Other·February 2, 2017

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 the investigation of an ABBREVIATED EXTENDED Survey for Complaint: CA00501128. Representing the California Department of Public Health: Health Facilities Evaluator Nurses by Federal ID: 28531, 37321, and 35757 The inspection was limited to the specific Complaint investigated and does not represent the finding of a full inspection of the facility. After the actual harm which resulted in Resident 1's death, and due to the the potential for serious harm from the facility's failure to ensure nurses understood and were able to provide Resident 3, one of four current dialysis (a life-saving medical procedure for kidney failure patients that filters their blood through an artificial kidney) residents with necessary care and treatment, an IMMEDIATE JEOPARDY (IJ) situation was called on 11/21/16 at 5:30 p.m., with the Administrator (Admin), the Director of Nurses (DON), a Corporate Consultant (CC), and the Senior Executive Director. The facility provided an acceptable Action Plan addressing the IJ situation on 11/21/16 at 9:15 p.m. The IJ was removed on 11/25/16 at 5:45 p.m., upon successful demonstration that all the elements of the Action Plan that addressed the immediacy had been initiated, and the Admin and the DON were given verbal notification. A second IJ situation was called on 12/6/16 at 5:25 p.m., with the Admin, DON, and Regional 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: ZKDB11 Facility ID: CA040000069 If continuation sheet 1 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 Nurse Manager (RNM) when the facility failed to ensure nurses verbalized understanding and were able to provide care for residents with Diabetes Mellitus (a disease that causes higher than normal blood sugar levels) that safely met their needs for blood sugar monitoring and interventions . The facility provided an acceptable Action Plan addressing the IJ situation on 12/6/16 at 8:15 p.m. The IJ was removed on 12/8/16 at 10:20 a.m., upon successful demonstration that all the elements of the Action Plan that addressed the immediacy had been initiated, with the Admin, the DON and the Medical Records Director.

F157 SS=G NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(b)(11)

F157 01/31/2017 A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 2 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record, administrative document, and the death certificate review, the facility failed to inform 1 of 5 sampled residents (Resident 1's) physician when hemodialysis (treatment for kidney failure - a medical procedure which filters blood through an artificial kidney) orders were not carried out on two consecutive occasions. This failure contributed to the untimely death of Resident 1. Findings: On 9/7/16, at 4:30 p.m., during a telephone interview, the complainant and family member of Resident 1 (Family [FM 1]) stated Resident 1 was admitted to the facility on the evening of 8/24/16. FM 1 stated Resident 1 was an established hemodialysis patient and dialysis service was to be transferred to a more conveniently located sister dialysis facility after placement at the skilled nursing facility (SNF). FM 1 stated Resident 1 was returned to the SNF without having received the dialysis treatment on 8/25/16. FM 1 stated she didn't understand the reason Resident 1 had not received the dialysis procedure, but the reason the staff at the dialysis center gave for sending him back without dialysis was a needed chest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 3 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 x-ray before starting dialysis. FM 1 stated Resident 1 missed his second consecutive dialysis on 8/27/16, because of a transportation "no show. " FM 1 stated Resident 1 had been admitted to the facility for rehabilitation after his leg amputation, and stated his death four days after admission was completely unexpected. The admission face sheet and nurses notes indicated Resident 1 was admitted to the facility on 8/24/16 at 7 p.m. for rehabilitation following a below knee amputation (BKA). Resident 1's diagnoses included: End Stage Renal Disease (kidney failure), Dependence on Renal (kidney) Dialysis, and Insulin (medication for high blood sugar) Dependent Diabetes Mellitus (a metabolic disease characterized by high blood sugar level). Resident 1's Clinical record review indicated Resident 1 was discharged on 8/24/16 from the acute care hospital following a RBKA. A nonacute transfer from the acute care hospital indicated hemodialysis services had been newly arranged at a sister facility (within the same corporation, but a new location than Resident 1 had previously attended) dialysis clinic on a weekly Tuesday (T), Thursday (TH), Saturday (Sat) schedule. Transportation services had been arranged with the same company Resident 1 had used before being admitted to the SNF. According to the record, Resident 1 had not received dialysis on Thursday and/or Saturday as ordered and Resident 1 died early on Sunday morning, which would have been his 4th day at the SNF. The Discharge (D/C) Summary from the acute care hospital indicated Resident 1 was discharged to the SNF on 8/24/16 in stable condition... "FOLLOWUP: The patient will be followed up by the physician at the skilled nursing facility. He needs to continue with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 4 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 outpatient dialysis..." Resident 1's SNF Physician Admission Orders, dated 8/25/16 indicated, "DIALYSIS SCHEDULE: T - TH - S." On 9/14/16 at 11 a.m., during an interview, RN 2 stated she admitted Resident 1 to the facility on 8/24/16 at approximately 7 p.m. RN 2 stated she also cared for Resident 1 when he was returned to the facility, without getting the dialysis procedure on 8/25/16, and when he missed dialysis again on 8/27/16. RN stated she knew Resident 1 missed his second consecutively scheduled dialysis treatment. RN 2 stated she did not notify Resident 1's physician of the missed dialysis treatments and she should have. On 10/31/16 at 9:10 a.m., a telephone interview with Medical Doctor (MD) 1 was conducted. MD 1 stated Resident 1 was a renal patient and was supposed to go to dialysis 3 times a week. MD 1 stated he did not know why Resident 1 had missed two dialysis procedures. MD 1 stated, "No one let me know he missed dialysis. They [the nurses] should have called me." MD 1 stated usually if a patient misses dialysis they need to be sent to the hospital in order to receive the hemodialysis procedure. MD 1 stated, "Nurses at dialysis or the SNF should have let me know he did not get dialysis..." The Certificate of Death (COD) from the County Coroner indicated the immediate cause of death was respiratory failure (breathing cessation) and the underlying cause was documented as pulmonary edema (excess fluid in the lungs) and cardiomyopathy (disease of the heart muscle). The COD indicated the Resident was last seen alive on 8/26/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 5 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 The facility policy and procedure titled, "NSG115 Physician/Mid -level Provider Notification," dated 1/1/14, indicated, "POLICY Upon identification of a patient who has a change in condition...a licensed nurse will perform appropriate clinical observations and data collection and report to physician/mid-level provider, the Medical Director will be contracted...Clinician judgment and patient baseline should always be the primary determinate of the timing of physician/mid-level provider notification...PURPOSE To communicate a change in patient's condition to physician/mid-level provider and initiate interventions as needed/ordered."

F224 SS=G PROHIBIT

F224 MISTREATMENT/NEGLECT/MISAPPROPRIA TN CFR(s): 483.13(c) 01/31/2017 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record and administrative document review, the facility failed to ensure a system was in place to prohibit neglect for one of five residents (Resident 1) when: Registered Nurse (RN) 1 failed to perform the required physical assessment (a systematic evaluation of the resident's physical, emotional and mental health status for the purpose of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 6 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 providing resident focused nursing services) for Resident 1. Due to the failure to perform a physical assessment, RN 1 had not recognized Resident 1's condition had significantly declined, and as a result RN 1 provided no needed intervention. Resident 2's clinical record entry by RN 1 had not been based on care received from RN 1. Resident 1 was diagnosed with end stage kidney failure and required hemodialysis (a process to filter the kidney with an external mechanical device). RN 2 failed to notify Resident 1's physician when the second of two consecutive scheduled dialysis treatments were missed. These failures resulted in Resident 1's untimely death which was evidenced by RN 1's failure to perform an assessment and recognize Resident 1's change of condition; provide physician notification, and the provision of possible life-saving intervention. Findings: The admission face sheet and nurses notes indicated Resident 1 was admitted to the facility on 8/24/16 at 7 p.m. for rehabilitation following a below knee amputation (BKA). Resident 1's diagnoses included End Stage Renal Disease (kidney failure), Dependence on Renal (kidney) Hemodialysis, and Insulin (medication for high blood sugar, also called blood glucose) Dependent Diabetes Mellitus (a metabolic disease characterized by high blood sugar and usually caused by deficiency of the hormone insulin). The Certificate of Death indicated Resident 1 died in the facility on 8/28/16 at 4:30 a.m. The Death Certificate indicated the Immediate cause of death was Respiratory Failure (too little oxygen passes from the lungs to the blood); Pulmonary Edema (buildup of fluid in the air sacs of your lungs and Cardiomyopathy (chronic disease of the heart muscle). End FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 7 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 Stage Renal Disease was indicated as "other significant conditions contributing to death." On 9/7/16, at 4:30 p.m., during a telephone interview, Resident 1's family member (Family Member [FM]1) stated Resident 1 was an established dialysis patient. FM 1 stated Resident 1's dialysis service was to be transferred to a more conveniently located sister dialysis facility after placement at the skilled nursing facility (SNF). FM 1 stated Resident 1 was returned to the SNF without having received the hemodialysis treatment on 8/25/16. FM 1 stated the reason given for sending Resident 1 back to the SNF without first having received dialysis was because the dialysis center needed Resident 1 to have a chest x-ray done prior to receiving dialysis. FM 1 1 stated Resident 1 missed his second consecutive dialysis on 8/27/16, because of a transportation "no show." FM 1 stated Resident 1's death four days after admission was completely unexpected. On 9/14/16 at 8:45 a.m., during an interview, RN 1 stated he was assigned to care for Resident 1 the night of 8/27/16, and stated Resident 1 died on his shift, on 8/28/16 at 4:30 a.m. RN 1 stated he went out of his way to not disturb Resident 1 the night he died. RN 1 stated he had checked Resident 1's vital signs around 1 a.m. RN 1 stated Resident 1 had looked up at him at the time. RN 1 stated he had not performed a physical assessment on Resident 1 as he had not wanted to disturb him. RN 1 stated the information he entered on Resident 1 into the electronic health record on 8/28/16 at 12:33 a.m., did not reflect the care he provided to Resident 1. RN 1 stated he cut and pasted (copied and transferred) the documentation from a previous entry made by another nurse rather than information based on a physical assessment by himself. RN 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 8 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 to enter information regarding an assessment done by a nurse from a previous shift provided false documentation. RN 1 stated he had not spoken to the resident, had not listened to his lung sounds, or ask Resident 1 how he was doing. RN 1 stated RN 2 gave him report at the beginning of his shift. RN 1 stated he had been informed Resident 1 had missed the dialysis procedure but new arrangements had been made for another day. On 9/14/16 at 11 a.m., during an interview, RN 2 stated she admitted Resident 1 to the facility on 8/24/16 at approximately 7 p.m. RN 2 stated she cared for Resident 1 when he returned to the SNF without having received the dialysis procedure, and again when he missed on 8/27/16. RN 2 stated she knew Resident 1 missed his second consecutively scheduled dialysis treatment. RN 2 stated she had not notified Resident 1's physician and she should have. The facility's policy and procedure (P&P) titled, "2.0 Abuse Prohibition," revision dated 8/1/16, indicated, "[The facility's Corporate name] Residential Care Facilities shall prohibit...neglect...for all residents... Neglect is defined as...deprivation of essential needs... PURPOSE To ensure that the Facility is doing all that is within its control to prevent occurrences of ...neglect..." The facility's P&P titled, "NSG205 Assessment: Nursing," revision dated 3/15/16, indicated, "POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed..." The facility's P&P titled, "NSG113 Nursing Documentation," revision dated 10/1/12, indicated, "POLICY...Nursing staff will not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 9 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 falsify...nursing documentation. PURPOSE To communicate patient's status and provide accurate accounting of care and monitoring provided."

