Health inspection·April 10, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based 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. Findings: During a review of Resident 13's Preadmission Screening Resident Review (PASRR) Level 1 Screening, dated 5/6/24, the PASRR indicated, 10. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder [a mental health condition characterized by persistent sadness and loss of interest], Anxiety Disorder [excessive worry, fear and other physical and behavioral symptoms that interfere with daily life], Panic Disorder [frequent and unexpected panic attacks], Schizophrenia/Schizoaffective Disorder [a chronic and severe brain disorder that disrupts a person's ability to think clearly, manage emotion, make decisions, and relate to others], or symptoms of Psychosis [a state where an individual experiences a loss of touch with reality, often characterized by hallucinations [seeing or hearing things that aren't there] and delusions [false beliefs), Delusions, and/or Mood Disturbance [significant and persistent changes in mood, energy levels, and behavior that can indicate a mood disorder]? Indicated No. The PASRR indicated, 12. The Individual has been prescribed psychotropic [drugs that affect a person's mental state] medications for mental illness. Indicated No. During a concurrent interview and record review on 4/7/25 at 2:40 p.m. with Registered Nurse (RN) 1, Resident 13's Diagnosis List was reviewed. The DL indicated Resident 13 has Bipolar Disorder [a mental health condition characterized by extreme mood swings, including periods of intense emotional highs and lows] disease, chronic upon admission. RN 1 stated diagnoses are listed on the Diagnosis List but not on the PASRR. During a review of Resident 13's Orders dated 9/25/24, the Orders indicated Resident 13 was on Risperidone (medication to treat bipolar disorder) 1 mg at bedtime for Bipolar Disorder. During an interview on 4/7/25 at 2:44 p.m. with Administrative Assistant (AA), AA stated PASRR was completed by the hospital upon admission but once the resident was admitted to the facility, it was the facility's responsibility to review and determine the need to complete an additional PASRR if necessary. During an interview on 4/9/25 at 11:53 a.m. with Risk and Regulatory Analyst (RRA), RRA stated the facility did not have a policy for PASRR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 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. Residents Affected - Few Findings: During an observation on 4/9/25 at 8:22 a.m. in Resident 4's room, LVN 2 administered Docusate Sodium (medication to manage or treat constipation) via GTube to Resident 4. LVN 2 administered the next medication. LVN 2 did not flush the GTube with water after administering Docusate Sodium and prior to administring the next medication. During an interview on 4/9/25 at 8:29 a.m. with LVN 2, LVN 2 stated she did not flush the GTube with water after administering the Docusate Sodium. LVN 2 stated she should have flushed the GTube after administering the Docusate Sodium. During a review of Resident 4's Registration Record, (RR) dated 8/25/23, the RR indicated Resident 4's admission date was 8/25/23. During a review of Resident 4's Order Information for: Tube Feeding, Continuous, and NPO [Nothing by Mouth], (OIFTFCAN) dated 11/22/24, the OIFTFCAN indicated, Feeding Type - My Multi Select Tube Feeding. During a review of the facility's policy and procedure (P&P) titled, MEDICATION ADMINISTRATION THROUGH A FEEDING TUBE, undated, the P&P indicated, PROCEDURE: COMPLIANCE - KEY ELEMENTS . J. Administer medication using a 60 ml [milliliter] syringe into resident's feeding tube slowly. (IF giving multiple medications, flush tube with 5-10 mL water in between meds [sic]). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0680 Ensure the activities program is directed by a qualified professional. 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 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. Residents Affected - Some Findings: During an interview on 4/9/25 at 3:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was taught how to fill out the Activities Evaluation in CERNER (an electronic health record charting system) and in paper chart by a unit clerk last month. CNA 1 stated the Director of Activities had been out on medical leave since February 2025. During an interview on 4/9/25 at 3:59 p.m. with Registered Nurse Manager (RNM) 1, RNM 1 stated the facility's Director of Activities had been out on medical leave since February 2025. RNM 1 stated the facility did not have an interim Director of Activities. RNM 1 stated there were CNAs who were trained to assess and complete the Activities Evaluation and to ensure activities were conducted in the facility. RNM 1 stated the facility did not currently have a Director of Activities. The facility was unable to provide a Job Description for Activities Director upon request. During a review of the facility's