Health inspection·July 11, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately notify the resident's Physician for one of three sampled residents (Resident 2) reviewed for accidents, of a change in condition when Resident 2 had a fall and was currently receiving anticoagulant (a group of medications that decreased your blood's ability to clot) medications. This deficient practice had the potential for Resident 2 to have complications from the use of anticoagulant due to frequent falls and not to receive the necessary interventions and negatively affect the provision of care and services. During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive the world around us including eyes for sight). During a review of Resident 2's Risk for Falls Care Plan dated 5/15/2025, the Care Plan indicated a goal for the resident to be free of falls and not sustain serious injury. The Care Plan interventions included bed in lowest position, concave mattress for special orientation, floor mats at bedside, and to place the resident in a sitter room for close observation. The Care Plan did not include the resident was legally blind. During a review of Resident 2's History and Physical (H&P) dated 5/18/2025 at 10:23 AM, the H&P indicated the resident did not have the capacity to understand and make medical decisions. The H&P indicated the resident's Head, Eyes, Ears, Nose, and Throat (HEENT, used to describe a physical examination that focused on these body systems) physical exam showed a dysconjugate gaze (a condition where the eyes did not move together in a coordinated manner, meaning they failed to move in the same direction at the same time) and Resident 2's Pupils, Equal, Round, Reactive, Light, Accommodation (PERRLA, used in medicine to describe the assessment of the pupils during a physical exam) only included PERLA. During a review of Resident 2's Anticoagulant Care Plan dated 5/19/2025, the Care Plan goals for the resident included to remain free of complications related to altered hematological status and the resident would not be re-hospitalized within 30 days. The Care Plan Interventions included to complete fall risk assessment and increase vigilance for falls, obtain and monitor lab/diagnostic work as ordered, and indicated a black box warning for Warfarin indicating the medication could cause major or fatal bleeding. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident had a fall in the last month and also had a fall in the last two to six months. During a review of Resident 2's Medication Administration Record (MAR) dated May 2025, the MAR indicated the resident was receiving Lovenox (also known as Enoxaparin sodium, to help prevent blood clots) injection solution prefilled syringe, inject 90 milligram (mg, unit of measurement) subcutaneously (beneath, or under Page 1 of 13 055706 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few all the layers of the skin) one time a day for deep vein thrombosis (DVT, formation of a blood clot in a deep vein, usually in the leg or arm). The MAR indicated the order date was on 5/15/2025 at 9:23 PM and the discontinue date was on 5/29/2025 at 10:19 PM. The MAR indicated Resident 2 received Lovenox from 5/18/2025 to 5/29/2025. During the same review of Resident 2's MAR dated May 2025, the MAR indicated the resident was receiving Warfarin sodium (helped prevent harmful blood clots from forming or growing larger in your body) oral tablet 7.5 mg, give one tablet by mouth in the evening for DVT for seven days. The MAR indicated the order date was on 5/22/2025 at 6:49 AM. The MAR indicated Resident 2 received Warfarin sodium from 5/22/2025 to 5/24/2025 and 5/26/2025 to 5/28/2025. The MAR indicated Resident 2 did not receive Warfarin sodium on 5/25/2025 because the resident was hospitalized . During a review of Resident 2's Change in Condition Progress Note dated 5/25/2025 at 6:53 AM, the Progress Note indicated at approximately 5:45 AM Resident 2 was seen on the floor lying face down. LVN 2 called for the Registered Nurse Supervisor to do an assessment and Resident 2 was assisted to bed in the lowest position with facility staff. During a review of Resident 2's Change in Condition Evaluation dated 5/25/2025 at 4:57 PM, the Evaluation indicated Resident 2 had a fall in the morning. The Evaluation indicated the Physician was notified at 3:30 PM with orders to send the resident to the general acute care hospital (GACH) for computed tomography (CT, a medical imaging technique that used x-rays and computer processing to create detailed cross-sectional images of the body) scan of the head due to the fall. During a review of Resident 2's Fall Risk Evaluation dated 5/25/2025 at 10:18 PM, the Fall Risk Evaluation indicated the resident had a fall risk score of 19. The Fall Risk Evaluation indicated the resident was disoriented times three, had a