Health inspection·November 5, 2025

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 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.Findings: During a review of Resident 1's PHYSICIAN FACE SHEET (PFS), dated 7/5/25, the PFS indicated Resident 1 is a [AGE] year old male who was admitted to the facility on [DATE] with the following diagnosis:a. Severe sepsis (a serious condition in which the body responds improperly to an infection) with septic shock (a life-threatening condition caused by infection),b. ALS (Amyotrophic lateral sclerosis - a disease that progresses over time causing loss of muscle control),c. Ventilator (a machine that blows air in and out of lungs) dependence, and;d. Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood) During a review of Resident 1's MDS (minimum data set - an assessment tool) Assessment, dated 9/3/25, under section GG (assesses functional abilities and goals), Resident 1 was completely dependent on staff for all activities of daily living (ADL refers to the basic, everyday tasks a person does which includes personal care and hygiene (including oral), eating, dressing, bathing, moving, and using the bathroom. During an observation on 11/5/25 at 11:32 a.m. in Resident 1's room, Resident 1 was in bed unable to verbally respond and minimally able to move eyes up and down when spoken to. Resident 1's lips were dry and had dry flaky skin particles throughout the upper and lower lips. Resident 1's teeth were covered in a white to yellowish sticky debris. Resident 1's tongue was covered with white to yellow debris/film (bacteria and food get caught between the tiny bumps on your tongue's surface if not properly and consistently cleaned) that elevated approximately 1/16 of an inch (a unit of measurement). During a concurrent observation and interview on 11/25/25 at 11:39 a.m. with Director of Staff Development (DSD - a nurse who oversees the training and development of nursing staff in a healthcare facility) in Resident 1's room, Resident 1's mouth and tongue were observed. DSD stated Resident 1's mouth and tongue, Needs to be cleaned. they [staff] should be doing it [oral hygiene] every shift . I think they [staff] do it [oral care for Resident 1], but they need to do it [oral care] better. During an interview on 11/25/25 at 11:53 a.m. with Respiratory Technician (RT 1), RT 1 stated, he had provided Resident 1 oral care earlier in the day (11/25/25) but Resident 1 is difficult to clean (could not specify). RT 1 stated he had not reported difficulties with cleaning Resident 1's mouth with his nurse and/or his supervisor. During a concurrent interview and record review on 11/25/25 at 12:09 p.m. with Quality Assurance Professional (QAP), Resident 1's Dental Care Plan (DCP), dated 8/2/25 was reviewed, the DCP indicated Resident 1 was to have staff assist with oral care to remove food debris. QAP reviewed the CPs and was not able to find documentation indicating Resident 1 had or caused difficulties with provision of oral care. During a review of the facility's policy and procedure (P&P) titled, ORAL CARE UTILIZING SUCTION TOOTHBRUSH, SOFT TOOTHBRUSH AND (PLAC-VAC) ORAL EVACUATOR Residents Affected - Few Page 1 of 2 056426 056426 11/05/2025 Adventist Health Delano 1401 Garces Hwy Delano, CA 93215

F 0677 Level of Harm - Minimal harm or potential for actual harm BRUSH [an instrument for dental cleaning], dated 12/18/24, the P&P indicated, The purpose of the procedure is for all residents to receive appropriate oral care for hygiene and to contribute to the resident's sense of well-being. Brush cheeks, palate and tongue to remove mucous film . Apply petroleum based lubricant, if mouth or lips are cracked and dry. Residents Affected - Few 056426 Page 2 of 2