Health inspection·January 29, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings: During a review of Resident 1's Order Sheet (OS), dated 10/26/24, the OS indicated, Restraint Monitor. Right hand mitten to prevent pulling medical devices. Monitor every 2 hours and release for 15 minutes and check for circulation and skin integrity. During an observation on 1/29/25 at 1:48 p.m. in Resident 1's room. Resident 1 was wearing mittens on his right hand. During an interview on 1/29/25 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated Resident 1 was wearing mittens on his right hand because he had a behavior of pulling medical devices like GT (Gastrostomy tube – feeding tube that is surgically inserted through the abdomen and into the stomach). LVN 1 stated Resident 1 was being monitored every two hours for his restraints to check for skin and circulation. During a concurrent interview and record review on 1/29/25 at 3:42 p.m. with Risk and Regulatory Analyst (RRA), Resident 1's Flowsheet Print Request (FPR [Restraint flowsheet]), the FPR indicated missing documentation of restraint monitoring on: a. 1/20/25 at 2 a.m., 4 a.m., and 6 a.m. b. 1/20/25 at 10 p.m. c. 1/24/25 at 4 a.m. and 6 a.m. d. 1/27/25 at 12 p.m., 2 p.m., 4 p.m., and 6 p.m. RRA stated there were missing documentation on the FPR. During a concurrent interview and record review on 1/29/25 at 3:42 p.m. with RRA, the facility's P&P titled, Restraint Management (Mechanical, Chemical, Seclusion), dated 1/20/21 was reviewed. The P&P indicated, To outline an organizational approach to restraints that protects the patient's health and safety and preserves their dignity, rights and well-being. Assessment and monitoring will be conducted at minimum, every 2 hours. RRA stated the P&P to monitor was not followed. During an interview on 1/31/25 at 2:09 p.m. with Manager for the Special Care Unit Manager (MSCU), MSCU stated, We document every two hours (monitoring of restraints). Documentation is supposed to be done timely. If the documentation is not done, we're not justifying why the person is on restraints. Page 1 of 4 056426 056426 01/29/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 1/31/25 at 2:17 p.m. with Registered Nurse (RN) 1, Resident 1's Orders, dated 1/31/25 was reviewed. The Orders indicated Resident 1's restraint was ordered by the physician on 10/26/24. RN 1 stated, It (Resident 1's order for restraint) has not been renewed every three days. The facility's P&P titled, Restraint Management (Mechanical, Chemical, Seclusion), dated 1/20/21 was reviewed. The P&P indicated, Orders will be renewed every 3 days if continued restraint(s) are needed. RN 1 stated the P&P was not followed. 056426 Page 2 of 4 056426 01/29/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some Findings: During a review of Resident 1's Minimum Data Set (MDS – an assessment tool), dated 1/29/25, the MDS Section GG (functional abilities and goals) indicated Resident 1 required total assist with maintaining personal hygiene. During a review of Resident 1's Care Plan (CP), dated 10/26/24, the CP indicated, Total dependent in all ADL (Activities of Daily Living - basic personal tasks performed daily) needs due to immobility. Interventions. Provide Assistance to Support Level of Need. During a review of Resident 2's MDS, dated [DATE], the MDS Section GG indicated Resident 2 required total assist with maintaining personal hygiene. During a review of Resident 2's CP, dated 8/6/24, the CP indicated, ADL Function. Interventions. Provide Assistance to Support Level of Need. During a review of Resident 3's MDS, dated [DATE], the MDS Section GG indicated Resident 3 required total assist with maintaining personal hygiene. During a review of Resident 3's CP, dated 11/12/24, the CP indicated, ADL Function. Interventions. Provide Assistance to Support Level of Need. During a review of Resident 4's MDS, dated [DATE], the MDS Section GG indicated Resident 4 required total assist with maintaining personal hygiene. During a review of Resident 4's CP, dated 10/8/23, the CP indicated, ADL Function. Interventions. Provide Assistance to Support Level of Need. During a concurrent observation and interview on 1/29/25 at 1:55 p.m. with Infection Preventionist (IP) in Resident 1's room. Resident 1 had long fingernails with dark gray debris on both hands. IP stated Resident 1 was at risk for developing infection because he also had a behavior of digging or putting his hand in his briefs. IP stated Resident 1's fingernails should have been trimmed. During an interview on 1/29/25 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the LVNs were assigned to trim the residents' fingernails. LVN 1 stated, It (Resident 1's fingernails) should've been done (trimmed). During a concurrent observation and interview on 1/29/25 at 3:04 p.m. with LVN 2 in Resident 2's room, Resident 2 had long fingernails with dark gray debris on both hands. LVN 2 stated Resident 2 needed assistance with trimming his fingernails. LVN 2 stated he should have trimmed Resident 2's fingernails. 056426 Page 3 of 4 056426 01/29/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 1/29/25 at 3:15 p.m. with IP in Resident 3 and Resident 4's room, Resident 3 had long fingernails with dark gray debris on both hands. IP stated Resident 3's fingernails should have been trimmed. Resident 4's both hands were contracted (tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and had long fingernails with dark gray debris touching his palms. IP stated Resident 4 was at risk for skin breakdown because of his long fingernails and contracted hands. IP stated Resident 4's fingernails should have been trimmed. During a concurrent interview and record review on 1/29/25 at 3:42 p.m. with Risk and Regulatory Analyst (RRA), the facility's P&P titled, Facility Procedure: Resident Care Management, dated 12/5/23 was reviewed. The P&P indicated, The resident care management is designed to assure a systematic comprehensive approach by assessing, planning for, and meeting residents' needs. The team will develop and implement a comprehensive, individualized plan of care. RRA stated the P&P was not followed. 056426 Page 4 of 4