Other·January 6, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: 656212 Representing the Department: 37697, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number 656212.

F684 SS=D Quality of Care CFR(s): 483.25

F684 12/16/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to schedule a timely follow-up with a wound care specialist as instructed by the emergency room provider. This failure resulted in wound care treatment delay for one of three sampled residents (Resident 1), and contributed to delayed healing of the right leg below the knee amputation (BKA-below the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE knee surgical removal of the leg) stump site. Findings: During a review of the clinical record for Resident 1, the "Progress Notes" dated 9/24/19, at 4:54 PM, indicated "11:00 [AM] resident [1] was taken outside to smoke by CNA [1] . . . and was left outside by himself smoking. Maintenance came in alert this nurse the [sic] there was a resident on the floor. Resident [1] was sitting on the floor with wheel chair behind and him leaning against wheelchair. Was trying to get cigarette from his shirt pocket, while sliding out of the chair. Resident [1] was assessed for injuries; bilateral BKA avulsion [skin torn from body due to trauma] of surgical incisions . . . Medicated for pain 8/10 [severe] to bilateral BKA. Given [pain narcotic medication] . . . was sent out to [acute care hospital emergency room] for further evaluation and treatment." During a review of the acute hospital record for Resident 1, the "ED [Emergency Department] Note" dated 9/24/19, at 3:52 PM, indicated "The patient [Resident 1] presents following fall. Additional history: [Resident 1] sent from [facility] for sliding out of his wheelchair earlier today while trying to grab cigarette in his shirt. Left BKA stump pain and bleeding since then. . . Physical Examination . . . Bilateral BKA. Left stump with dehiscence and oozing. . . Diagnosis. . . Wound dehiscence." The record indicated Resident 1 was discharged the same day (9/24/19) with recommendations from the emergency room provider to follow-up in oneto-two days with the wound care clinic. During a review of the acute care hospital clinical record for Resident 1, the "Emergency Dept [Department] Documents" dated 9/25/19, indicated "[Resident 1] was sent back over by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE [emergency medical services] for excessive bleeding to the left lower stump. . . left [stump] has blood soaked gauze and removed there was active bleeding from the edge of the stump wound had completely dehisced. . . Due to excessive bleeding I [physician] closed the wound with staples. . . Description. . . Laceration 14 cm [centimeters - a unit of measurement] in length. Left BKA. . . muscle involvement." The record indicated the emergency room provider recommended Resident 1 to follow up with "the wound care clinic this week." During an interview with Director of Nursing (DON), dated on 10/23/19, at 4:05 PM, she reviewed the clinical record for Resident 1 and could not find documentation that Resident 1 followed up with the wound clinic during the timeframe recommended by the emergency room provider. DON stated Resident 1 did not see a wound specialist until 10/9/19 (14 days after his 9/25/19 emergency room visit). During a review of the clinical record for Resident 1 the "INITIAL WOUND EVALUATION [and] MANAGEMENT SUMMARY" dated 10/9/19, indicated Resident 1's right stump wound was, "in an inflammatory stage and is unable to progress to a healing phase because of the presence of biofilm [bacteria adhering to a wound, resistant to antibiotics, and prevents healing]." The record indicated Resident 1 had surgical removal of necrotic [dead] tissue done during the wound evaluation, "with clean surgical technique . . . 42.0 cm . . . of devitalized [dead] tissue and necrotic muscle and surrounding fascial [tissue beneath the skin that separates and surrounds muscle] fibers were removed at a depth of 0.5 cm . . ." The record indicated Resident 1 needed medicated cream for 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the facility policy and procedure titled "Surgery-Related (Pre- and Postoperative) Management - Clinical Protocol" dated 10/2010, indicated "the physician and staff will maintain appropriate communication with the referring surgeon to ensure that the resident receives adequate postoperative care and that the staff and Attending Physician receive relevant medical information . . . The staff and physician will monitor for, and address, postoperative risk and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, failure of surgical wounds to heal . . ."

