Delano District Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Delano District Skilled Nursing Facility, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 5, 2024

  Based on observation, interview, and record review, the facility failed to provide physical assistance and/or use of transfer device during ambulation (walking) to ensure safety for one of three sampled residents (Resident 1), when the Director of Rehabilitation (DOR), who was assisting Resident 1 while walking, did not provide a hand support to Resident 1 due to DOR was holding a cellphone on her left hand and holding a wheelchair on her right hand. This failure resulted in Resident 1 falling, sustaining a right shoulder tendon (connective tissue that connects the muscle to the bone) tear, suffering from severe pain, and going to the general acute care hospital. […]

• Actual harm, isolatedF684Mar 6, 2024

  Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 1) when Resident 1 experienced repeated seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and the Registered Nurse (RN 1) failed to identify the seizure activity, call the physician promptly, send Resident 1 out to a higher level of care promptly and ensure qualified staff monitored the resident when the resident was experiencing seizures. These failures resulted in a delay in receiving prompt medical attention and resulted in an overall decline in Resident 1 ' s physical condition. […]

• Actual harm, isolatedF600Dec 6, 2021

  Based on interview and record review the facility failed to prevent abuse for one of three sampled residents (Resident 1). This failure resulted in Resident 1 crying, and stating she felt embarrassed, humiliated and hurt. Findings: During a review of the facility's Investigation of Abuse Report Form, dated 8/11/21 to 8/12/21, the Investigation of Abuse Report indicated, [Resident 1] stated the following: Yesterday 8/10/21 I was told by my CNA [Certified Nursing Assistant (CNA 1)] go outside and get out of my room. I was so confused; I didn't understand why she was telling me to leave my own room. The Housekeeper [HSK 1] was there when my CNA told me this and I asked her, why does she tell me to leave, I live here? I felt very humiliated and hurt. […]

• No harm, potential for more than minimal, widespreadF628Nov 14, 2025

  Based on interview and record review, the facility failed to:1. Provide discharge notice before discharging one of three sampled residents (Resident 1) to include the reasons for discharge. This failure had the potential for Resident 1 being discharged inappropriately and not prepared for his discharge.2. Send a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman (Ombudsman-an elderly advocacy agency) for 12 of 13 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11 and Resident 12). […]

• No harm, potential for more than minimal, widespreadF812Jan 6, 2022

  Based on observation, interview, and record review, the facility failed to ensure: 1. Pre-made food items were labeled with use-by-date and discarded when expired. 2. Perishable foods were labeled and dated. 3. Food brought in from outside the facility was dated. These failures had the potential to cause foodborne illness (sickness resulting from contaminated food) to the residents residing in the facility. Findings: 1. During a concurrent observation and interview on [DATE], at 9:20 AM, with Dietary Aide (DA), in the walk-in refrigerator, the following was noted: Two small cups of pre-made mixed fruits labeled F on plastic wrap, dated ,d+[DATE]. Four small cups of pre-made mixed fruits labeled F on plastic wrap, dated ,d+[DATE]. […]