Resident 3's gum pain and discomfort with appropriate interventions. This failure had the potential to result in Resident 3 not receiving appropriate care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care to two of 24 sampled residents (Resident 5 and Resident 10) when the following were noted: 1. Resident 5, with a right hand contracture (muscles, tendons, or tissues get really tight and can't stretch out properly), wore a loosely fitted hand roll which kept coming off and it was difficult for Resident 5 to keep it in the right place. 2. Swelling, black/bluish discoloration and pain in Resident 10's both feet was not addressed for at least two days. These failures resulted in Resident 5 feeling frustrated, getting teary and placed her at risk of discomfort, pain, skin breakdown, and worsening of right hand contracture. Resident 10's untreated swelling, discoloration and pain placed him at risk for further discomfort and potential for compromised blood circulation.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine medication, as ordered by the prescriber, and provide pharmaceutical services which includes procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications to meet each resident's needs when: 1. Lisinopril (medication to treat high blood pressure) was not available for administration for one of five sampled residents (Resident 304). 2. One of two intravenous (IV, into the vein) drug emergency kits (E-kit) was opened and the IV Drug Emergency Kit Use Form had no accurate record of medication used and was not re-ordered timely. These failures resulted in Resident 304 not receiving the medication as prescribed and had the potential for facility residents with a census of 97 to not receive emergency IV medications when needed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a medication error rate below five percent for two of five sampled residents (Resident 75 and 304) when: 1. Resident 75 was administered multi-vitamin with minerals instead of multi-vitamins as prescribed by physician's order. 2. Resident 304's toprol xl (medication to treat high blood pressure) extended release (ER) was crushed and administered. 3. Resident 304's lisinopril (medication to treat high blood pressure) was not administered as ordered. These failures resulted in three medication errors out of 28 opportunities during observation of medication administration which resulted in the facility having a medication error rate of 10.71%. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food waste trash and garbage was disposed of in a sanitary manner when the lid of outside trash container was not closed. This failure had the potential of harborage and feeding of pest.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records that was accurately documented when: 1. One of five sampled residents (Resident 302) lidocaine patch (medicine that prevents pain by blocking the signals at the nerve endings in the skin) 5% was documented as administered in the Electronic Medication Administration Record (E-MAR) prior to administration. 2. Facility staff back dated Resident 47's discharge care planning notes. These failures resulted in Resident 47 and 302's medical record to reflect inaccurate clinical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary environment to prevent transmission of infections for three (Resident 21, 24 and 247) of eleven sampled residents when; 1. Resident 21's urinary drainage bag laid on the floor; 2. Resident 247's urinary bag was touching the floor without privacy cover. 3. Resident 24's tube feeding pole had dried light mater sticking on it; tube feeding pole is a portable, vertical pole used to support and hold the bag of formula or medication during tube feeding. This failure placed the residents at increased risk for healthcare associated infections.

Inspectors wroteBased on interview and record review, the facility failed to provide a written discharge notice within the expected time frame to Resident, Resident Representative, and Ombudsman, for one of six sampled residents, Resident 95.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to meet professional standards of quality for one of one sampled resident (Resident 302) when Resident 302's lidocaine patch (medicine that prevents pain by blocking the signals at the nerve endings in the skin) 5% was not removed according to physician's order. This failure resulted in Resident 302 to receive excessive dose of lidocaine in a 24-hour period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to maintain physical and psychosocial well-being for one of twenty four sampled residents (Resident 44) when Resident 44 was not positioned properly in the dining room prior to eating lunch. This failure had the potential to cause Resident 44 aspiration and emotional distress.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide at least 80 square feet per resident for residents who occupied the following multiple resident bedrooms: Rooms 1, 3, 5, 6, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 29, 31, 32, 33, 34, 35, 37, and 39. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and a lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on interview and record review, the facility failed to report a verbal abuse allegation made by one of four sampled residents (Resident 3) against a Certified Nursing Assistant (CNA 1) to the required agencies, including California Department of Public Health, Long Term Care Ombudsman and Local Law Enforcement agency. This failure resulted in facility not responding to abuse allegation appropriately and placed Resident 3 at risk for experiencing further unreported abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate a verbal abuse allegation by one of four sampled residents (Resident 3) against Certified Nursing Assistant (CNA 1). Facility did not remove CNA 1 from resident care areas and did not complete and/or report the results of investigation to California Department of Public Health (CDPH) within 5 working days of the incident. This failure resulted in facility not responding to abuse allegation appropriately and placed Resident 3 and other residents residing at the facility at risk for experiencing further unreported abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented when the facility did not have oxygen tubing labeled for 2 of 6 residents (Residents 10 and 12) receiving oxygen. The facility did not have tubing or nasal cannula (pronged tubing that sits in nostrils to deliver oxygen) stored in a plastic bag when not in use for one of six residents (Resident 10) receiving oxygen, and the nasal cannula and tubing were on the floor. These failures placed Residents 10 and 12 at risk for healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility had four medication errors out of 28 medication pass observations which resulted in an error rate of 14.29%. Physician Orders were not followed during medication administration for Resident 67 and 63. For Resident 67, this had a potential to cause poor pain control when Lidocaine 5% patches (a patch with local anesthetic applied to skin to help control pain) were cut in half, and another 1/2 patch was applied on the left knee without physician orders. For Resident 63, Cozaar 50 milligram (mg) tablet (a type of medication that helps manage high blood pressure), was not given and could result in poor management of high blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 80) had an accurate discharge assessment. Resident 80 was discharged to the community. This deficient practice had the potential to cause improper planning for Resident 80's care upon discharge from the facility.