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/16/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to supervise one of three sampled residents (Resident 1) while he smoked. This failure resulted in Resident 1 falling and sustaining an injury and pain to bilateral below the knee amputation (BKA-surgical removal of the leg below the knee) stump sites. As a result of the fall Resident 1 was transferred to the Emergency Department for treatment of his injuries. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the clinical record for Resident 1, the "NURSING - FALL RISK OBSERVATION/ASSESSMENT" dated 8/29/19, indicated Resident 1 scored a fall risk assessment of 20 (high risk for falls). The smoking care plan dated 9/1/19, indicated Resident 1 had a potential for burn and injury while smoking. The interventions listed included, "[Resident 1] is provided supervision while smoking in designated area." The goal for Resident 1's plan of care was, "Will have no injuries. . ." The "NURSING - SMOKING OBSERVATION/ASSESSMENT" dated 9/7/19, at 7:44 PM, indicated Resident 1 had a BIMS [brief interview for mental status- an assessment tool for cognition] score of 8 [mildly-impaired cognition] and required supervision for smoking as well as assistance with going to designated smoking area. During a review of the clinical record for Resident 1, the "Progress Notes" dated 9/24/19, at 4:54 PM, indicated "11:00 [AM] resident [1] was taken outside to smoke by CNA [Certified Nursing Assistant, 1] . . . and was left outside by himself smoking. Maintenance came in alert this nurse the [sic] there was a resident on the floor. Resident [1] was sitting on the floor with wheel chair behind and him leaning against wheelchair. Was trying to get cigarette from his shirt pocket, while sliding out of the chair. Resident [1] was assessed for injuries; bilateral BKA avulsion [skin torn from body due to trauma] of surgical incisions . . . Medicated for pain 8/10 [severe] to bilateral BKA. Given [pain narcotic medication] . . . was sent out to [acute care hospital emergency room] for further evaluation and treatment." During a review of the acute care hospital clinical record for Resident 1, the "ED [Emergency Department] Note" dated 9/24/19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated "The patient [Resident 1] presents following fall. Additional history: [Resident 1] sent from [facility] for sliding out of his wheelchair earlier today while trying to grab cigarette in his shirt. Left BKA stump pain and bleeding since then. . . Physical Examination . . . Bilateral BKA. Left stump with dehiscence and oozing. . . Diagnosis. . . Wound dehiscence." The record indicated Resident 1's BKA were dressed with a blood-clot inducing material and discharged back to the facility the same day. During a review of the clinical record for Resident 1, the "Progress Notes" dated 9/25/19, at 12:04 AM, indicated Resident 1 continued to have bleeding complications from his 9/24/19 fall. The record indicated "Assigned CNA reports that [Resident 1] dressings to both of his [BKA stumps] are bleeding. Both stumps are checked. Left stump dressing is intact and re-enforced . . . Right stump stapled healed wound noted to be completely open (dehiscence). Dressing removed and wound cleansed. . . Left stump continue to bleed moderately. [Doctor] notified and sent [Resident 1] to [Emergency Department] for evaluation and treatment." During a review of the acute care hospital clinical record for Resident 1, the "Emergency Dept. [Department] Documents" dated 9/25/19, indicated "[Resident 1] was sent back over by [emergency medical services] for excessive bleeding to the left lower stump. . . left [stump] has blood soaked gauze and removed there was active bleeding from the edge of the stump wound had completely dehisced. . . Due to excessive bleeding I [physician] closed the wound with staples. . . Description. . . Laceration 14 cm [centimeters - a unit of measurement] in length. Left BKA. . . muscle involvement." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Licensed Vocational Nurse (LVN) 1, on 10/7/19, at 3 PM, she stated Resident 1 fell on 9/24/19. LVN 1 stated she was informed by maintenance staff that Resident 1 fell outside in the smoking area of the facility. LVN 1 stated she went out to assess Resident 1, and noted there was no staff with him. LVN 1 stated Resident 1's bilateral stumps were bleeding, and he needed to be sent to the hospital. LVN 1 stated she asked the Certified Nursing Assistant (CNA) 1 assigned to Resident 1, why did she leave him outside by himself and she responded that Resident 1 wanted to stay outside to smoke. LVN 1 stated Resident 1 was not to be left alone outside. LVN 1 stated the facility has a policy that staff need to be with residents whenever they are smoking. During an interview with LVN 2, on 10/7/19, at 3:35 PM, he stated on 9/24/19, he assisted LVN 1 in assessing Resident 1 when he was found on the ground by himself in the smoking area. LVN 2 stated Resident 1's BKA sites were bleeding. LVN 2 stated Resident 1 had gone outside with CNA 1 in order to smoke. LVN 2 stated Resident 1 should not be left alone when taken out to smoke. During a review of the facility policy and procedure titled "Smoking Policy - Residents" dated 7/2017, indicated "The facility shall establish and maintain safe resident smoking practices. . . The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include. . . Ability to smoke safely with or without supervision. . . Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPPM11 Facility ID: CA050000325 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555053 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VIEW CARE CENTER 729 Browning Rd Delano, CA 93215 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: YPPM11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA050000325 (X5) COMPLETE DATE If continuation sheet 8 of 8