history of one to two falls in the past three months, was regularly incontinent, and was legally blind. The Fall Risk Evaluation indicated the resident required use of assistive devices, was taking one to two medications, and had one to two predisposing diseases present. During an interview on 7/11/2025 at 9:31 AM, Licensed Vocational Nurse (LVN) 3 stated upon entering the facility LVN 3 was informed of Resident 2's fall and noticed the Physician was not notified right away after the fall at 6:53 AM on 5/25/2025. LVN 3 stated because Resident 2 was on an anticoagulant the facility's protocol was to inform the Physician right away in case of bleeding. LVN 3 stated even though time had passed the Physician had to be notified and that was why LVN 3 started a Change in Condition (COC, document used to officially report a significant shift or alteration in someone's situation, typically with implications for health). During a review of Resident 2's Order Summary Report dated 7/3/2025, the Order Summary Report indicated Warfarin sodium oral tablet, give 2.5 mg by mouth in the evening for treating/preventing blood clots until 7/11/2025 at 4:59 PM. During a concurrent interview and record review of Resident 2's Change in Condition dated 5/25/2025 at 4:57 PM on 7/11/2025 at 10:51 AM, LVN 1 stated as soon as an incident occurred the incident must be reported to the Physician. LVN 1 stated from 5:45 AM to 3:30 PM was not as soon as possible and because Resident 2 was on blood thinners, the resident could have potentially had a bleed. During the same interview on 7/11/2025 at 2:33 PM, the DON stated she expected the facility staff to contact the Physician right away for a fall because the Physician could give new orders or have a new plan of care. During a review of the facility's policy and procedure (P&P) titled, Incidents and Accidents dated February 2023, the P&P indicated It is the policy of this facility to implement and maintain measures to avoid hazards and accidents. Should an accident/incident occur, the resident, staff member will be provided immediate attention by a licensed nurse, who will notify medical provider, family member. The P&P indicated, Licensed nurse will notify medical provider of the incident and obtain orders for further evaluation or treatment. During a review of the facility's P&P titled, Change in Condition dated April 2025, the P&P indicated If, at any time, it 055706 Page 2 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware including a fall or other related incident. The P&P indicated The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR (Situation, Background, Assessment, and Recommendation, structured communication framework used in healthcare to ensure clear, concise, and efficient information was exchanged, especially during critical situations) or similar process to obtain new orders or interventions. The P&P indicated There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. 055706 Page 3 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool), accurately reflected resident's vision status for one out of three sampled residents (Resident 2), who has visual impairment (a term describing any vision loss that cannot be fully corrected). Resident 2 was assessed having adequate vision (sees fine detail, such as regular print in newspapers/books). This deficient practice had the potential for Resident 2 to not receive care to address Resident 2's visual impairment. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive the world around us including eyes for sight). During a review of Resident 2's History and Physical (H&P) dated 5/18/2025 at 10:23 AM, the H&P indicated the resident did not have the capacity to understand and make medical decisions. The H&P indicated the resident's Head, Eyes, Ears, Nose, and Throat (HEENT, used to describe a physical examination that focused on these body systems) physical exam showed a dysconjugate gaze (a condition where the eyes did not move together in a coordinated manner, meaning they failed to move in the same direction at the same time) and Resident 2's Pupils, Equal, Round, Reactive, Light, Accommodation (PERRLA, used in medicine to describe the assessment of the pupils during a physical exam) only included PERLA. During a review of Resident 2's Minimum Data Set, dated [DATE], signed by MDS Nurse (MN), indicated the resident has severely impaired cognition (a person's ability to think, learn, remember, use judgement, and make decisions). The MDS also indicated that the resident did not exhibit disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). The MDS indicated that the resident is dependent (helper does all the effort) on activities of daily living, including eating, hygiene, and bathing. The MDS indicated the resident requires substantial assistance (helper does more than half the effort) on