F281 SS=K SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.20(k)(3)(i)

F281 01/31/2017 The services provided or arranged by the facility must meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record and administrative document review, the facility failed to ensure residents with diabetes mellitus (a metabolic disease characterized by higher than normal sugar levels in the blood caused by insulin deficiency) were monitored in accordance with professional standards of quality for 3 of 7 sampled residents (Residents 4, 5, and 7) and 12 of 12 randomly sampled residents (Residents 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19). The facility failed to consistently follow physician orders for obtaining morning finger stick blood sugars (FSBS) and accurately document values. The facility failed to evaluate and appropriately implement interventions meant to address physician ordered measures for unsafe FSBS values (less than 60 mg/dl and greater than 350 mg/dl). Registered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 10 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 Nurses (RN) and Licensed Nurses (LN) did not inform the physician of the FSBS values outside of the acceptable range (above 60 mg/dl and below 350 mg/dl) for diabetic residents. These failures placed Residents 4, 5, and 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19 at risk of unsafe fluctuations in blood sugar levels. Blood sugar finger stick levels lower than 60 mg/dl (milligrams per deciliter, a unit of measure that shows the concentration of a substance in a specific amount of fluid) may lead to nausea, shakiness, dizziness, confusion and loss of consciousness and coma and death if not immediately addressed. Blood sugar levels greater than 350 mg/dl may lead to increased thirst, increased frequency of urination, increased hunger coupled with weight loss, confusion, headaches and if not addressed in a timely manner may lead to dehydration and deposits of glucose in the small blood vessels and peripheral nerves (nerves branching out from brain and spinal cord into all other areas of the body). Due to the serious potential harm related to inadequate monitoring and appropriately intervening for low and high blood sugar levels on 15 Residents, an Immediate Jeopardy (IJ) situation was called on 12/6/16 at 5:25 p.m. with the Administrator (ADM), Director of Nurses (DON) and Regional Resource Nurse Manager (RNM). The facility submitted an approved Action Plan addressing the IJ situation and implemented actions addressing the immediacy and the IJ was removed on 12/8/16 at 10:20 a.m. with the ADM and the DON. Findings: On 11/19/16 at 5:15 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 11 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 observation and interview, LN 9 exited Resident 16's room with the glucometer (an instrument for measuring/checking/monitoring blood for sugar levels) in hand. LN 9 stated Resident 16's FSBS value was 140. LN 9 was asked to display the glucometer reading, which read 198. LN 9 stated, "Oops, made a mistake." LN 9 had entered documentation on Resident 16's November 2016 Medication Administration Record (MAR) at 5:15 a.m., in the 6:30 a.m. time space, indicating Resident 16's FSBS value was 140 on 11/19/16. LN 9 went back and wrote over the 140, converting the FSBS value 140 to indicate 198 (the actual value indicated in the glucometer). On 11/19/16 at 5:20 a.m., during an observation and concurrent interview, RN 1 exited Resident 12's room carrying a glucometer. RN 1 stated he would give regular insulin (a quick acting medication, onset within 30 minutes to one hour, used to regulate and lower the amount of sugar in the blood) if needed, at the time he obtained the high FSBS reading. RN 1 stated the morning breakfast meal was served at 7:30 a.m. each day. During this interview, RN 1 did not respond when asked if the time difference between obtaining the FSBS and the serving of breakfast would affect his decision to administer insulin if a resident needed the medication. On 11/19/16 at 5:25 a.m., during a concurrent interview and clinical record review of Resident 12's MAR, RN 1 stated Resident 12's morning FSBS checks were ordered for 6:30 a.m. each morning. When asked the reason RN 1 obtained the scheduled 6:30 a.m. morning FSBS prior to 5:30 a.m., RN 1 stated there were too many FSBS checks ordered at 6:30 a.m. to complete and administer insulin before shift report at 7 a.m. Review of Resident 12's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 12 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 MAR indicated spaces for documenting FSBS entries for 11/6/16 at 9 p.m. and 11/8/16 at 9 p.m. were left blank. RN 1 offered no explanation for the missing documentation of the FSBS values. On 11/19/16 at 8:20 a.m., during a concurrent interview and clinical record review, RN 1 stated it was acceptable to complete FSBS checks and administer insulin as long as it is within an hour before or an hour after the scheduled time printed on the MAR. RN 1 confirmed Resident 5 had physician orders to obtain FSBS at 6:30 a.m. each morning. Review of Resident 5's MAR indicated documentation of FSBS values from 11/10/16 through 11/19/16 at 6:30 a.m. were left blank. When asked about the blank spaces on the MAR for documenting Resident 5's FSBS, RN 1 stated he had documented the 6:30 a.m. FSBS for Resident 5 in the time space below his initial/signature (time space designated for 11:30 a.m. on the MAR). RN 1 stated he documented Resident 5's morning FSBS values and gave no explanation for not documenting in the correct indicated 6:30 a.m. time space (above initial/signature) for Resident 5. On 11/19/16 at 8:25 a.m., during a concurrent interview and clinical record review, RN 1 stated Resident 11's morning blood sugar was 299. RN 1 stated regular insulin was used for residents who were on a sliding scale (progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges) insulin administration. RN 1 stated he would administer regular insulin at the time a high FSBS was obtained. RN 1 stated onset for regular insulin was one hour or less. RN 1 stated morning FSBS for all residents had been completed by 5:30 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 13 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 and administering regular insulin two hours before resident ate breakfast could put the resident at risk for a low blood sugar. RN 1 stated it was acceptable to prophylactically (as a precaution) give orange juice to residents with low FSBS values. RN 1 stated sweating, shakiness and confusion were symptoms of low blood sugars. RN 1 stated blood sugars are re-checked with or without a physician order when it is suspected a resident has a low blood sugar and after giving a resident orange juice. RN 1 confirmed he did not document FSBS recheck values on Resident 11's or any other Resident's MAR or in their clinical record. On 11/19/16 at 8:35 a.m., during an observation inspection of the glucometer used for residents residing in Hall/Station 100 and a concurrent interview, LN 2 stated the time reading of the glucometer used for Residents in Hall/Station 100 did not match the actual time. When asked about this, LN 2 stated the time reading on the glucometer was off by one hour and had not been re-calibrated (adjusted for accuracy) after day light savings time changed. Review of values stored in the memory of the glucometer indicated there were three values recorded on 11/19/16. The last glucometer reading of 89 indicated a time of 6:15 a.m. (actual time of 5:15 a.m.). The value 89 corresponded to the FSBS value documented in the pre-printed time space on Resident 12's MAR (11/19/16 at 6:30 a.m.) and was not corrected to reflect the actual time the FSBS value 89 was obtained (5:15 a.m.). The second glucometer reading of 81 indicated a recorded date and time of 11/19/16 at 5:58 a.m. (actual time 4:58 a.m.) and did not correspond to any FSBS result documented on the MARs for any Resident on Hall/Station 100. The first glucometer reading of 299 indicated a time of 5:55 a.m. (actual time 4:55 a.m.). The value 299 corresponded to the FSBS value FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 14 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 documented in the pre-printed time space on Resident 11's MAR (11/19/16 at 6:30 a.m.) and was not corrected to reflect the actual time the FSBS value 299 was obtained (4:55 a.m.). When asked about the discrepancy between the actual FSBS time and the documented, pre-printed time of 6:30 a.m., LN 2 did not provide an explanation. On 11/19/16 at 8:45 a.m., during an inspection of the glucometer used for residents residing in Hall/Station 300 and a concurrent interview, LN 2 stated the time reading of the glucometer used for Residents in Hall/Station 300 did not match the actual time. When asked about this, LN 2 stated the time reading was off by one hour and had not been re-calibrated after the day light savings time change. Review of the values stored in the memory of the glucometer indicated there were four values for 11/19/16. The last glucometer reading of 136 indicated a date and time of 11/19/16 at 5:58 a.m. (actual time 4:58 a.m.) and did not correspond to any FSBS result documented on the MAR's for any Resident on Hall/Station 300. The third glucometer reading of 90 indicated a time of 5:37 a.m. (actual time 4:37 a.m.) The value 90 corresponded to the FSBS value documented in the pre-printed time space on Resident 9's MAR (11/19/16 at 6:30 a.m.) and was not corrected to reflect the time the FSBS value 90 was actually obtained at 4:37 a.m. The second glucometer reading of 157 indicated a time of 5:31 a.m. rather than the actual time the FSBS was done at 4:31 a.m. The value 157 corresponded to the FSBS value documented in pre-printed time space on Resident 13's MAR for the following day (11/20/16 at 6 a.m.) and was not corrected to reflect the actual date and time the FSBS value 157 was obtained on 11/19/16 at 4:31 a.m. The first glucometer reading of 186 indicated a time of 5:27 a.m. (actual time 4:27 a.m.). The value 186 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 15 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 corresponded to the FSBS value documented on Resident 10's MAR on 11/19/16 at 6:30 a.m. and was not corrected to reflect the actual time the FSBS value of 186 was obtained at 4:27 a.m. On 11/24/16 at 4:58 a.m., during an observation and interview, LN 7 performed an FSBS check on Resident 8 and administered 2 units of regular insulin. LN 7 stated Resident 8's blood sugar was 162. On 11/24/16 at 5:20 a.m., during an interview, when asked about the decision to administer insulin two hours before breakfast was scheduled to be served between 7 a.m. and 7:30 a.m., LN 7 stated it was okay because Resident 8 asks for food and eats in her room. On 11/24/16 at 5:45 a.m., during an interview, LN 3 stated she completed Resident 7's FSBS at 