Delta Healthcare & Wellness Center, Lp

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) when medical records were not provided to the responsible party (R/P) for one of 18 sampled residents (Resident 1) as requested. This failure resulted in Resident 1's R/P not being provided with Resident 1's medical records. Findings:During a review of Resident 1's Durable Power of Attorney (DPA) dated 8/18/12, the DPA indicated, I, (Resident 1).hereby appoint (Family Member 1) .as my attorney-in-fact ( Agent) to exercise the powers and discretions described below.My Agent's powers shall include, but not be limited to, the power to.have access to my healthcare and medical records and statements regarding billing, insurance and payments.During a review of Resident 1's Resident Request for Access to Protected Health Information (RRAPHI) dated 4/13/25, the RRAPHI indicated, (Resident 1).I would like to access and inspect my Protected Health Information (PHI) .I would like the facility to send a copy of my PHI to (FM1).I would like a summary of my requested PHI.Signature (FM 1).During an interview on 7/28/25 at 10:56 a.m. with Medical Records Supervisor (MRS), MRS stated when there was a medical records request, the request was submitted in writing to her and the request was forwarded to corporate and corporate determines whether or not the medical record can be released. MRS stated Resident 1's medical records were requested on 4/13/25 by FM 1. MRS stated the request was denied due to the facility not having the DPA on file. MRS stated the DPA was provided to the facility and the medical record was still not provided to FM 1. During a

review of the facility's policy and procedure (P&P) titled, Resident Access to PHI (Protected Health Information) dated 11/1/15, the P&P indicated, All requests by a resident or a resident's personal representative for access to PHI must be directed to the HIAA Privacy Officer.Time and manner of Access a. The HIPAA Privacy Officer will allow the resident and/or their personal representative to access to inspect

the resident's medical record at the facility within twenty-four (24) hours of receipt of a written request for access, excluding weekends and holidays. b. If the resident and/or their personal representative requests a copy of the resident's medical record, the HIPPA Privacy Office will provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Delta Healthcare & Wellness Center, LP

514 North Bridge Street Visalia, CA 93291

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 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

Based on interview and record review, the facility failed to provide an itemized statement per the admission agreement to one of 18 sampled (Resident 1) residents when requested. This failure had the potential for Resident 1 to be unaware of services she was being billed for. Findings:During a review of Resident 1's monthly statements dated 5/31/25, 6/20/25, and 7/20/25, the monthly statements did not include an itemized billing.During an interview on 8/6/25 at 10:48 a.m. with Family Member (FM) 1, FM 1 stated he had requested an itemized bill from the facility and it had not been provided. During an interview on 8/6/25 at 1:42 p.m. with Administrator, Administrator stated FM 1 had requested an itemized bill indicating how much Resident 1 was being charged for each service. Administrator stated FM 1 was provided with a generic statement that did not indicate the individual service charge. Facility policy requested and none provided.During a review of the facility's California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities (CSAASNFICF) undated, the CSAASNFICF indicated, The resident shall receive a monthly, itemized statement of all charges incurred by the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Delta Healthcare & Wellness Center, LP

514 North Bridge Street Visalia, CA 93291

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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Based on interview and record review, the facility failed to collaborate care with hospice (specialized form of medical care provided to individuals with terminal illness) for one of 18 sampled residents (Resident 1) when a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was identified to Resident 1's lower back by hospice, and the facility was unaware. This failure had the potential for Resident 1's pressure ulcer to go untreated and worsen.Findings:During a review of Resident 1's Hosp SN Visit (HSV-hospice documentation) dated 5/16/25, the HSV indicated, Integumentary (skin) Status.Wounds 1 lower back pressure ulcer/injury, stage 2-partial thickness skin loss of exposed dermis, observable, most problematic pressure ulcer/injury.cleanse with DWS (dermal wound spray-used to clean wounds) and pat dry. Apply hydrogel (medication used to promote healing) to wound bed and cover with pink Allevyn sacral dressing for extra padding. Change Mondays and Thursdays or PRN soiling/dislodgement.date first identified.5/16/25.During a review of Resident 1's Order Summary Report (OSR) dated 5/1/25-5/31/25, the OSR indicated there were no physician orders for treatment of a stage 2 to

the lower back.During a review of Resident 1's Treatment Administration Record (TAR) dated 5/1/25-5/31/25, the TAR indicated there were no treatments administered to a stage 2 to the lower back.During an interview on 8/21/25 at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when Resident 1 was admitted to hospice on 5/16/25, she was Resident 1's nurse and hospice did not report that Resident 1 had stage 2 to her lower back. LVN 1 stated when the hospice nurse identified the stage 2 pressure ulcer they should have reported it to the facility.During a concurrent interview and record review, on 8/21/25 at 2:58 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed.

DON was unable to provide documentation of stage 2 to Resident 1's lower back being identified or treated by the facility. DON stated hospice did not report a stage 2 pressure ulcer to the nurse and the facility did not receive any treatment orders from the hospice nurse regarding a stage 2 pressure ulcer.During an

interview on 8/27/25 at 3:56 p.m. with DON, DON stated hospice was expected to communicate any skin issues identified to the nurse. DON stated when a stage 2 to the lower back was identified on Resident 1 it should have been reported to the nurse. During a review of the facility's policy and procedure (P&P) titled Hospice Care of Residents dated 1/1/12, the P&P indicated, If the resident and/or surrogate decision maker decides to utilize hospice care.The hospice and facility will collaborate on a care plan for the resident.facility and hospice staff will collaborate on a regular basis concerning the resident's care.Documentation.Hospice notes will be included in the facility progress notes.nursing staff will be informed of any changes recommended by the hospice staff.

Event ID:

Facility ID:

If continuation sheet