activities such as rolling in bed from left to right, changing positions from sitting to lying in bed, lying in bed to sitting, and sitting to standing. The MDS also indicated that the resident was assessed to have adequate vision (sees fine detail, such as regular print in newspapers/books). The MDS also indicated the resident did not wear corrective lenses such as contacts, glasses, or magnifying glass, and never needed someone to help when reading instructions, pamphlets, or other written material from the doctor or pharmacy During a review of Resident 2's Occupational Therapy Evaluation (OTE) from General Acute Care Hospital (GACH) prior to the admission to the facility, included the following evaluation notes regarding Resident 2's vision: Dated 5/13/2025, Spontaneously tracks laterally but no visual tracking, No consistent blink to threat; and Dated 5/6/2025, Impaired visual foundation skills, impaired visual perceptual skills. During a review of Resident 2's Initial admission Record (IAR), dated 5/15/2025, timed at 10:20 PM, signed by a Registered Nurse (RN), indicated the following regarding Resident 2's vision. The IAR indicated Resident 2's ability to see adequate light (with glasses or other visual appliances) was impaired (sees large print but no regular print in newspaper/books). The IAR also indicated the resident does not wear corrective lenses. The IAR also added that corrective lenses were present during the resident's admission. During a review of Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment, dated 5/16/2025, signed by Occupational Therapist (OTR), included precautions for Resident 2 including risk of falls and bilateral eye blindness. During a review of Resident 2's Optometric Notes, dated 5/24/2025, the notes indicated there was Residents Affected - Few 055706 Page 4 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few suspicion that Resident 2 was blind. The notes added the resident mentioned to facility staff that I (Resident 2) can't see. The notes indicated that Resident 2 has a problem of Cortical blindness (a condition where vision loss is caused by damage to the visual processing areas of the brain). During an observation and interview on 7/11/2025 at 8:48 AM inside Resident 2's room bathroom, Resident 2 was approached for an interview. Resident 2 stood 2 feet facing the surveyor but did not look into the surveyor's eyes when responding to questions. During the interview, Resident 2 stated her eyesight is blurry and could not see the surveyor's face. Resident 2 stated she was only able to see shapes but could not distinguish details. Resident 2 stated she cannot read anything that is put in front of her regardless of distance. During an interview on 7/11/2025 at 9:05 AM with Resident 2's assigned Certified Nursing Assistant (CNA), CNA 1 stated Resident 2 requires help with walking to the bathroom because of her vision. CNA 1 stated Resident 2 requires assistance with setting up for meals because she cannot see what is in front of her. During an interview on 7/11/2025 at 10:10 AM with Resident 2's assigned Licensed Vocational Nurse (LVN), LVN 1 stated Resident 2 can only see shadows and is partially blind. LVN 1 stated Resident 2 requires assistance with walking using a walker because of her vision. LVN 1 stated Resident 2 is at risk of falls because of her blindness. During an interview on 7/11/2025 at 11:58 AM with MN, MN stated when she conducted the vision section of Resident 2's MDS, dated [DATE], she based her findings on the social worker's notes and her own assessment. MN stated when she assessed Resident 2, Resident 2 would look at [her] and [Resident 2's] eyes was like looking at [her]. During the same interviews on 7/11/2025 at 11:58 AM with MN, Resident 2's records were concurrently reviewed. MN stated the IAR, dated 5/15/2025, indicated the resident had impaired vision. MN stated she did not refer to the IAR when she conducted Resident 2's MDS. MN stated Resident 2's OTE, dated 5/13/2025, from GACH indicated the resident had no visual tracking. MN stated she was not aware of the OTE from GACH. MN stated Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment, dated 5/16/2025, indicated the resident had bilateral eye blindness. MN stated she was not aware of the record. During a follow up interview on 7/11/2025 at 12:55 PM with Resident 2, Resident 2 was observed in the facility's dining room. Resident 2 stated her vision has been blurry even before her admission to the facility. During an interview and concurrent record review on 7/11/2025 at 1:17 PM with Social Worker (SW), Resident 2's Social Services Assessment/Evaluation (SSE), dated 5/21/2025, was reviewed. SW stated she does not conduct an assessment of the resident's visual acuity on her evaluation of the resident. During a review of the SSE, dated 5/21/2025, it did not