5:00 a.m., administered regular insulin (quick acting) one half hour after the FSBS. LN 3 stated regular insulin is short acting, onset is 30 minutes to one hour and breakfast is served beginning at 7:30 a.m. When asked about the dangers of the practice of administering insulin approximately two hours before breakfast, LN 3 stated, starting FSBS checks at 6:30 a.m. would not allow enough time to administer insulin prior to change of shift at 7 a.m. On 11/24/16 at 5:50 a.m., during a concurrent interview, the DON and LN 3 stated morning FSBS checks were scheduled for 6:30 a.m. Both nurses stated the nurses had an hour before and up to an hour after the printed time on the MAR to administer medication, including insulin. The DON and LN 3 confirmed the facility practice of administering insulin up to two hours prior to breakfast was not appropriate. When asked about the effects of administering insulin approximately two hours FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 16 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 before breakfast, the DON responded, "hypoglycemia" (low blood sugar). When asked about the decision to administer insulin two hours before the serving of breakfast, LN 3 stated there was not enough time before change of shift and would continue to do FSBS checks and administer insulin earlier than the scheduled time of 6:30 a.m. because there was not enough time to get all the FSBS checks done before change of shift. On 11/30/16 at 3:30 p.m., during a clinical record review of Resident 5's MAR and concurrent interview with RN 3 and the DON, Resident 5's 11/16 MAR indicated spaces for documenting FSBS values were left blank from 11/10/16 through 11/19/16 at 6:30 a.m. When asked about the blank spaces for Resident 5's FSBS values, RN 3 stated she had documented Resident 5's 11:30 a.m. FSBS value on the MAR in the time space below her initials/signature (time slot designated for 4:30 p.m.). RN 3 and the DON confirmed 6:30 a.m. FSBS values were documented in the 11:30 a.m. time space designated for 11:30 a.m. The FSBS were documented in the space for the 4:30 p.m. time space and 4:30 p.m. blood sugar FSBS values were documented in the 9:00 p.m. time space. The FSBS values for 9:00 p.m. were not documented. RN 3 who worked the day shift stated on five of nine days she documented Resident 5's FSBS in the MAR on the line below her initials (pointed to the 4:30 p.m. time space) and the correct time spot for 11:30 a.m. FSBS values had documentation from the nurse on the previous shift (night shift). RN 3 stated she did not report this to anyone or take any action and continued to document Resident 5's FSBS values in the 4:30 p.m. time space even though the FSBS values were obtained before the noon meal (11:30 a.m.). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 17 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and Resource Nurse Manager (RNM) discussed the care for Residents 4, 8, 9, 10, 11, 12, 13, 14 and 17. The DON and RNM confirmed Resident 4's MDS indicated a diagnosis of diabetes mellitus and there was no evidence from July 2016 through November 2016 in the clinical record or on the MAR which indicated Resident 4's diabetes mellitus was being monitored. On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and RNM confirmed Resident 8's clinical record indicated a diagnoses of diabetes mellitus and had a physician order for FSBS before meals and at bedtime (6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.) with sliding scale insulin administration. Resident 8's November 2016 MAR indicated, spaces for documenting FSBS values were left blank on 11/2/16 at 4:30 p.m., 11/4/16 at 11:30 a.m. and 11/19/16 at 6:30 a.m. and FSBS values were written over and not legible on 11/1/16 at 11:30 a.m., 11/7/16 at 6:30 a.m. and 11/10/16 at 6:30 a.m. The DON and RNM offered no explanation for the blank spaces and areas of documentation written over FSBS values documented on Resident 8's MAR. On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and RNM confirmed Resident 9's clinical record indicated diagnoses of diabetes mellitus and had a physician order for FSBS before meals and at bedtime (6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.). The DON and RNM confirmed the FSBS checks were not performed and no values documented for the following dates and times: 11/12/16 at 11:30 a.m., 11/17/16 at 11:30 a.m. and 11/19/16 at 6:30 a.m. The DON and RNM offered no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 18 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 explanation for missing FSBS values on Resident 9's MAR. On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and RNM confirmed Resident 10's clinical record indicated a diagnosis of diabetes mellitus. Resident 10's November 2016 MAR had two separate and distinct physician orders for diabetes monitoring. The first order for diabetes monitoring indicated FSBS checks were to be performed before meals (6:30 a.m., 11:30 a.m. and 4:30 p.m.) with a start date of 11/15/16. The second order on the MAR indicated a physician order for insulin, Humalog Insulin Mix 75/25 Suspension (rapid acting - onset within 15 minutes) 15 units routinely to be administered two times a day at mealtime, breakfast and dinner (7 a.m. and 5 p.m.), start date 11/15/16. There was no physician order or documentation on the MAR indicating FSBS checks in conjunction with the order for Humalog Insulin Mix 75/25 Suspension. FSBS checks for Resident 10 were documented on the MAR as performed at 6:30 a.m. and 7 a.m. each day from 11/15/16 to 11/28/16. Resident 10's November 2016 MAR indicated FSBS values documented on the MAR at 6:30 a.m. did not match the FSBS values documented on the MAR at 7 a.m. on the following days: 11/16/16 6:30 a.m. value was 261, 7 a.m. value was 186, 11/17/16 6:30 a.m. value was 183, 7 a.m. value was 357, 11/18/16 6:30 a.m. value was 106, 7 a.m. value was 330, 11/19/16 6:30 a.m. value was 186, 7 a.m. value was 435, 11/20/16 6:30 a.m. value was 110, 7 a.m. value was 220, 11/21/16 6:30 a.m. value was 210, 7 a.m. value was 212, 11/22/16 6:30 a.m. value was 162, 7 a.m. value was 332, 11/23/16 6:30 a.m. value was 133, 7 a.m. value was 310, 11/24/16 6:30 a.m. time space was blank, 7 a.m. value was 315, and 11/26/16 6:30 a.m. value was 181, 7 a.m. value FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 19 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 was 146. Resident 10's November 2016 MARs indicated a hand written notation, "duplicate order" and blank spaces for FSBS values on 11/29/16 and 11/30/16 at 6:30 a.m., 11:30 a.m. and 4:30 p.m. Resident 10's FSBS values from 11/29/16 to 12/6/16 were documented in spaces on the MAR for Humalog Insulin Mix 75/25 Solution administration at 7 a.m. and 5 p.m. There was no physician order or documentation on the December 2016 MAR indicating FSBS checks in conjunction with the order for Humalog Insulin Mix 75/25 Suspension. Resident 10's December 2016 MAR had a hand written notation, "duplicate order" in the space for FSBS documentation. The DON and RNM stated each resident should have only one order for FSBS checks on the MAR and did not know the reason Resident 10 had two separate and distinct orders for FSBS. The DON and RNM stated the expectation was that licensed nurses would have determined the reason for the "duplicate order" and would not have generated two orders for FSBS checks on the MAR. The DON and RNM stated the duplicate order caused Resident 10 to have unnecessary FSBS checks and morning FSBS checks should be performed one time daily at 6:30 a.m. The DON and RNM stated, Licensed Nurses should report to their chain of command when errors in resident records are found. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 11's clinical record indicated a diagnosis of diabetes mellitus. The MAR for Resident 11 indicated the following FSBS parameters to notify the Medical Doctor (MD): if FSBS is less than 70 or greater than 400. The DON and RNM confirmed the FSBS values were less than 70 or greater than 400 for the following dates and times: 11/2/16 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 20 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 4:30 p.m. (526), 11/6/16 at 11:30 a.m. (532), 11/11/16 at 11:30 a.m. (471), 11/17/16 at 11:30 a.m. (418), 11/17/16 at 9 p.m. (56), 11/19/16 at 4:30 p.m. (429), 11/23/16 at 6:30 a.m. (484). The DON and RNM confirmed there was no documented evidence the MD was notified of the less than 70 FSBS value 56 and greater than 400 FSBS values 526, 532, 471, 418, and 429. The DON and RNM confirmed the expectation was the licensed nurse was to call the MD with each FSBS value below 70 or greater than 400 and document the reason for all omissions on the back of the MAR or in the nurse's progress notes. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 12's clinical record indicated a diagnosis of diabetes mellitus and had a physician order for FSBS before meals and at bedtime (6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.). The DON and RNM confirmed the FSBS checks were not performed and no values were documented for the following dates and times: 11/6/16 at 9 p.m. and 11/8/16 at 9 p.m. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 13's clinical record indicated a diagnosis of diabetes mellitus. Resident 13's November 2016 MAR indicated physician orders for FSBS checks one time a day with a start date of 11/15/16 and Humulin N Suspension 100 unit/ml (Insulin NPH (Human) Isophane)) Inject 15 unit one time a day for diabetes with a start date and time 11/15/16 at 11 a.m. Resident 13's MAR indicated documentation of FSBS checks from 11/15/16 to 11/23/16 at 6 a.m. and at 11 a.m. (order was FSBS one time a day). The line on the MAR with the FSBS checks had a hand written time of 6 a.m. scribed over the preFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 21 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 printed 11 a.m. time. The line on the MAR with the insulin administration had a pre-printed time of 11 a.m. Resident 13's FSBS value of 157 (actual time obtained on 11/19/16 at 4:31 a.m.) scheduled for 11/19/16 at 6 a.m. (hand scribed time) was documented in the space on 11/20/16 at 6 a.m. Resident 13's MAR had values written over and not legible on the following days and times: 11/15/16 at 6 a.m., 11/19/16 at 11 a.m., and 11/20/16 at 11 a.m. On 11/21/16 in the FSBS time space for 6 a.m., a FSBS value of 130 was written and crossed out. (138 was written beneath the 130 FSBS value). On the back of Resident 13's MAR under nurse ' s notes was the following documentation: "11/20/16, 6:25, M, BS 130". The DON and RNM offered no explanation for the value obtained on 11/19/16 which was documented on the MAR as obtained on 11/20/16 at 6 a.m. The DON and RNM confirmed Resident 13 FSBS checks were ordered for one time a day and the hand written time change for FSBS caused Resident 13 to have unnecessary FSBS checks. The DON and RNM stated it was the expectation that licensed nurses document changes on the back of the MAR or in the nurse's progress notes. The back of the MAR indicated headings for documentation of the following: date, time, order change, reason, result, and initials. The DON and RNM confirmed licensed nurses are expected to document accurate information in all Resident's clinical records and on MARs. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 14's clinical record indicated a diagnosis of diabetes mellitus and physician orders for insulin administration (sliding scale). Resident 14's November 2016 MAR indicated three FSBS values equal to or greater than 351 on the following dates and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 22 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 times: 11/29/16 at 11:30 a.m. (351), 11/30/16 at 11:30 a.m. (491) and 11/30/16 at 4:30 p.m. (455). The DON and RNM confirmed there was no documented evidence on the MAR or in the nurse's progress notes the MD was notified of Resident 14's FSBS value on 11/30/16 at 4:30 p.m. (455). The DON and RNM stated the expectation was the licensed nurse was to call the MD for FSBS values greater than 351. On 12/7/16 at 3:25 p.m. during a concurrent interview and record review, RN 2 confirmed Resident 19's MAR indicated FSBS value of 400 documented on 11/25/16 at 4:30 p.m. RN 2 confirmed Resident 19's November 2016 MAR indicated physicians order to administer 15 units regular insulin (sliding scale) for FSBS value of between 351 and 400. RN 2 confirmed documentation on MAR of administration of 18 units of regular insulin. RN 2 stated she gave too much insulin for Resident 19's FSBS value of 400. RN 2 stated she did not know she had made the error and did not notify the MD. On 12/7/16 at 3:40 p.m., during a concurrent interview and record review, LN 5 confirmed she cared for Resident 14 on 11/30/16 on 3 p.m. - 11:30 p.m. shift. LN 5 confirmed her initials in the signature space FSBS value (455) documented on Resident 14's MAR on 11/30/16 at 4:30 p.m. LN 5 confirmed MD was not notified and stated she should have called MD about Resident 14's FSBS greater than 351 On 12/6/16 at 4:30 p.m. during a concurrent interview and record review, the DON and RNM confirmed Resident 17's clinical record indicated a diagnosis of diabetes mellitus and physician orders for FSBS every morning, notify MD if blood sugar less than 60 or greater than 350. The DON and RNM confirmed Resident 17's blood sugars FSBS values were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 23 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 greater than 350 for the following dates: 11/21/16 (376), 11/26/16 (392), 11/27/16 (375), 11/28/16 (372), 11/29/16 (368), and 11/30/16 (392). The DON and RNM confirmed there was no documented evidence in Resident 17's clinical record or on the MAR indicating the MD was notified. On 12/8/16 at 2:05 p.m., LN 2 confirmed signature and documentation on Resident 17's MAR of FSBS values on the following dates and times: 11/21/16 (376), 11/26/16 (392), 11/27/16 (375) and 11/28/16 (372). LN 2 confirmed there was no documented evidence the MD was notified. LN 2 stated, "I should have notified the doctor." When asked about the timing of the FSBS checks, LN 2 stated Resident 17's blood sugars values would be higher when FSBS checks are done after eating lunch and that was the way it was ordered by the doctor. LN stated she did not consider clarifying the physician's order. On 12/8/16 at 10 a.m., during a concurrent interview and record review, the DON discussed the care for Residents 15, 16 and 18. The DON confirmed Resident 15's clinical record indicated diagnoses of diabetes mellitus. Resident 15's November 2016 MAR indicated a physician order for FSBS in the morning every Wednesday, notify MD if blood sugar less than 60 and greater than 350. The DON confirmed the spaces for documenting FSBS checks were left blank for the following dates and times: 11/2/16 at 6:30 a.m., 11/9/16 at 6:30 a.m., 11/16/16 at 6:30 a.m., 11/23/16 at 6:30 a.m. and 11/30/16 at 6:30 a.m. The DON offered no explanation for missing FSBS values on Resident 15's MAR. On 12/8/16 at 10 a.m., during a concurrent interview and clinical record review, the DON confirmed Resident 16's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 24 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 a diagnosis of diabetes mellitus. Resident 16's November 2016 indicated physician orders for FSBS, was to notify the MD if blood sugar less than 60 or greater than 350 and administer Insulin Aspart Solution (rapid onset) before meals. The DON confirmed there was no documented evidence in Resident 16's clinical record or on the MAR indicating the MD was notified of the FSBS values greater than 350 for the following dates and times: 11/13/16 at 4:30 p.m. (380), 11/15/16 at 11:30 a.m. (378), 11/19/16 at 4:30 p.m. (385), 11/25/16 at 4:30 p.m. (448), 11/26/16 at 11:30 a.m. (395), 11/26/16 at 4:30 p.m. (490), 11/27/16 at 4:30 p.m. (388). The DON confirmed the spaces for documenting FSBS checks and insulin administration were left blank on 11/9/16 at 4:30 p.m. The DON confirmed there were written over (not legible) FSBS values on 11/7/16 at 4:30 p.m. and 11/12/16 at 6:30 p.m. The DON offered no explanation for the missing FSBS values and insulin administration documentation on Resident 16's MAR. On 12/8/16 at 10 a.m., during a concurrent interview and clinical record review, the DON confirmed Resident 18's clinical record indicated a diagnosis of diabetes mellitus and physician orders for FSBS before meals and at bedtime, notify MD if BS is less than 60 or greater than 350. Resident 18's November 2016 MAR indicated FSBS values were written over and not legible on the following dates and times: 11/8/16 at 4:30 p.m., 11/9/16 at 4:30 p.m., 11/10/16 at 4:30 p.m., 11/17/16 at 4:30 p.m., 11/21/16 at 4:30 p.m., and 11/30/16 at 9 p.m. The DON offered no explanation for the written over FSBS values on Resident 8's MAR. On 12/8/16 at 2:50 p.m., during an interview, Resident 18 confirmed a diagnosis of diabetes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 25 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 mellitus since 1997. Through use of hand motions, nodding head up/down or side to side and writing on dry erase board, Resident 18 indicated the nurses were doing FSBS checks between 4 a.m. and 5 a.m. in the morning and would give insulin at that time if needed. Resident indicated breakfast was served at 8 a.m. On 12/8/16 at 4:05 p.m. during a concurrent interview and clinical record review, LN 1 confirmed Resident 19's clinical record indicated a diagnosis of diabetes mellitus and physician orders for FSBS checks before meals; notify MD if blood sugar is less than 60 or greater than 401. LN 1 confirmed Resident 19's MAR indicated three FSBS values less than 60 on the following dates and times: 11/28/16 at 11:30 a.m. (48), 11/29/16 at 6:30 a.m. (58) and 11/29/16 at 4:30 p.m. (47). LN 1 confirmed there was no documented evidence in Resident 19's clinical record or on the MAR indicating the MD was notified of the less than 60 FSBS values obtained on 11/28/16 at 11:30 a.m. (48) and 11/29/16 at 6:30 a.m. (58). LN 1 stated she did not notify the physician, the physician should have been notified of the FSBS value of 58. The facility policy and procedure titled, "Diabetic Care Protocol" revision date 1/2/14, indicated, "Perform fingerstick blood glucose monitoring as ordered, Administer insulin/oral hypoglycemic (low blood sugar) medications as ordered ... Treat hypoglycemic episode according to Hypoglycemic Protocol ... Report blood glucose results to physician/mid-level provider according to ordered parameters." The facility protocol titled, "Hypoglycemia Protocol" revision date 1/2/14, indicated documentation of the following: "Assessment of the patient's condition, Fingerstick glucose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 26 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 levels, Interventions and patient's response, Physician notification and response, Follow-up, if indicated, Include patient on 24-Hour Summary Report." The facility did not provide a policy and procedure directed at guiding staff on the interval of time for safe administration of insulin and other medications. Review of professional reference, "Hold the Insulin! " <http://www.nursingcenter.com//upload/static/ 849327/Hold.htm> page 30, indicated, " Prandial (during or relating to mealtime) and preprandial (before mealtime) insulin is given to prevent postprandial (after mealtime) hyperglycemia. Because rapid-acting prandial or bolus (a single dose of a medication given all at once) insulin mimics the normal pancreatic (a glandin the body, part of the digestive system that produces insulin)response to eating, it's given with each meal. Regular insulin is considered a preprandial insulin because it takes about 30 minutes to start working. Prandial insulins such as Humalog (insulin lispro) (a fast acting insulin that starts to work in 15 minutes), NovoLog (insulin aspart) (a fast acting insulin that starts to work in 5 to 10 minutes), and Apidra (insulin glulisine) (a fast acting insulin that starts to work in 15 minutes) start working in 5 to 10 minutes. Administering these insulins at the right time is critical to minimize the patient's risk of hypoglycemia. For example, a patient might take 5 units of NovoLog with breakfast, 8 units with lunch, and 10 units with dinner. If the breakfast dose is scheduled for and administered at 0800 [8 a.m.] but breakfast doesn't arrive until 0900 [9 a.m.], the patient is at risk for hypoglycemia." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 27 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 SS=K PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/31/2017 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record and administrative document review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for two of five residents (Residents 1 and Resident 3) diagnosed with End Stage Renal Disease (the kidneys no longer are working and do not filter the blood) and required hemodialysis (a lifesaving procedure where the blood is filtered through an external artificial kidney machine) when: 1. Resident 1 had a sudden change in status and subsequently expired in the facility after missing two consecutive hemodialysis procedures. Resident 1's Registered Nurses (RNs) and Licensed Vocational Nurses (LNs) failed to provide necessary services which included performing physical assessments, appropriate nurse to physician and nurse to nurse notification regarding the missed dialysis procedures; of resident care status, and failed to administer critical physician ordered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 28 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 medication in a timely manner. Resident 1's Clinical Record indicated Resident 1 was admitted for rehabilitation following a below the knee amputation on 8/24/16, and missed two consecutive dialysis treatments. Resident 1 then died on 8/28/16. RN 2 did not inform the physician when Resident 1 missed two hemodialysis procedures in a row prior to Resident 1's death. RN 1 did not perform a physical assessment on Resident 1 the night he died. 2a. Resident 3's Central Venous Catheter (a tube inserted through the skin and into a large vein) which served as the hemodialysis access site was inaccurately assessed as having a bruit (a swooshing sound heard with a stethoscope) and thrill (a vibration when felt) which are present with hemodialysis access fistula or graft (surgically placed connection between an artery and vein for hemodialysis access). 