Health inspection·January 21, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings: During an observation on 1/22/25 at 3:48 p.m. in the facility medication room (FMR), two boxes with Resident 12's name on it were observed. The boxes had a label that indicated, Albuterol Sulfate (medication used to prevent and treat breathing difficulties) 2.5mg (milligram – a unit of measurement)/3 ml (milliliter – a unit of measurement). Inhale (breathe in) 3 ml (2.5 mg) via nebulizer (a tool used to turn liquid medicine into a mist to breath in) every 6 hours. The boxes had 120 vials (a small container) of Albuterol Sulfate left. The boxes had a date indicated 12/22/24. On the boxes was a note indicating Resident 1 was discharged (no date indicated). During an interview on 1/22/25 at 3:48 p.m. with Facility Manager (FM), FM stated Resident 1 was discharged home a month ago (did not know exact date). FM stated Resident 1's Albuterol should have been sent home with him since his insurance had purchased the medication. During a review of Resident 1's order summary (OS), dated 1/22/25, the OS indicated, Resident 1 was discharged on 12/27/24. During an interview on 1/22/25 at 3:50 p.m. with FM, a request for the facility policy and procedure for discharge medications was made and none was provided. Page 1 of 8 056426 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based 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. Findings: During a concurrent observation and interview on 1/22/25 at 3:24 p.m. with Quality Assurance (QA) in the activities room, the following was observed not secured and accessible by residents: a. Eight oz (ounce – unit of measurement) can of dust/lint remover (a flammable can of chemicals that removes dirt and lint). b. 18 oz bottle of foaming germicidal cleaner (a chemical cleaning product used on surfaces to kill bacteria and viruses). c. Eight cans of 8.23 oz of liquid glycol with wick (a type of fuel that is lit and used to keep foods hot). QA stated these items should not be in resident care areas, because it poses a risk to the residents. QA stated these items should be stored and locked away from resident care areas. QA stated the liquid glycol should not be used in the facility. QA stated liquid glycol should not be used because there were residents in the facility using oxygen and participate in activities in the activities room. QA stated, Oxygen is flammable, it (liquid glycol) can (combined with oxygen) explode and harm and/or kill the resident (s). During a review of the facility document titled Full list of residents with Oxygen Orders (FLROO), undated, the FLROO indicated, residents requiring oxygen frequently in the activities room were 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. During a review of the facility's policy and procedure (P&P) titled, FACILITY PROCEDURE: HAZARDOUS MATERIALS, WASTE MANAGEMENT HANDLING, STORAGE, TRANSPORT & DISPOSAL (HMWM), 3/28/23, the P&P indicated, To ensure that the hazardous wastes generated or hazardous chemicals used within the hospital are properly identified, segregated, contained, stored, transported, treated, and disposed of in a manner that will minimize health risk to patients, staff, visitors, and community. DEFINITIONS . Hazardous Substance/Material - Any substance or mixture of substances that; is toxic; corrosive; an irritant; a strong sensitizer; flammable or combustible; generates pressure through decomposition, heat, or other means. If the substance or mixture of substances may cause substantial harm to the environment, personal injury or substantial illness during or as a proximate result of any customary or reasonably foreseeable handling or use, including reasonably foreseeable ingestion by children. Hazardous 056426 Page 2 of 8 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0689 chemicals will be stored according to manufacturers guidelines . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 056426 Page 3 of 8 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based 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). Findings: During a concurrent interview and record review on 1/22/25 at 3:48 p.m. with Facility Manager (FM), the facility medication room temperature logs (MRTL), dated were reviewed. The MRTL indicated the following days had missing entries: a. January 2025, there were missing signatures for 1/2 and 1/6. b. December 2024, there were missing signatures for 12/20 and 12/30. c. November 2024, there were missing signatures for 11/2, 11/3, and 11/30. d. October 2024, there were missing signatures for 10/3, 10/8, 10/10, 10/11, 10/24 and 10/31. e. September 2024, there was a missing signature for 9/15. f. August 2024, there were missing signatures for 8/6, 8/9, 8/11, 8/12, 8/22, 8/24 and 8/25. h. June 2024, there were missing signatures for 6/13, 6/23, and 6/31. FM stated there should be no missing entries on any of the dates. FM stated the purpose of the MRTL is, To ensure temperature of the room is appropriate so the (resident) medications do not go bad. FM stated all residents in the facility had medication in this medication room, including 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 33, and Resident 34. During a review of the facility's policy and procedure (P&P) titled, MODEL PROCEDURE: AIR EXCHANGE RATE, FILTRATION, AIR PRESSURE RELATIONSHIP, TEMPERATURE, AND HUMIDITY, dated 7/27/22, the P&P indicated, Room temperature is measured in the Patient Vicinity. Wall thermostats and their read-outs are for control of the space ventilation and for a frame of reference, but not used as the space temperature used to demonstrate compliance or non-compliance with adopted code. On a daily basis, results must be documented in the Air Pressure Relationship, Temperature and Humidity - Mitigation form (Appendix C), including any mitigation and corrective actions (ex: work orders) for failures. The 056426 Page 4 of 8 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0761 Level of Harm - Minimal harm or potential for actual harm notification process will be followed by the defined mitigation plan. Daily is defined as when the department is open. May exclude weekends and holidays if closed. If