include a section to assess the resident's visual acuity. During a concurrent interview and record review on 7/11/2025 at 2:10 PM with OTR, Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment notes, dated 5/16/2025, was reviewed. OTR stated the notes indicated the resident was blind on both eyes. OTR stated when he evaluated Resident 2, the resident could not read regardless of the distance. OTR stated the resident stated she could not see and that the resident would only focus on his voice During a concurrent interview and record review on 7/11/2025 at 2:33 PM with the Director of Nursing (DON), Resident 2's entire medical records and the facility's policy and procedure for completing the MDS titled, CMS RAI Version 3.0 Manual (RAI Manual) were reviewed. DON stated Resident 2's records, including the Occupational Therapy OT Evaluation & Plan of Treatment notes, dated 5/16/2025, the IAR, dated 5/15/2025, and the OTE from GACH prior to the admission to the facility, all indicated the resident did not have adequate visual acuity. DON stated the RAI Manual indicated the assessment for the resident's MDS includes asking other direct care staff about the resident's visual acuity. DON stated MN should have taken into account other direct care staff's documentation and assessment of the resident when completing Resident 2's MDS. During a review of the facility's P&P 055706 Page 5 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for completing the MDS, titled CMS RAI Version 3.0 Manual, dated 10/2024, indicated steps to assess the resident's vision include to ask family, caregivers, and/or direct care staff over all shifts, if possible, about the resident's usual vision patterns and to ask the resident about their visual abilities. The P&P also indicated the following regarding a resident's vision: Adequate vision indicates the resident can see fine detail, such as regular print in newspapers/books. Impaired vision indicates that the resident can see large print, but no regular print in newspapers/books. Moderately impaired vision indicates that the resident has limited vision; not able to see newspaper headlines but can identify objects. Highly impaired vision indicates the resident's ability to identify objects is questionable, but the resident's eyes appear to follow objects. Severely impaired vision indicates that the resident has no vision or sees only light, colors of shapes; eyes do not appear to follow objects. 055706 Page 6 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered plan of care for one out of three sampled residents (Resident 2) who was assessed to have visual impairment (a term describing any vision loss that cannot be fully corrected) did not have a care plan to address interventions for the resident's visual impairment. This deficient practice had the potential for Resident 2 not to receive care and services for visual impairment such as keeping the resident safe and to prevent accidents and falls. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive the world around us including eyes for sight). During a review of Resident 2's History and Physical (H&P) dated 5/18/2025 at 10:23 AM, the H&P indicated the resident did not have the capacity to understand and make medical decisions. The H&P indicated the resident's Head, Eyes, Ears, Nose, and Throat (HEENT, used to describe a physical examination that focused on these body systems) physical exam showed a deconjugate gaze (a condition where the eyes did not move together in a coordinated manner, meaning they failed to move in the same direction at the same time) and Resident 2's Pupils, Equal, Round, Reactive, Light, Accommodation (PERRLA, used in medicine to describe the assessment of the pupils during a physical exam) only included PERLA. During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 5/20/2025, the MDS indicated the resident had severe impaired cognition (the ability to think, learn, remember, use judgement, and make decisions). The MDS indicated that the resident is dependent (helper does all the effort) on activities of daily living, including eating, hygiene, and bathing. The MDS indicated the resident requires substantial assistance (helper does more than half the effort) on activities such as rolling in bed from left to right, changing positions from sitting to lying in bed, lying in bed to sitting, and sitting to standing. The MDS also indicated that the Resident 2 was assessed to have adequate vision (sees fine detail, such as regular print in newspapers/books). The MDS indicated the resident had a fall in the last month and in the last two to six months. During a review of Resident 2's Fall Risk Evaluation dated 5/24/2025 at 3:36 PM, the Fall Risk Evaluation indicated the resident had a fall risk score of 18 and was at high risk for falls. The Fall Risk Evaluation indicated the