Inspectors wroteBased on observation, interview, and record review, for one of 18 sampled residents (Resident 75), the facility failed to develop an individualized nursing care plan to address Resident 75's right and left arm discolorations. This failure had the potential for Resident 75 to have delayed and or inappropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate fingernail care for two of 18 sampled residents (Residents 19 and 26). This failure had the potential to cause Residents 19 and 26 injury, pain and infection. During a concurrent observation and interview on 11/15/22, at 10:42 a.m., with Resident 19, Resident 19's fingernails were observed long with dark gray matter under the fingernails of both hands. Resident 19 stated staff had never cut residents fingernails. Resident 19 stated it made them feel upset. During a concurrent observation and interview on 11/15/22, at 11:01 p.m. with Assistant Director of Nursing (ADON), Resident 19's fingernails were observed. ADON stated Resident 19's fingernails were, long and a little dirty. ADON stated Resident 19's fingernails needed to be cut. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not destroy the controlled substance (CS - drug or other substance that is tightly controlled by the government because it may be abused or cause addiction), to render it unusable after removing them in their individual packaging. This deficient practice could result in a potential case of controlled substance diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by failing to wear hair restraints while inside kitchen. This deficient practice had the potential to spread food borne illnesses.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide at least 80 square feet per resident for residents who occupied the following multiple resident bedrooms: Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, and BB This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and a lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on interview and record review, the facility failed to maintain a safe environment for one (Resident 184) of 80 sampled residents, when two-person staff assist was not provided while repositioning Resident 184 resulting in her falling out of bed. This failure resulted in Resident 184 sustaining bilateral leg fracture (broken bone).

Inspectors wroteBased on interview and record review, the facility failed to ensure two (Resident 43 and 42) of 80 sampled residents received an accurate assessment when: 1. Resident 42's Minimal Data Set (MDS- an assessment tool) did not reflect ambulation and range of motion (ROM) services being provided during the Restorative Nurse Aide (RNA) program. 2. Resident 43's MDS was inaccurately coded for using no bed rails when bed rails were being used every day. This failure resulted in Resident 42 and 43's MDS's to reflect inaccurate clinical status.

Inspectors wroteBased on observation, interview and record review, for one (Resident 70) of 80 sampled residents, the facility failed to address resident's significant weight loss. This failure resulted in Resident 70's fifteen percent weight loss over six months.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, explain risks and benefits and obtain an informed consent prior to using bed rails for six of (Resident 43, 186, 79, 42, 47, and 36) of 80 sampled residents. This failure had the potential for the above listed 6 residents to suffer from avoidable and hazardous accidents such as entrapment, entanglement, skin injuries, and the feeling of isolation, agitation, due to being restrained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe storage of laboratory test supplies when expired laboratory sample collection kits were found stored with currently used laboratory collection kits. This failure had the potential to jeopardize the quality of the collected data and could result in inaccurate result impacting physician's treatment decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure for food storage, when following food items were stored in freezer section of Medication room [ROOM NUMBER]'s Medication Refrigerator: a. One undated and unlabeled brown colored drink frozen hard in a Jack in the Box plastic cup. b. One undated and unlabeled, with no open date, box of Fudgsicles with 11 fudgsicles left in the box. This failure resulted in facility not following its safe food handling practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to safely store and reheat residents' food brought in by family/visitors. This failure resulted in residents to waste the leftovers brought in families and/or visitors and feel left out at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection prevention practices when following were observed: 1. Two sets of personal clothing items were stored in medication room [ROOM NUMBER] at the nursing station; 2. Resident 51's oxygen cannula attached to nebulizer was not changed for 15 days. This failure had the potential to spread infections to the residents whose medications were stored and/or prepared in the medication room [ROOM NUMBER] and Resident 51 to suffer from respiratory infections from using the oxygen cannula that was not changed per facility's policy.

Inspectors wroteBased on observation and interview, the facility failed to provide at least 80 square feet per resident for residents who occupied the following multiple resident bedrooms: Rooms 1, 3, 5.6, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 29, 31, 32, 33, 34, 35, 37 and 39. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (Resident 79, 48, 42) of 80 sampled residents were provided with a clean and sanitary environment, when thick, dark brown, dried matter was sticking all over the commode and toilet bowl in a shared bathroom between room [ROOM NUMBER] and 22. This failure resulted in Resident 79, 48 and 42 to not receive a clean, sanitary and homelike environment.

Inspectors wroteBased on observation, interview and records review, for one (Resident 63) of 80 sampled residents the facility failed to monitor and develop a nursing care plan to address Resident 63's Left Lower Leg edema (swelling). This deficient practice had the potential for Resident 63's condition went unnoticed or delayed for treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide quality of care to two (Resident 184 and 73) of 80 sampled residents, when: 1. the facility failed to reassess pain for Resident 184 after she was given Tylenol for pain due to a fall. 2. For Resident 73, an initial smoking assessment was not completed. This failure resulted in Resident 184 to stay in pain for four hours until she was transferred to Acute Care Hospital (ACH) 1 where she was diagnosed with bilateral lower extremities fractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order to provide routine dental services for two (Residents 19 and 70) of 81 sampled residents, when: 1. Resident 19 did not receive routine follow up dental services for broken and decayed teeth. 2. Resident 70 did not receive routine dental services since admission. These failures had the potential to cause resident avoidable dental issues and weight loss.