the area is opened for an emergency case/procedure, the area department leader or designee will conduct a manual temperature and document on the Air Pressure Relationship, Temperature and Humidity- Mitigation form. Residents Affected - Many 056426 Page 5 of 8 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some Findings: During a concurrent observation and interview on 1/21/25 at 3:57 p.m. with Facility Manager (FM) in the activities room, a refrigerator had a sign indicated, FOR [facility] RESIDENTS ONLY! THANK YOU! The refrigerator also had another sign that stated, NO OPEN BOTTLES LABEL ALL FOOD ITEMS WITH DATE AND TIME NO PLASTIC BAGS! In the refrigerator the following was observed: a. Approximately 24 inch (a unit of measurement) long piece of chocolate cake with a use by date of 12/20/24. b. Approximately 12 inch lemon pie with a use by date of 12/20/24. c. Liter (unit of measurement) of diet soda that was 1/4th (a unit of measurement) full, with no open date listed. d. 32 oz (ounce - a unit of measurement) bottle of cheese dip that was half full, with no open date. e. 23 oz jar of salsa that was half full, with no open date. f. 16.5 oz bottle of relish that was half full, with no open date. g. 20 oz bottle of ketchup that was half full, with no open date. h. 15.5 oz bottle of green salsa that was almost finished, with no open date. i. 14 oz container of mustard with the seal missing (indicated that it had been used), with no open date. j. Seven lemons that had turned brown in color and dry. k. Two containers approximately 23 oz containing a beige pudding like texture food item with no label, no date, and no identification of what it was or who it is for. l. One container approximately 23 0z containing an orange pudding like texture food item with no label, no date, and no identification of what it was or who it is for. m. 32 oz bottle of jalapenos that was half gone with, no open date. n. One slice of what appears to be cheesecake, with no label, date, or indication of who it was for. 056426 Page 6 of 8 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0813 o. 12 oz bottle of hot wing sauce that was half full, with no open date. Level of Harm - Minimal harm or potential for actual harm p. 64 oz container of vanilla creamer that was half empty, with no open date. q. One 8 0z Styrofoam cup of uncooked rice that was not covered, not labeled, and not dated. Residents Affected - Some r. 1.5 quart (a unit of measurement) of ice cream that was half full, with no open date. FM stated the food items should have been labeled and dated but were not. FM stated, I'm going to throw it [food items] out right now. FM stated the food items did not indicate which resident the food belonged to. During a concurrent observation and interview on 1/22/25 at 3:24 p.m. with FM in the activities room, in the resident refrigerator the following was observed: a. Two liter bottle of orange soda that was half full, with no open date. In the activities room resident cabinets, the following was observed: a. Seven oz container of coffee grounds that was almost finished, with no open date. b. 9.6 oz container of coffee grounds that was 1/4th full, with no open date. c. 9 oz box of thin mint cookies containing two packages of cookies. One of two packages had been finished. There is no open date. d. Plastic bag with approximately half a pound (unit of measurement) of what appeared to be uncooked rice. The bag is not labeled or dated. e. Five approximately two oz tubes of brown colored syrupy type substances that were not labeled or dated. FM stated he did not know what the five brown colored tubes were but they could possibly be honey. FM stated all the food items should have been labeled and dated. FM stated, There should have been no other unlabeled food items or food items without an open date especially after yesterday's (1/21/25) findings. FM stated the food items did not state which resident the food belonged to. During a review of the facility record Oral diet (OD), dated 1/30/25, the OD indicated, Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11 were residents in the facility who ate food orally (by mouth). During a review of the facility's policy and procedure (P&P) titled, Use and Storage of Foods Brought to Residents by Family and Visitors (USFB), undated, the P&P indicated, To ensure safe and sanitary storage, handling and consumption of foods brought into the facility by residents (sic) family and visitors. The facility provides safe and sanitary storage and handling of foods brought in from the outside by family and visitors, and ensures staff assist residents to access and consume these foods. Food brought in from the outside will be checked by a member of the food and nutrition department or a licensed nursing staff to perform the following steps . Food item(s) will be labeled with the resident's name, content, the date it was prepared, if known, and a discard/use by date. Foods 056426 Page 7 of 8 056426 01/21/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some brought in for a potluck event will be inspected by a licensed nurse or food service personnel and either served immediately or labeled/dated and immediately refrigerated in designated spaces. If the food is an item to be served hot, reheat to >165 F (one time only) in the facility designated microwave oven, just prior to service. Non-perishable foods, specifically foods not requiring refrigeration, with the exception of fresh fruits with their peels intact, will be stored in an airtight container or ziplock bag to prevent staleness and pest infestation. The container will be labeled with the resident's name, content and date. The container may be stored in the resident room or in the designated food storage space on each nursing unit. Residents' perishable food will be kept in refrigeration units separate from the main facility kitchen food storage. Those designated areas include the Activity room . Temperature monitoring, disposal of outdated food and cleaning procedures for these areas will follow facility food safety and sanitation practices and the tasks will be completed by the Activities Director or other designee. 056426 Page 8 of 8