2b. Resident 3's medication Kayexalate (used to treat life-threatening high potassium level physician order was transcribed from a physician's telephone order inaccurately and not administered timely. The physician was not notified when administration of the Kayexalate was delayed. Licensed Nurses were unable to verbalize the indication for Kayexalate's use and had not communicated pertinent resident care status from one nurse to another or from one shift to another shift. 2c. On 11/22/16 Resident 3 was returned to the facility after being at the hospital for less than 24 hours and the first three sets of vital signs (blood pressure and pulse) were below the parameters set by the physician, and the physician was not notified. Due to the potential and actual harm of not providing the necessary care and treatment for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 29 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 dialysis residents, an Immediate Jeopardy (IJ) situation was called on 11/21/16 at 5:30 p.m. with the Administrator, the DON, the Nurse Consultant and the Senior Executive Director. The facility provided an acceptable Action Plan addressing the IJ situation on 11/21/16 at 9:15 p.m., and implemented all elements of the Action Plan that addressed the immediacy. The IJ was removed on 11/25/16 at 5:45 p.m. in the presence of the Administrator and the DON. Findings: 1. On 9/7/16, at 4:30 p.m., a telephone interview with Resident 1's family member (FM), FM 1, was conducted. FM 1 stated Resident 1 was an established dialysis patient and hemodialysis service was to be transferred to a more conveniently located sister dialysis facility after placement at the skilled nursing facility (SNF). FM 1 stated Resident 1 was returned to the SNF without having had the dialysis procedure on 8/25/16; and a transportation "no show" caused Resident 1 to also miss a second consecutive (two in a row) dialysis treatment on 8/27/16. FM 1 stated the family member, Resident 1, had been admitted to the facility for rehab [rehabilitation] following his foot amputation, and had not been admitted to hospice (end of life care) services, on 8/24/16, but died unexpectedly, early in the morning on 8/28/16, less than four days later. Resident 1's clinical record review indicated Resident 1 was discharged on 8/24/16, from the Acute Care Hospital following his right below knee amputation (RBKA). The medical record from the hospital indicated dialysis services had been newly arranged at another (within the same corporation, but a location other than Resident 1 had previously attended) dialysis clinic for three times per week on a Tuesday (T), Thursday (TH), and Saturday (Sat) schedule. Transportation services had also been arranged with the same company FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 30 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 Resident 1 had used before admittance to the SNF. Resident 1's clinical record indicated he was admitted to the SNF on 8/24/16, at 7 p.m., with diagnoses which included, End Stage Renal Disease (kidney failure), Dependence on Renal Dialysis, Type II Diabetes Mellitus (a metabolic disorder resulting from the body's inability to make enough, or to properly use insulin resulting in high sugar in the blood), Generalized Edema (swelling from an abnormal accumulation of fluid), Acquired Absence of the Right (Rt) Leg Below the Knee from gangrene (localized death and decomposition of body tissue from either obstructed circulation or bacterial infection), and Phantom Limb Syndrome with Pain (perceived pain, often severe, from the amputated limb). According to the record, Resident 1 had not received dialysis on Thursday 8/25/16 or Saturday 8/27/16 as ordered. Resident 1 died on Sunday morning, 8/28/16 at 4:30 a.m., which was his 4th day at the SNF. The Discharge (D/C) Summary from the acute care hospital indicated, Resident 1 was admitted on 7/25/16 and discharged thirty-one days later, on 8/24/16 to the SNF. The D/C summary indicated, "Discharged to a skilled nursing facility...on 8/24/16 in stable condition...He needs to continue with outpatient dialysis..." Resident 1's SNF Physician Admission Orders, dated 8/25/16 indicated, "DIALYSIS SCHEDULE: T - TH - S" (the corresponding dates were 8/25/16 and 8/27/16.) The order also indicated the name, address and contact information of the newly arranged dialysis center, and the transportation company and phone number. On 9/8/16 at 12:30 p.m., an interview with Licensed Vocational Nurse (LN) 1 and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 31 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 concurrent review of Resident 1's clinical record was conducted. In response to Resident 1's clinical status on 8/26/16, LN 1 stated, "I didn't realize the patient was going bad..." On 9/14/16 at 10:45 a.m., an interview and concurrent clinical record review (including the note above) was conducted with RN 2. Nurses Note penned by Registered Nurse (RN) 2, dated 8/27/16 at 6:33 p.m., indicated the resident was sitting up in a wheelchair waiting for the transportation company to pick him up and take him to the dialysis center. RN 2 documented she phoned the transportation company at 6 p.m. to find out why no one had come for Resident 1. RN 2's documentation indicated awareness of this being the second consecutive missed dialysis treatment. RN 2 further documented the transport staff stated all drivers had gone home and no one was available. RN 2 documented she was unable to make contact with the dialysis center by phone. There was no documentation indicating the physician had been notified. RN 2 stated she was the assigned nurse to care for Resident 1 on the 3 p.m. to 11 p.m. shift, Wed. 8/24; Thurs. 8/25; and Sat 8/26. RN 2 stated, "On Saturday, [8/26/16] Resident 1 asked what's the plan? When is transport coming to take me to dialysis? RN 2 stated, the transport driver didn't show up.RN 2 stated she called the transport company. "All the drivers had gone home. Dialysis didn't answer the phone... I didn't contact the physician. I should have..." On 9/14/16 at 8:45 a.m., during an interview, RN 1 stated he was assigned to care for Resident 1 during the night of 8/27/16, and Resident 1 died on his shift, on 8/28/16, at 4:30 a.m. When asked about Resident 1's condition, RN 1 stated the only interaction during his shift, was when Resident 1 looked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 32 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 up at him while the resident's vital signs (blood pressure, pulse and respirations) were checked at approximately 12:45 to 1 a.m. RN 1 stated he had not performed a physical assessment, except for the vital signs he obtained. RN 1 stated the documented nurses notes he entered into the computer on 8/28/16 at 12:33 a.m., were cut and pasted (copied and transferred) from a previous entry made by another nurse. When asked about the accuracy of cut and pasting narrative nurses note entries, RN 1 agreed the cut and paste he had done in the electronic record represented false documentation. RN 1 made the following statement about the night before Resident 1 died, "I never spoke to the resident. I did not listen to lung sounds, I did not ask him how he was doing." In response to the request to explain his decision not to perform an assessment on Resident 1, RN 1 stated RN 2 gave him report at the beginning of his shift. RN 1 stated he heard in report Resident 1 had missed dialysis and RN 2 had made arrangements for a new dialysis appointment date on Monday (8/29/16). On 9/14/16 at 11:22 a.m., an interview and concurrent record review were conducted in the Admin office. The Admin reviewed the nurses notes dated 8/26/16 at 2:15 a.m., 8/27/16 at 12:28 a.m. and 2:47 p.m., and 8/28/16 at 12:33 a.m., and admitted the notes were nearly identical and stated they looked "cookie cutter (nearly identical)." The Admin stated it was unacceptable to copy and paste another nurse's note and all nurses should be performing and charting their own assessments. The Admin admitted she was aware that nurses' notes could be copied and pasted. Internet website titled, "http://allnurses.com/dialysis-renalurology/bruit-and -thrills-20465-page2.html" indicated, "...Patients that have a tunneled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 33 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 dialysis catheter will NOT have a bruit or thrill unless they also have a fistula or graft. Catheters alone don't have bruits/thrills. This is the feeling and sounds that is created with a fistula and/or graft from the connection of an artery to a vein." 2a. On 11/17/16 at 5 p.m., during an interview and concurrent clinical record review, the Clinical Nurse Manager (CNM) reviewed the Hemodialysis Communication Record (HCR) (form used for written communication between the SNF facility and the dialysis facility) documentation. The clinical record indicated Resident 3 was scheduled for dialysis every Tuesday, Thursday, and Saturday. There were 13 HCRs dated 10/22/16 through 11/15/16. The SNF documentation Pre-dialysis form (correctly) did not document a bruit or a thrill on 13 of 13 HCRs. The SNF documentation Post dialysis form (incorrectly) documented the presence of a bruit and thrill on 7 of the 13 HCRs. These forms were dated 10/22, 10/25, 10/27, 10/29, 11/1, 11/5, and 11/12/16. The CNM stated she was not aware and could not explain why nurses had not documented bruit and thrill consistently on the form. The CNM stated the Medication Administration Record (MARs) contained consistent documentation of bruit and thrill each shift (three times each day). The Monthly MARs for 9/16, 10/16, and 11/16 indicated nurses had documented for each shift (three times each day) they had observed and monitored a bruit and thrill for Resident 3. The hospital record did not indicate a bruit and thrill was documented when Resident 3 was in the hospital 10/13/16 through 10/17/16, and the documentation stopped on 11/17/16. On 11/19/16 at 8:45 a.m., during an interview and concurrent observation assessment of Resident 3's dialysis catheter, LN 6 described the sound and feel of a bruit and thrill as she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 