resident had a history of one to two falls in the past three months, was regularly incontinent (involuntary loss of bodily fluids, such as urine or stool), and was legally blind. During a review of Resident 2's Fall Risk Evaluation dated 5/25/2025 at 10:18 PM, the Fall Risk Evaluation indicated the resident had a fall risk score of 19 and was at high risk for falls. The Fall Risk Evaluation indicated the resident was disoriented times three, had a history of one to two falls in the past three months, was regularly incontinent, and was legally blind. During a review of Resident 2's Fall Risk Evaluation dated 6/7/2025 at 11:39 AM, the Fall Risk Evaluation indicated the resident had a fall risk score of 22 and was at high risk for falls. The Fall Risk Evaluation indicated the resident was disoriented times three, had three or more falls in the past three months, was regularly incontinent, and was legally blind. During a review of Resident 2's Occupational Therapy Evaluation (OTE) from General Acute Care Hospital (GACH) prior to the admission to the facility, included the following evaluation notes regarding Resident 2's vision: Dated 5/13/2023, Spontaneously tracks laterally but no visual tracking, No consistent blink to threat; and Dated 5/6/2025, Impaired visual 055706 Page 7 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few foundation skills, impaired visual perceptual skills. During a review of Resident 2's Initial admission Record (IAR), dated 5/15/2025, timed at 10:20 PM, signed by a Registered Nurse (RN), indicated the following regarding Resident 2's vision. The IAR indicated Resident 2's ability to see adequate light (with glasses or other visual appliances) was impaired (sees large print but no regular print in newspaper/books). The IAR also indicated that the resident does not wear corrective lenses. The IAR also added that corrective lenses were present during the resident's admission. During a review of Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment, dated 5/16/2025, signed by Occupational Therapist (OTR), included precautions for Resident 2 including risk of falls and bilateral eye blindness. During a review of Resident 2's Optometric Notes, dated 5/24/2025, the notes indicated that there was suspicion that Resident 2 was blind. The notes added the resident (Resident 2) mentioned to facility staff that I (Resident 2) can't see. The notes indicated that Resident 2 has a problem of Cortical blindness (a condition where vision loss is caused by damage to the visual processing areas of the brain). During a review of Resident 2's entire (from 5/15/2025 to 7/11/2025) care plans did not include documented evidence for the development of a comprehensive person-centered care plan to address the necessary intervention to meet the resident's need due to blindness or visual impairment. During an observation and interview on 7/11/2025 at 8:48 AM inside Resident 2's room bathroom, Resident 2 was approached for an interview. Resident 2 faced the surveyor, who was about 2 feet in front of Resident 2, but did not look into the surveyor's eyes when responding to questions. Resident 2 stated her eyesight was blurry and could not see the surveyor's face. Resident 2 stated she was only able to see shapes but could not distinguish details. Resident 2 stated she cannot read anything that is put in front of her regardless of distance. During an interview on 7/11/2025 at 9:05 AM with Resident 2's assigned Certified Nursing Assistant (CNA), CNA 1 stated Resident 2 required help with walking to the bathroom because of her vision. CNA 1 stated Resident 2 required assistance with setting up for meals because she cannot see what was in front of her. During a concurrent interview and record review on 7/11/2025 at 10:33 AM with Resident 2's assigned Licensed Vocational Nurse (LVN), LVN 1, Resident 2's entire care plans were reviewed. LVN 1 stated Resident 2 can only see shadows and is partially blind. LVN 1 stated there is no care plan for Resident 2's blindness or visual impairment. LVN 1 added if there was no care plan for Resident 2's blindness, staff would not know interventions to address the resident's problem. During an interview on 7/11/2025 at 2:33 PM with the Director of Nursing (DON), the DON stated the purpose of a care plan was to direct the care for the residents. The DON added that without a care plan, the staff taking care of the resident would not be able to know how to care for the resident. The DON stated the care plan was also used to track the interventions that work and those that need to be revised. The DON further added that for Resident 2, interventions for the resident's blindness would include interventions such as orienting the resident to the environment. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 4/2025, indicated it is the policy of the facility to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The P&P also indicated that the comprehensive plan of care will be reviewed and/or revised by the [Interdisciplinary Team] after each assessment. 055706 Page 8 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented for one out of three sampled residents (Resident 2), reviewed for accidents when Resident 2, who had history of multiple falls at the facility (5/24/2025, 5/25/2025, 6/7/2025, and 6/10/2025), did not have a floor mat in place when the resident was lying in bed, as indicated in the resident's care plan titled Actual Fall. This deficient practice had the potential for recurrent falls for Resident 2 and sustain major injuries as a result of a fall from the resident's bed. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive the world around us including eyes for sight). During a review of Resident 2's History and Physical (H&P) dated 5/18/2025 at 10:23 AM, the H&P indicated the resident did not have the capacity to understand and make medical decisions. The H&P indicated the resident's Head, Eyes, Ears, Nose, and Throat (HEENT, used to describe a physical examination that focused on these body systems) physical exam showed a dysconjugate gaze (a condition where the eyes did not move together in a coordinated manner, meaning they failed to move in the same direction at the same time) and Resident 2's Pupils, Equal, Round, Reactive, Light, Accommodation (PERRLA, used in medicine to describe the assessment of the pupils during a physical exam) only included PERLA. During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 5/20/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident's ability to see in adequate light with glasses or other visual appliances was adequate, meaning the resident was able to see fine detail, such as regular print in newspapers/books, did not wear corrective lenses such as contacts, glasses, or magnifying glass, and never needed someone to help when reading instructions, pamphlets, or other written material from the doctor or pharmacy. The MDS indicated the resident had a fall in the last month and also had a fall in the last two to six months. During a review of Resident 2's Fall Risk Evaluation dated 5/24/2025 at 3:36 PM, the Fall Risk Evaluation indicated the resident had a high fall risk score of 18. The Fall Risk Evaluation indicated the resident was disoriented times three (a resident who is alert but disoriented to person, place, and time), had a history of one to two falls in the past three months, was regularly incontinent (involuntary loss of bodily fluids, such as urine or stool), and was legally blind. The Fall Risk Evaluation indicated the resident had a balance problem while standing/walking, required use of assistive devices, and had one to two predisposing diseases (having a higher chance of developing a disease due to inherited genetic factors or family history) present. During a review of Resident 2's second Fall Risk Evaluation dated 5/25/2025 at 10:18 PM, the Fall Risk Evaluation indicated the resident had a higher fall risk score of 19. The Fall Risk Evaluation indicated the resident was disoriented times three, had a history of one to two falls in the past three months, was regularly incontinent, and was legally blind. The Fall Risk Evaluation indicated the resident required use of assistive devices, was taking one to two medications, and had one to two predisposing diseases present. During a review of Resident 2's third Fall Risk Evaluation dated 6/7/2025 at 11:39 AM, the Fall Risk Evaluation indicated the resident had a higher fall risk score of 22. The Fall Risk Evaluation indicated the resident was disoriented times three, had three or more falls in the past three 055706 Page 9 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few months, was regularly incontinent, and was legally blind. The Fall Risk Evaluation indicted the resident had a balance problem while standing/walking, required used of assistive devices, was taking one to two medications, and had one to two predisposing diseases present. During a review of Resident 2's Fall Risk Evaluation dated 6/10/2025 at 3:56 AM, the Fall Risk Evaluation indicated the resident had a fall risk score of back to 18. The Fall Risk Evaluation indicated the resident was disoriented times three, had one to two falls in the past three months, was regularly incontinent, and had adequate vision with or without glasses. The Fall Risk Evaluation indicated the resident had a balance problem while standing/walking, required use of assistive devices, was taking three to four medications, and had one to two predisposing diseases present. During a review of Resident 2's care plan for falls, initiated on 5/15/2025, the care plan included an intervention to have the resident's bed on the lowest position with a floor mat for