policy and procedure (P&P) titled, FACILITY POLICY: ACTIVITIES PROGRAM - GENERAL POLICIES, dated 5/2/24, the P&P indicated, POLICY SUMMARY/INTENT: The purpose of the activities program is to provide the highest quality of life possible for each resident. f. Responsibilities .ii. It is the responsibility of the Director of Nursing of Adventist Health [NAME] [sic] to see that the activities person is hired, trained and provided with necessary equipment to run the program .iv. It is the responsibility of the activities person for the daily activities functions of the program and for developing a quality assurance program for the unit .D. ACTIVITIES PROGRAM SUPERVISON 1. The resident activity program is under the direct supervision of an Activities Coordinator. 2. The Activities Coordinato [sic] is responsible for: a. Planning, Coordinating, and directing a program of activities that provides entertainment, Intercommunication, exercise, relaxation, opportunity to express creative talents, and to fulfill basic psychological, social and emotional needs .c. Working with the residents attending physician and with nursing services, as well as other support services, in planning the residents individualized activities plan .e. Paticipating [sic] in resident assessents [sic], resident care meeting, etc., in planning for the resident's total plan of care. 3. The Activities Coordinator, in conjunction with the Clinical Director, has the responsibility and accountability to implement the esblished [sic] resident activity policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. Findings: During a concurrent observation and interview on 4/7/25 at 7:40 a.m. with Lead [NAME] (LC), in the Dry Food Storage Room, LC inspected the 12 ounce cans of garbanzo beans for dents. LC removed two cans from the six cans of garbanzo beans. Can 1, 12-ounce garbanzo bean can, had a dent at the seam approximately 2 inch long and ½ inch deep; Can 2 had an approximately 2 inch long and ½ deep dent. LC stated the dented garbanzo bean cans should not be in the dry food storage area with other canned foods for resident use. LC stated two out of six garbanzo bean cans had dents. LC stated the dented garbanzo bean cans posed a food safety risk and should be removed. During a concurrent interview and record review on 4/7/25 at 10:25 a.m. with LC, the facility's policy and procedure (P&P) titled, FACILITY PROCEDURE: STORAGE OF FOODS/PHYSICAL ENVIRONMENT, dated 5/1/24 was reviewed. The P&P indicated, Department food equipment and products must be maintained in a manner that ensures an acceptable level of safety and quality. 2. Separate storage area shall be provided for the following items. A. Food (canned) . R. Any dented can shall be placed in the dented can section for return/credit. LC stated the P&P was not followed and should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings: During a concurrent interview and record review on 4/10/25 at 2:03 p.m. with the facility's Registered Nurse Manager (RNM) 2, the minutes of the facility's QAA committee dated 1/20/25, 9/12/24, and 5/23/24 were reviewed. The RNM 2 stated the above minutes reflected the meetings of the facility's QAA committee during the past 12 months. The RNM 2 stated the facility's QAA committee met at least quarterly but was not able to hold quarterly meetings during the past year. During a review of the facility's policy and procedure (P&P) titled [Facility's Name] Quality Assurance and Performance Improvement Plan (QAPI) . 2025, dated 2025, the P&P did not indicate the frequency of QAA committee meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2a. During a concurrent observation and interview on 4/7/25 at 8:10 a.m. with LVN 1, in Resident 37's room doorway, a Contact (type of precautions to take) ICP sign was on the door. LVN 1 stated Resident 37 was on Contact precautions. LVN 1 stated she did not know about the different types of infection control precautions. LVN 1 stated she would need to ask the charge nurse what contact precautions were and why Resident 37 had contact precautions. LVN 1 stated she should know about the different types of ICPs and the reason a resident was on ICP. Residents Affected - Some During a concurrent interview and record review on 4/7/25 at 8:21 a.m. with Registered Nurse (RN) 1, Resident 37's Medical Record Isolation Section (MRIS) was reviewed. The MRIS indicated Resident 37's current ICP was standard (no additional precautions). The MRIS did not indicate Resident 37 currently had contact precautions ordered. RN 1 stated Resident 37's Contact ICP signage was incorrect. RN 1 stated the facility's residents were on Enhanced Barrier Precautions (EBP, set of precautions designed to reduce the transmission of multidrug-resistant organism germs [MDRO]) unless other precautions were ordered. RN 1 stated Contact ICP was different from EBP. RN 1 stated Contact ICP was ordered and implemented when a resident had an existing infection. RN 1 stated Resident 