34 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 had documented on Resident 3's record as being assessed on Resident 3's right groin dialysis catheter. At the bedside, LN 6 was asked to assess Resident 3's right groin dialysis catheter and was asked if it was the type of line that would have a bruit and thrill. LN 6 stated it was not, and stated she did not know what she was hearing and feeling. On 11/19/16 at 8:50 a.m., during an interview, the CNM stated Resident 3 had a dialysis catheter (dialysis access that does not have a bruit or thrill), not an Arterial Venous (AV) shunt (type of dialysis access that does have a bruit and thrill). The CNM stated nurses were consistently documenting an assessment that included the presence of a bruit and thrill that was not going to be there. On 11/21/16 at 4:58 p.m., LN 9 stated Resident 3's right groin dialysis catheter did not have a bruit or a thrill. LN 9 stated he had checked, and he had listened for both the bruit and the thrill. LN 9 stated, "On 11/6/16, he thought he had determined a bruit and thrill were present, and documented accordingly." Hospital records indicated Resident 3's right groin dialysis catheter was placed 6/9/16, and replaced on 9/7/16, 10/21/16, and 11/29/16. The right groin remained the dialysis catheter site after each of the replacement procedures. The hospital's "Final Report" dated 6/9/16, indicated placement of a dialysis catheter in the right groin. Final Report dated 9/7/16, indicated the right groin dialysis catheter had inadequate blood flow and was replaced with a new catheter. Final Report dated 10/21/16, indicated the right groin catheter was accidentally withdrawn at least 10 centimeters (a metric measurement) and replaced with a new dialysis catheter. Final Report dated 11/29/16, indicated infection was resolved and another dialysis catheter was placed at the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 35 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 same site in the right groin. The facility policy and procedure (P&P) titled, "NSG205 Assessment: Nursing," dated 6/1/96, indicated, "POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed...PURPOSE To determine patient's condition and clinical needs... 4. Notify physician/mid-level provider of assessment results as indicated. 5. Document physician/mid-level provider notification and response if indicated." The facility P&P titled, "NSG113 Nursing Documentation, "dated 8/1/05, indicated, "POLICY Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate...Nursing staff will not falsify or improperly correct nursing documentation. PURPOSE To communicate patient's status and provide accurate accounting of care and monitoring provided. PRACTICE STANDARDS 1. Nurses will not: 1.1 Document services that were not performed..." 2b. Resident 3's Physician telephone order dated 11/18/16 at 3:52 p.m., indicated Kayexalate 15 grams (gm) (a metric measurement) to be given by mouth, one time, one day, for high Potassium level. On 11/21/16 at 11:30 a.m., during a telephone interview, Resident 3's physician (P) 1 stated he ordered the Kayexalate to be given once each day until Resident 3 could have the dialysis procedure performed. On 11/21/16 at 11:30 a.m., LN 1 stated she phoned Resident 3's physician, (P) 1 and made FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 36 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 him aware Resident 3 was not going to be able to get dialysis until her dialysis catheter could be replaced. LN 1 stated she informed P 1 that Resident 3's Potassium level was elevated at 5.7 (normal range is 3.5 - 5.2). LN 1 stated P 1 ordered Kayexalate 15 grams to be given one time. On 11/21/16 at 3:30 p.m., LN 1 stated when she documented P 1's phone order, the medication order entry had not matched the nurses note. LN 1 stated she re-entered the nurses note to match the way the medication order was written. LN 1 stated she should have phoned the physician and clarified whether he intended the Kayexalate order to be one time or ONE time each day. Review of Resident 3's clinical record indicated Resident 3's Physician telephone order for Kayexalate was dated 11/18/16 at 3:52 p.m. The Pharmacy order form documented the Kayexalate was taken from the Emergency Kit (E-Kit ) (back up pharmacy storage), on 11/18/16 at 9 p.m. E-kits contained medications stored in the facility and were available to be given immediately. The nurse's note dated 11/18/16 at 11:37 p.m., indicated Resident 3 had refused to take the medication and wanted to take it in the morning. On 11/19/16 at 8:45 a.m., during an interview with Resident 3, with LN 6 present, Resident 3 stated she had been told there was a new medication, but it was arriving late, and it would be started in the morning. Resident 3 stated she was not told what it was for. Resident 3 stated she had not refused to take any medication. On 11/19/16 (Saturday morning) at 6 a.m., during observation, interview, and Resident 3's clinical record review, LN 9 stated, "Missing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 37 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 dialysis even one time is crucial and I would phone the physician." LN 9 stated he should have been told in report Resident 3 would not be going to dialysis that morning. LN 9 stated he found out by reading nurses notes in the computer and at 4 a.m. he had canceled transport. LN 9 stated today was the first day he knew Resident 3 was going to miss dialysis. LN 9 stated he saw a new order for Kayexalate. LN 9 validated the Kayexalate was on the medication cart and stated LN 10 reported Resident 3 had refused the medication. LN 9 validated this on the MAR which indicated on 11/18/16 at 9 p.m., Resident 3 had refused the Kayexalate three times, and it had been rescheduled to be given at 9 a.m. When LN 9 was asked what the indication for use of Kayexalate was, LN 9 stated, "I have no idea." LN 9 stated he did not know Resident 3 had missed dialysis on 11/17, and 11/19/16 would be the second, not the first, missed dialysis treatment. On 11/19/16 at 7:27 a.m., LN 6 stated Resident 3 had a new order for Kayexalate, it came from the e-kit and pointed to the medication on the medicine cart. On 11/19/16 at 7:45 a.m., LN 6 stated the dialysis nurse had phoned previously and stated Resident 3's dialysis catheter was not working and she was unable to be dialyzed on Thursday. LN 6 stated Resident 3 would be missing her second consecutive dialysis treatment today (Saturday, 11/19/16). LN 6 stated the hospital was supposed to be making arrangements to get Resident 3's catheter replaced. LN 6 stated they were waiting for an appointment and it would not be until Monday. On 11/30/16 at 6 p.m., during a telephone interview, LN 10 stated she did not notify the physician when the Kayexalate was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 38 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 administered as ordered and administration was delayed until the next day. The facility's P&P titled, "6.2 Medication Administration Times," dated 8/01/02, indicated, "POLICY...To provide uniform and efficient practices in safe medication administration... Physician/Prescriber direction and/or the Center's Pharmacy Committee may determine if specific drugs should be administered at designated times... If medication administration times are changed for any medication, consult with physician regarding clinically appropriate timing. 2.1 Document physician consultation in the medical record. 3. Medication administration pass may commence 60 minutes before the designated times of administration but may not exceed 60 minutes after the designated times of administration." 2c. Clinical record review indicated Resident 3's Nurses Note dated 11/22/16 at 8:30 p.m., penned by LN 9 indicated, "Patient came back via ambulance...[from a hospital stay] VSS (vital signs stable) ..." Resident 3's Nurses Note dated 11/23/16 at 1:45 a.m., penned by LN 7 indicated, [VS]... [B/P] 91/54." Resident 3's Nurses Note dated 11/23/16 at 5:49 a.m., penned by LN 7 indicated, [VS]... [B/P] 94/62." On 11/23/16 at 4 p.m., an interview with the Director of Nurses (DON) and the Administrator (Admin) and concurrent clinical record review of Resident 3's vital signs (listed above) and physician orders was conducted. The DON stated Resident 3 had just returned from the hospital and was on alert charting which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 39 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 nurses should have heightened awareness of Resident's condition for 72 hours. Resident 3's Physician order dated 11/21/16 indicated, "Check B/P and Pulse..." and to notify the physician if the top number of the B/P was less than 100 or the P was less than 60. The DON stated based on Resident 3's vital signs and the parameters set by the physician, both LN 7 and 9 should have phoned the physician with the information. On 11/23/16 at 7 p.m., during an interview and concurrent record review, LN 9 stated Resident 3's vital signs were due each shift. LN 9 stated he should have notified the physician. On 11/24/16 at 5 a.m., during an interview, LN 7 reviewed Resident 3's vital signs and physician's order and stated, "I just missed it." LN 7 stated the Certified Nurses Assistant (CNA) that took Resident 3's vital signs told him she had checked them twice. LN 7 stated the CNA had rechecked Resident 3's vital signs but did not tell him to look closer at the number values to see if something was outside the parameters. LN 7 stated, "I was just doing the task. I didn't see it as an assessment piece. I didn't assess it and I didn't call the MD." The facility policy and procedure titled, "NSG205 Assessment: Nursing," dated 6/1/96, indicated, "POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed...PURPOSE To determine patient's condition and clinical needs... 4. Notify physician/mid-level provider of assessment results as indicated..." Because of the potential and actual harm of not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 40 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 providing the necessary care and treatment for dialysis residents, an Immediate Jeopardy (IJ) situation was called on 11/21/16 at 5:30 p.m., and the Admin, DON, a Corporate Consultant, and Senior Executive Director were given verbal notification. The facility provided an acceptable Action Plan addressing the IJ situation on 11/21/16 at 9:15 p.m. The IJ was removed on 11/25/16 at 5:45 p.m., after successful demonstration that all elements of the Action Plan that addressed the immediacy had been implemented, with the Admin and the DON. The facility policy and procedure titled, "NSG205 Assessment: Nursing," dated 6/1/96, indicated, "POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed...PURPOSE To determine patient's condition and clinical needs... 4. Notify physician/mid-level provider of assessment results as indicated..."

F333 SS=E RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.25(m)(2)

F333 01/31/2017 The facility must ensure that residents are free of any significant medication errors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 41 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 This REQUIREMENT is not met as evidenced by: Based on interview, clinical record and administrative document review, the facility failed to ensure one of five sampled residents (Resident 3) diagnosed with End Stage Renal Disease (ESRD - or kidney failure) and on hemodialysis (life-saving medical procedure for kidney failure that filters blood through an external artificial kidney machine) was free of a significant medication error when a medication (Kayexelate) used to treat a high level of Potassium was prescribed and not given when ordered. Midodrine and Clonidine, two medications prescribed for high blood pressure, were given routinely, without parameters (specific numerical values, previously specified by the physician for blood pressure and pulse to support whether medications should be to be given or held. These failures resulted in the potential harm of Resident 3 being administered medications that: Would treat a serum blood level of a high blood Potassium that had the potential affect of causing heart dysrrthmia and death; and medications which have opposite effects on blood pressure could possibly lead to the risk of taking medication not meant to be prescribed routinely and/or concurrently. Findings: 1. Resident 3's medication Kayexalate (used to treat life-threatening high potassium level physician order was transcribed from a physician's telephone order inaccurately and not administered timely. The physician was not notified when administration of the Kayexalate was delayed. Licensed Nurses were unable to verbalize the indication for Kayexalate's use and had not communicated pertinent resident care status from one nurse to another or from one shift to another shift. Resident 3's Physician telephone order dated 11/18/16 at 3:52 p.m., indicated Kayexalate 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 42 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 grams (gm) (a metric measurement) to be given by mouth, one time, one day, for high Potassium level. On 11/21/16 at 11:30 a.m., during a telephone interview, Resident 3's physician (P) 1 stated he ordered the Kayexalate to be given once each day until Resident 3 could have the dialysis procedure performed. On 11/21/16 at 11:30 a.m., LN 1 stated she phoned Resident 3's physician, (P) 1 and made him aware Resident 3 was not going to be able to get dialysis until her dialysis catheter could be replaced. LN 1 stated she informed P 1 that Resident 3's Potassium level was elevated at 5.7 (normal range is 3.5 - 5.2). LN 1 stated P 1 ordered Kayexalate 15 grams to be given one time. Review of Resident 3's clinical record indicated Resident 3's Physician telephone order for Kayexalate was dated 11/18/16 at 3:52 p.m. The Pharmacy order form documented the Kayexalate was taken from the Emergency Kit (E-Kit ) (back up pharmacy storage), on 11/18/16 at 9 p.m. E-kits contained medications stored in the facility and were available to be given immediately. The nurse's note dated 11/18/16 at 11:37 p.m., indicated Resident 3 had refused to take the medication and wanted to take it in the morning. On 11/19/16 at 8:45 a.m., during an interview with Resident 3, with LN 6 present, Resident 3 stated she had been told there was a new medication, but it was arriving late, and it would be started in the morning. Resident 3 stated she was not told what it was for. Resident 3 stated she had not refused to take any medication. On 11/19/16 (Saturday morning) at 6 a.m., during observation, interview, and Resident 3's clinical record review, LN 9 stated, "Missing dialysis even one time is crucial and I would phone the physician." LN 9 stated he should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 43 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 have been told in report Resident 3 would not be going to dialysis that morning. LN 9 stated he found out by reading nurses notes in the computer and at 4 a.m. he had canceled transport. LN 9 stated today was the first day he knew Resident 3 was going to miss dialysis. LN 9 stated he saw a new order for Kayexalate. LN 9 validated the Kayexalate was on the medication cart and stated LN 10 reported Resident 3 had refused the medication. LN 9 validated this on the MAR which indicated on 11/18/16 at 9 p.m., Resident 3 had refused the Kayexalate three times, and it had been rescheduled to be given at 9 a.m. When LN 9 was asked what the indication for use of Kayexalate was, LN 9 stated, "I have no idea." LN 9 stated he did not know Resident 3 had missed dialysis on 11/17, and 11/19/16 would be the second, not the first, missed dialysis treatment. On 11/19/16 at 7:27 a.m., LN 6 stated Resident 3 had a new order for Kayexalate, it came from the e-kit and pointed to the medication on the medicine cart. On 11/21/16 at 3:30 p.m., LN 1 stated when she documented P 1's phone order, the medication order entry had not matched the nurses note. LN 1 stated she re-entered the nurses note to match the way the medication order was written. LN 1 stated she should have phoned the physician and clarified whether he intended the Kayexalate order to be one time or ONE time each day. On 11/30/16 at 6 p.m., during a telephone interview, LN 10 stated she did not notify the physician when the Kayexalate was not administered as ordered and administration was delayed until the next day. 2. The clinical record for Resident 3 indicated Midodrine and Clonidine were given routinely, without parameters (specific numerical values, previously specified by the physician for blood pressure and pulse to support whether FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 44 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 medications should be to be given or held). Resident 3's Physician admission orders dated 7/1/16, indicated Midodrine 5 milligrams (mg) (a metric measurement) to be given by mouth twice a day for hypotension (low blood pressure). Medication administration records (MARs) indicated Midodrine was given twice a day, regardless of blood pressure readings 7/16 through 11/16, except when Resident 3 was at the dialysis center or the hospital, and was not in the facility. Resident 3 returned from the hospital on 10/18/16, on Clonidine for hypertension (high blood pressure). Resident 3's Physician (P) 1 ordered Clonidine by topical patch (applied to skin) 0.2 mg per 24 hours, to be applied once every 7 days. Physician order dated 10/18/16 indicated, "Check BP [Blood Pressure] and Pulse one time a day..." The order also indicated to notify the physician if the top number of the BP was less than 100 or the pulse/heart rate was less than 60. The monitoring for the BP and Pulse was scheduled at 9 a.m., however the Midodrine was documented as given at 9 a.m., and also at 5 p.m. Resident 3's MARs, dated 10/16 and 11/16 indicated the Clonidine patch was scheduled on Tuesday's when Resident 3 was at dialysis. There was no documentation the nurse attempted to obtain a more convenient schedule. There were no parameters for use to indicate when the medications were to be given or were to be held based on the B/P and Pulse readings. The 10/16 and 11/16 MARs indicated the patch was applied without consideration of the blood pressure value. On 10/25/16, the MAR indicated Resident 3 was on a LOA (Leave of Absence). There was no documentation the Clonidine was given when Resident 3 returned to the facility. There was also no documentation P 1 was notified if the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 45 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 medication was not given. One MAR indicated Resident 3 had a Clonidine patch applied to her back on 11/22/16, while another MAR indicated the patch should be started on 11/23/16. On 11/23/16, the MAR indicated Resident 3 was LOA, with no indication the medication patch was applied later or physician notification of the patch being held (not given). On 11/23/16 at 6:10 p.m., during a telephone interview, P 1 stated the order for Midodrine was for hypotension (low blood pressure). P 1 stated it might be necessary for the staff at dialysis to give if the resident was hypotensive (having abnormally low blood pressure), in order for dialysis to continue. P 1 was reminded the orders in question were for facility staff nurses, not the nurses at dialysis. P 1 was reminded the order was written to give twice a day, routinely. P 1 was asked if it might be more appropriate to give, as needed, with parameters to ensure Resident 3's blood pressure and pulse could support use. P 1 stated Resident 3 came in on the Midodrine and he didn't change it or question it. P 1 stated, "If you d/c [discontinue] the Clonidine patch the blood pressure will go through the roof and she will stroke." On 11/25/16 at 4 p.m., during an interview, the Consultant Pharmacist (CPharm) 1 stated, "Midodrine orders should always have parameters. If Midodrine is needed very often you would wonder about the hypertensive medication being a weekly medication, and might need to be changed to something given daily with parameters and could be held prn (as needed)." CPharm stated she had searched through pharmacy review notes and could not find where a CPharm had questioned the concurrent, routine Midodrine and the Clonidine orders for Resident 3. On 12/6/16 at 3:55 p.m., during an interview and concurrent review of Resident 3's MARs, the Director of Staff Development (DSD) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 46 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 identified some of the nurses by their initials and signatures on the MAR. The DSD stated Licensed Vocational Nurses (LN) 2, 5,6, 9, 10 and 11, and Registered Nurse (RN) 4 all gave Resident 3 Midodrine when documented BP did not indicate she was hypotensive. The DSD stated nurses gave the a.m. dose regardless of the BP, and the p.m. dose was given without taking a BP. The DSD stated all BP medications should have a BP to verify the BP supports the administration of the medication. On 12/8/16 at 4 p.m., during an interview, LN 1 stated, "I gave the Midodrine and Clonidine [to Resident 3] without questioning... I should have questioned it and called the pharmacy and/or the physician. I did not take the BP in order to give the medications. Parameters were not asked for." The manufacturer's product insert for Midodrine indicated, "...CONTRAINDICATIONS: Midodrine ...tablets are contraindicated in patients with...acute renal [kidney] failure...It is essential to monitor supine (lying flat on your back) and sitting blood pressures in patients maintained on Midodrine...Midodrine use has not been studied in patient's with renal impairment..."