37 did not have an existing infection. RN 1 stated Resident 37 should be on EBP. During an observation on 4/8/25 at 8:10 a.m. EBP signage was posted on Resident 32's door. During a concurrent interview and record review on 4/8/25 at 9:05 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 32's MRIS was reviewed. The MDSC stated Resident 32's MRIS indicated Resident 32' was on contact precautions. During a concurrent observation and interview on 4/8/25 at 9:07 a.m. with MDSC, an EBP sign was posted on Resident 32's door. MDSC stated Contact precautions were ordered for Resident 32 MDSC stated she did not know why EBP signage was posted when the current order was contact. During a concurrent interview and record review on 4/8/25 at 9:14 a.m. with MDSC, Resident 32's Order Sheet (OS), dated 6/10/24 was reviewed. The OS indicated, Isolation. Continuous Order, Contact Precautions, C-Auris [Candida Auris, MDRO] Positive. MDSC stated Resident 32 should have the most current isolation order implemented. MDSC stated Resident 32's current order was for contact precaution. During a concurrent observation and interview on 4/7/25 at 9:30 a.m. with LVN 3, at Resident 12's room, an enhanced barrier precautions (EBP- infection control to protect high risk for infection residents) sign was posted on the door. LVN 3 stated Resident 12 was on EBP's, and she did not know what EBP meant. LVN 3 stated she should know about the different types of ICPs and the reason a resident was on ICP. During a concurrent interview and record review on 4/9/25 at 9 a.m. with Registered Nurse Manager (RNM) 2 the facility's document titled, Sign In Sheet, dated 6/3/24 was reviewed. The Sign In Sheet indicated, Meeting Title: EBP Meeting Begins: 0900 Ends: 09:10 Length: 10 mins Location SCU. Name. [LVN 3 attendance signature]. [LVN 4 attendance signature]. ENM 2 stated LVN 1 signature was not on the attendance training log. During a concurrent interview and record review on 4/9/25 at 1:56 p.m. with Registered Nurse Manager (RNM) 2, the facility's document titled, Contact Isolation LIST SPECIAL CARE UNIT undated was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reviewed. The Contact Isolation LIST indicated four residents were on contact isolation. RNM 2 stated the Contact Isolation List was last updated on 4/7/25. The Contact Isolation LIST indicated Resident 32 was on the list of four residents on the Contact Isolation List. RNM 2 stated Resident 32 was on contact precautions. During a review of the facility's ICP sign titled, Contact Precautions (undated), the ICP sign indicated Everyone must:/Todos deben: [spanish translation] Clean hands when entering and leaving the room .Wear a gown before entering the room .Wear gloves before entering the room .Equipment/upplies: Dedicate the use of non-critical patient care equipment to a single patient when possible (Thermometer, stethoscope, blood pressure cuff) Disinfect reusable equipment with a hospital approved disinfectant wipe after use on a patient. During a review of the facility's ICP sign titled, Enhanced Barrier Precautions (undated), the ICP sign indicated Everyone must: Clean their hands, including before entering and leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering/ Transferring, Changing Linens, Providing Hygiene .Do not wear the same gown and gloves for the care of more than one person. During an interview on 4/10/25 at 11:41 a.m. with IPI, IPI stated he was responsible for updating the precaution levels for residents. IPI stated ICP's were expected to be accurate, current, and implemented as ordered. IPI stated the nurses were expected to be up to date with ICP education and knowledgeable regarding the ICPs. 2b. During an observation on 4/8/25 at 10:07 a.m., in the doorway of Resident 2's room, EBP sign was posted on Resident 2's door. EMTT assisted transfer of Resident 2 from a gurney (bed on wheels) back to Resident 2's bed wearing a gown and gloves. During an observation and interview on 4/8/25 at 10:12 a.m., in the hallway near Resident 2's room, with LVN 4, EMTT exited Resident 2's room with his gown and gloves on. EMTT did not remove his gown, gloves, and clean his hands before exiting Resident 2's room. LVN 4 stated EMTT should have removed the used gown, gloves, and cleansed his hands prior to exiting Resident 2's room. During an interview on 4/8/25 at 10:14 a.m. with EMTT, EMTT stated he should have removed his used gown, gloves, and cleansed his hands prior to exiting Resident 2's room. EMTT stated it was important to follow infection control procedures to prevent the spread of germs. During a review of the facility's ICP sign titled, Enhanced Barrier Precautions (undated), the EBP sign indicated, EVERYONE MUST: Clean their hands, including.when leaving the room. During an interview on 4/10/25 at 11:41 a.m. with IPI, IPI stated all staff including transportation services were expected to follow ICP's and perform hand hygiene before and after provided care. During a