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.60(a),(b)

F425 01/31/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 47 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record and administrative document review, the facility failed to ensure pharmaceutical services met the needs of one of two Residents sampled (Resident 3) when there was no documented evidence, the physician, the pharmacist and the nurses did not question giving two medications, for blood pressure control concurrently and routinely when the two medications had the opposite indication for use. This failure had the potential for adverse reactions for Resident 3. Findings: During a clinical record review of Resident 3's record there was no documented evidence, the physician, the pharmacist and the nurses did not question giving two medications used for blood pressure concurrently and routinely when the two medications had the opposite indication for use. Midodrine (a medication to treat low blood pressures) and Clonidine (a medication to treat high blood pressure) were given routinely, without parameters (specified blood pressure levels to indicate whether medication was required to be given or to be held), and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 48 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 without questioning the reason to give two medications in which indications for their use was the exact opposite of the other. Resident 3's Physician admission orders dated 7/1/16, indicated Midodrine 5 milligrams (mg) (a metric measurement) to be given by mouth twice a day for hypotension (low blood pressure). Medication administration records (MARs) indicated Midodrine was given twice a day, regardless of blood pressure readings 7/16 through 11/16, except when Resident 3 was at the dialysis center or the hospital, and was not in the facility. Resident 3 returned from the hospital on 10/18/16, on Clonidine for hypertension (high blood pressure). Resident 3's Physician (P) 1 ordered Clonidine by topical patch (applied to skin) 0.2 mg per 24 hours, to be applied once every 7 days. Physician order dated 10/18/16 indicated, "Check BP [Blood Pressure] and Pulse one time a day..." The order also indicated to notify the physician if the top number of the BP was less than 100 or the pulse/heart rate was less than 60. The monitoring for the BP and Pulse was scheduled at 9 a.m., however the Midodrine was documented as given at 9 a.m., and also at 5 p.m. Resident 3's MARs, dated 10/16 and 11/16 indicated the Clonidine patch was scheduled on Tuesday's when Resident 3 was at dialysis. There was no documentation the nurse attempted to obtain a more convenient schedule. There were no parameters for use to indicate when the medications were to be given or were to be held based on the B/P and Pulse readings. The 10/16 and 11/16 MARs indicated the patch was applied without consideration of the blood pressure value. On 10/25/16, the MAR indicated Resident 3 was on a LOA (Leave of Absence). There was no documentation the Clonidine was given when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 49 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 Resident 3 returned to the facility. There was also no documentation P 1 was notified if the medication was not given. One MAR indicated Resident 3 had a Clonidine patch applied to her back on 11/22/16, while another MAR indicated the patch should be started on 11/23/16. On 11/23/16, the MAR indicated Resident 3 was on a LOA (Leave of Absence), with no indication the medication patch was applied later or if there was physician notification of the patch being held (not given). On 11/23/16 at 6:10 p.m., during a telephone interview, P 1 stated the order for Midodrine was for hypotension (low blood pressure). P 1 stated it might be necessary for the staff at dialysis to give if the resident was hypotensive (having abnormally low blood pressure), in order for dialysis to continue. P 1 was reminded the orders in question were for facility staff nurses, not the nurses at dialysis. P 1 was reminded the order was written to give twice a day, routinely. P 1 was asked if it might be more appropriate to give, as needed, with parameters to ensure Resident 3's blood pressure and pulse could support use. P 1 stated Resident 3 came in on the Midodrine and he didn't change it or question it. P 1 stated, "If you d/c [discontinue] the Clonidine patch the blood pressure will go through the roof and she will stroke." On 11/25/16 at 4 p.m., during an interview, CP 1 stated, "Midodrine orders should always have parameters. If Midodrine is needed very often you would wonder about the hypertensive medication being a weekly medication, and might need to be changed to something given daily with parameters and could be held prn (as needed)." CP 1 stated she had searched through pharmacy review notes and could not find where a CP had questioned the concurrent, routine Midodrine and the Clonidine orders for Resident 3. On 11/25/16 at 5 p.m., the Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 50 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 (Admin) stated pharmacy reports were not documented in the same manner by different consultant pharmacist. Admin stated the same Consultant Pharmacist (CP) had not consistently provided review. Admin stated two CPs had provided review for only two months each, and now they had CP 1. The Admin stated she was unable to provide clinical record documentation all medications had been reviewed monthly. Admin stated there was no CP review which identified the Midodrine and/or the Clonidine as a concern. On 12/6/16 at 3:55 p.m., during an interview and concurrent review of Resident 3's MARs, the Director of Staff Development (DSD) identified some of the nurses by their initials and signatures on the MAR. The DSD stated Licensed Vocational Nurses (LN) 2, 5,6, 9, 10 and 11, and Registered Nurse (RN) 4 all gave Resident 3 Midodrine when documented BP did not indicate she was hypotensive. The DSD stated nurses gave the a.m. dose regardless of the BP, and the p.m. dose was given without taking a BP. The DSD stated all BP medications should have a BP to verify the BP supports the administration of the medication. On 12/8/16 at 4 p.m., during an interview, LN 1 stated, "I gave the Midodrine and Clonidine [to Resident 3] without questioning... I should have questioned it and called the pharmacy and/or the physician. I did not take the BP in order to give the medications. Parameters were not asked for." On 12/27/16 at 11:45 a.m., during a telephone interview, CP 2 stated it was a nursing responsibility to know the blood pressure and pulse and hold the medication accordingly. CP 2 stated the facility had electronic charting and the nurses should be able to see parameters not written in the order. CP 2 stated there was documentation of a daily blood pressure for Resident 3, and acknowledged the Midodrine was given twice a day with no explanation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 51 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 The manufacturer's product insert for Midodrine indicated, "...CONTRAINDICATIONS: Midodrine ...tablets are contraindicated in patients with...acute renal [kidney] failure...It is essential to monitor supine (lying flat on your back) and sitting blood pressures in patients maintained on Midodrine...Midodrine use has not been studied in patient's with renal impairment."

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.65 01/31/2017 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 52 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, administrative document review, the facility failed to maintain an effective infection control program when staff left a food item used for medication administration uncovered on top of a medication cart and did not wash their hands or use hand hygiene measures between caring for residents in accordance with professional standards of practice and facility policy and procedure. These failures had the potential to spread infectious organisms to staff and residents. Findings: On 11/19/16 at 5:10 a.m., during an observation and concurrent interview, an uncovered bowl containing a moist yellow pureed substance was sitting on top of the medication cart near room 102. When asked the contents of the bowl, Registered Nurse (RN) 1 pulled plastic wrap up over top of the bowl and stated it was applesauce used to administer medications to three residents. RN 1 stated he should not have left the bowl uncovered while administering medications to residents. RN 1 stated the uncovered applesauce was exposed to air and could cause contamination to residents. On 11/19/16 at 5:20 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 53 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 observation, RN 1 exited room 109 (Resident 12's room) carrying a glucometer (an instrument for measuring/checking/monitoring blood for sugar levels). RN 1 opened the top drawer on the medication cart in hallway 100 and placed the glucometer inside the drawer and walked away. RN 1 did not clean the glucometer, wash hands or use hand hygiene products. On 11/19/16 at 5:30 a.m., during an observation and concurrent interview, when asked about the process for cleaning glucometers, RN 1 stated sanitizer wipes were used to clean glucometers. RN 1 stated there were no sanitizer wipes available on the medication cart (cart in 100 hallway). After checking the medication room at the nurse's desk, RN 1 stated there were no sanitizer wipes in the medication room. RN 1 exited the medication room, entered room 113 and assisted a Resident. RN 1 did not use gloves, wash hands or use hand hygiene products when performing these tasks. On 11/19/16 at 5:35 a.m., during an observation, RN 1 exited room 113 and entered room 115 with ungloved hands. RN 1 assisted Resident 5. RN 1 exited room 115 obtained a pair of gloves from the top of the medication cart in 300 hallway and did not wash hands or use hand hygiene products before re-entering room 115. On 11/19/16 at 5:45 a.m., during an observation and concurrent interview, RN 1 was assisting a resident in room 107 bathroom. RN 1 exited room 107 and entered room 109, obtained an incontinent brief and went back into room 107. RN 1 did not use gloves, wash hands or use hand hygiene products. When asked about staff practices to prevent the spread of infection, RN 1 did not respond and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 54 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 put on a pair of gloves (used as a protective barrier to prevent spread of infection) without washing hands or using hand hygiene products. On 11/19/16 at 5:50 a.m., during an observation and concurrent interview, Certified Nursing Assistant (CNA) 1 did not use gloves, wash hands or use hand hygiene products between assisting two individual residents in room 109. CNA 1 exited room 109 and assisted a resident in room 107 bathroom and did not wash hands or use hand hygiene products prior to assisting resident. CNA 1 stated the best way to prevent spread of infection is to wash hands and use gloves. CNA 1 stated she should have washed her hands between providing care to individual residents to prevent the spread of infection. On 11/19/16 at 6:10 a.m., during an observation and concurrent interview, CNA 3 went from room 206 to room 202 with a cup in one hand and water pitcher in the other hand. CNA 3 placed the water pitcher on the bedside table in room 202. CNA 3 went from room 202 to the staff break room, placed the cup in the microwave and took the cup back to room 206. CNA 3 stated she was warming a cup of soup for a resident in room 206 and the resident had eaten some of the soup. CNA 3 did not use gloves, wash hands or use hand hygiene products. When asked about staff practices to prevent the spread of infection, CNA stated she should have helped residents individually and washed her hands between residents to prevent cross contamination. On 11/19/16 at 6:25 a.m., during an observation and concurrent interview, CNA 4 assisted a resident in room 209 using gloves, exited the room and went into room 207. CNA did not change gloves, wash hands or use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 55 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 hand hygiene products before entering room 207. When asked about staff practices to prevent the spread of infection, CNA 4 stated she should have washed her hands or used a hand hygiene product and used a new pair of gloves to prevent the transfer of bacteria (germs). The facility policy titled, " IC203 Hand Hygiene " revision date 11/28/16, indicated the following: " Wash hands with soap and water in the following situations: 1.1 After removing gloves or other personal protective equipment (PPE); 1.2 Before and after direct patient care; 1.3 Immediately after contact with blood, body fluids, or other potentially infectious materials; 1.4 before and after entering/leaving work unit; before and after handling food; when hands are visibly soiled or contaminated. " Review of professional reference, "Centers for Disease Control Recommendations for Hand Hygiene in Health Care Settings (edited for long term care)" <https://www.clinishield.com/html/cdc.html&g t; page 1, indicated " Wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water ... If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations ... Before having direct contact with residents, before donning sterile gloves ... After contact with a resident ' s intact skin. After contact with body fluids/excretions, mucous membranes, nonintact skin, and wound dressings if hands are visibly soiled. If moving from a contaminatedbody site to a clean-body site during resident care. After contact with inanimate objects in the immediate vicinity of the resident. After removing gloves. (Alternately), wash hands with an antimicrobial soap and water in all clinical situations above. (If alcohol-based hand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 56 of 57 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: _______________ 056225 (X3) DATE SURVEY COMPLETED 01/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORCHARD POST ACUTE 4840 E Tulare Ave Fresno, CA 93727 (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 rub is not available). " FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZKDB11 Facility ID: CA040000069 If continuation sheet 57 of 57