review of the Centers for Disease Control and Preventions (CDC, National Health Organization) document titled Standard Precautions for All Patient Care dated 4/3/24. the document indicated Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare provides from infection and prevent the spread of infection from patient to patient. During a review of the facility's P&P titled, FACILITY POLICY:ENHANCED BARREIR PRECAUTIONS IN SCU, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 4/7/25, the P&P indicated, Special Care Unit (SCU) adopts the following California Department of Public Health (CDPH) Enhanced Barrier Precautions (EBP) to prevent transmission of multidrug-resistant organisms (MDRO). C. Implement Enhanced Barrier Precautions (EBP) for high-risk residents: 1. Use of EBP is based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission. 3. Use of Gloves and Gowns. b Hand hygiene, gowns and gloves prevent the transfer of infectious agents from the resident's skin, clothing, bedding and environmental surfaces to the HCP skin and clothing. d. Gowns and gloves should always be removed inside the room when the care activity is complete. Gowns and gloves should not be worn outside of the room when resident care is not being performed. Perform hand hygiene after glove removal. During a review of the facility's P&P titled, FACILITY POLICY: Infection control in SCU [Special Care Unit], dated 5/2/24, the P&P indicated, POLICY SUMMARY/INTENT: To provide a safe environment for residents in Special Care Unit. and to prevent the development and transmission of diseases and infection. C. Care of the Residents. 9. Personal protective equipment will be utilized by staff members during care of residents as needed and to be disposed of immediately at the point of use. D. In-service Education: 2. At least one in-service Education Program will be conducted by the Infection Control Nurse annually. 3. Additional Education programs will be presented by Infection Control Nurse as needed depending upon observed practice of the problems within the department. Based 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). This failure had the potential to spread disease causing organisms (germs) to other residents, staff and ultimately the community. 2b. Emergency Medical Technician Transport (EMTT) did not dispose of his personal protective equipment (PPE- disposable gown, gloves, mask, and eye protection) and clean his hands after providing care for one of four sampled residents (Resident 2). This failure had the potential to spread germs to other residents, staff and ultimately the community. Findings: 1. During a concurrent observation and interview on 4/8/25 at 11:25 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 used a Super Sani-Cloth Germicidal Disposable Wipe (cleaner and disinfectant) to disinfect the glucometer after checking Resident 17's finger stick blood sugar (FSBS). LVN 1 stated she always used the purple top (Super Sani-Cloth Germicidal Disposable Wipe) Sani-Cloth to clean the glucometer after each resident use. During an observation on 4/8/25 at 11:34 a.m. in the hallway, LVN 1 used a Sani-Cloth wipe to disinfect the glucometer after checking Resident 40's FSBS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Delano 1401 Garces Hwy Delano, CA 93215 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 4/8/25 at 11:42 a.m. in the hallway, LVN 1 used a Sani-Cloth wipe to disinfect the glucometer after checking Resident 34's FSBS. During an interview on 4/9/25 at 9:54 a.m. with Infection Preventionist Interim (IPI), IPI stated the facility uses the Sani-Cloth wipes to disinfect glucometers. IPI stated the Sani-Cloth wipes do not contain bleach. IPI stated the Sani-Cloth wipes contain 55% Isopropyl Alcohol. During a review of the glucometer machine's manufacturer guidelines titled MODEL PROCEDURE: POINT OF CARE TESTING NOVA STATSTRIP GLUCOSE METER, (Manufacturer Guidelines), dated 5/9/24, the Manufacturer Guidelines indicated, 2. Clean the meter .b. Clean the meter with hospital approved germicidal bleach products that are EPA [Environmental Protection Agency]-registered to be bactericidal, virucidal . During a review of the Super Sani-Cloth Germicidal Wipes Material Safety Data Sheet (MSDS, provides information about product including chemical make-up), dated 09/07/2023, the MSDS indicated 3. Composition/information on ingredients .Isopropyl alcohol, Quaternary ammonium compounds [antimicrobial, preservative], n-Alkyl Dimethyl Benzyl Ammonium Chloride [cleaning agent]. During a review of the facility's policy and procedure (P&P) titled, INFECTION CONTROL IN SCU, dated 5/2/24, the P&P indicated, POLICY SUMMARY/INTENT: To provide a safe environment for residents in Special Care Unit for a prolonged period of time, if not for the remainder of their lives, and to prevent the development and transmission of disease and infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056426 If continuation sheet Page 10 of 10