poor safety awareness. During a review of Resident 2's care plan for Actual Fall, initiated on 6/10/2025, included an intervention for placing a floor mat. During an observation and interview on 7/10/2025 at 1:18 PM inside Resident 2's room, Resident 2 was observed lying in bed. A floor mat was not observed beside Resident 2's bed. Resident 2 stated she did not know that the floor mat was not in place. Resident 2 added that the purpose of the floor mat was to ensure her safety. During a concurrent observation and interview on 7/10/2025 at 2:25 PM inside Resident 2's room, Certified Nursing Assistant (CNA) 2 stated there is no floor mat right next to Resident 2's bed. CNA 2 stated the floor mat must be in place when the resident is laying in her bed. During an interview on 7/11/2025 at 10:51 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2's fall care plans include interventions such as placing a floor mat next to Resident 2's bed. LVN 1 stated the purpose of the floor mat is to prevent major injury if the resident falls from the bed. LVN 1 added the resident could suffer major injuries if the resident falls from the bed onto the hard floor, and not on the floor mat. During an interview on 7/11/2025 at 2:33 PM with the Director of Nursing (DON), the DON stated Resident 2 had rolled out of the bed and had fallen from the bed as a result. The DON stated that the interventions implemented to prevent injury from falling from the bed include placing a floor mat beside the bed. The DON stated that the floor mat serves as a cushion to prevent major injury in the event of a fall from the bed. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention- Falling STAR Program, revised 1/24/2024, indicated it is the policy of the facility to reduce the number and severity of falls and to take precautionary measures. The P&P also indicated staff are to check at the beginning of every shift for correct placement of safety devices. During a review of a review of the facility's P&P titled, Fall Management System, revised 4/2025, indicated it is the facility's policy to provide an environment that remains as free of accident hazards as possible. The P&P also indicated it is the facility's policy to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 055706 Page 10 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately document in the Fall Risk Evaluation (FRE) on 6/10/2025 and accurately document in the Minimum Data Set (MDS, a federally mandated resident assessment tool) that one of three samples residents (Resident 2) had visual impairment (a term describing any vision loss that cannot be fully corrected) and was at high risk for accidents and fall due to blindness. This deficient practice had the potential for Resident 2 not to receive care to address Resident 2's visual impairment that could lead to a lack of or delay in delivery of necessary care or services to Resident 2 such as monitoring and supervision to prevent recurrent accidents and falls.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included history of falling, abnormalities of gait and mobility (a change to your walking pattern), and personal history of other diseases of the nervous system (a complex network of nerves and tissues that allowed us to think, feel, and move) and sense organs (parts of the body that helped us perceive the world around us including eyes for sight). During a review of Resident 2's Risk for Falls Care Plan dated 5/15/2025, the Care Plan indicated a goal for the resident to be free of falls and not sustain serious injury. The Care Plan interventions included bed in lowest position, concave mattress for special orientation, floor mats at bedside, and to place the resident in a sitter room for close observation. The Care Plan did not indicate Resident 2 was legally blind and at risk for accidents and fall due to blindness or impaired vision. During a review of Resident 2's Initial admission Record (IAR), dated 5/15/2025 at 10:20 PM, signed by a Registered Nurse (RN), indicated Resident 2's ability to see adequate light (with glasses or other visual appliances) was impaired (sees large print but no regular print in newspaper/books). The IAR also indicated that the resident did not wear corrective lenses. The IAR also added that corrective lenses were present during the residents' admission.? During a review of Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment, dated 5/16/2025, signed by the Occupational Therapist (OTR), included precautions for Resident 2 including risk of falls and bilateral eye blindness.? During a review of Resident 2's History and Physical (H&P) dated 5/18/2025 at 10:23 AM, the H&P indicated the resident did not have the capacity to understand and make medical decisions. The H&P indicated the resident's Head, Eyes, Ears, Nose, and Throat (HEENT, used to describe a physical examination that focused on these body systems) physical exam showed a dysconjugate gaze (a condition where the eyes did not move together in a coordinated manner, meant they failed to move in the same direction at the same time) and Resident 2's Pupils, Equal, Round, Reactive, Light, Accommodation (PERRLA, used in medicine to describe the assessment of the pupils during a physical exam) only included PERLA. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident's ability to see in adequate light with glasses or other visual appliances was adequate, meaning the resident was able to see fine details, such as regular print in newspapers/books, did not wear corrective lenses such as contacts, glasses, or magnifying glass, and never needed someone to help when reading instructions, pamphlets, or other written material from the doctor or pharmacy. The MDS indicated the resident had a fall in the last month and also had a fall in the last two to six months. The MDS did not indicate Resident 2 was legally blind. During a review of Resident 2's Optometric Notes, dated 5/24/2025, the note indicated that there was suspicion that Resident 2 was blind. The note added the resident mentioned to facility staff that I (Resident 2) can't see. The note 055706 Page 11 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated that Resident 2 had a problem of Cortical blindness (a condition where vision loss is caused by damage to the visual processing areas of the brain).? During a review of Resident 2's Change in Condition Evaluation dated 5/24/2025 at 2:19 PM, the Evaluation indicated Resident 2 had a witnessed fall in the morning. During a review of Resident 2's Fall Risk Evaluation dated 5/24/2025 at 3:36 PM, the Fall Risk Evaluation indicated the resident had a fall risk score of 18. During a review of Resident 2's Change in Condition Evaluation dated 5/25/2025 at 4:57 PM, the Evaluation indicated Resident 2 had a fall in the morning and was ordered by the physician to be sent to hospital for computed tomography (CT, a medical imaging technique that used x-rays and computer processing to create detailed cross-sectional images of the body) scan of the head due to the fall. During a review of Resident 2's Fall Risk Evaluation dated 5/25/2025 at 10:18 PM, the Fall Risk Evaluation indicated the resident had a fall risk score of 19. During a review of Resident 2's Change in Condition Evaluation dated 6/7/2025 at 9:30 AM, the Evaluation indicated Resident 2 had a fall in the morning. During a review of Resident 2's Change in Condition Evaluation dated 6/10/2025 at 3:43 AM, the Evaluation indicated Resident 2 had a fall in the night and had pain to the right shoulder with a pain score of 8 (a numerical pain scale in which 0 indicates no pain and 10 represents the worst pain imaginable). The Evaluation indicated the Resident 2's Physician ordered the resident to transfer to the hospital. During a review of Resident 2's Fall Risk Evaluation dated 6/10/2025 at 3:56 AM, the Fall Risk Evaluation indicated the resident had a fall risk score of 18. The Fall Risk Evaluation indicated the resident was disoriented times three, had one to two falls in the past three months, was regularly incontinent, and had adequate vision with or without glasses. The Fall Risk Evaluation did not indicate Resident 2 was legally blind and was at risk for accidents and fall due to blindness or impaired vision. During an interview on 7/11/2025 at 8:48 AM, CNA 1 stated Resident 2 was blind and that was why the resident needed help. During an interview on 7/11/2025 at 9:05 AM with Resident 2's assigned CNA, CNA 1 stated Resident 2 required help with walking to the bathroom because of her vision. CNA 1 stated Resident 2 required assistance with setting up meals because she could not see what was in front of her.?? During a concurrent interview and record review on 7/11/2025 at 10:10 AM, LVN 1 stated Resident 2 was partially blind and could only see shadows. LVN 1 stated to prevent falls and injuries for Resident 2, the resident required help with walking and the resident had a floor mat to prevent injury from any fall. LVN 1 stated the purpose of the Fall Risk Evaluation (FRE) was to find the reason the resident fell and to do interventions. LVN 1 stated accurately documenting the FRE was important to prevent falls otherwise the facility would not fully get the information of the resident, and the resident could end up having another fall. During an interview on 7/11/2025 at 11:58 AM with the MDS Nurse (MN), MN stated when she conducted the vision section of Resident 2's MDS, dated [DATE], MS stated she based her assessment on the social worker's notes and she did not review other clinical history records related to Resident 2's blindness. MN stated when she assessed Resident 2, she observed Resident 2 would look at [her] and [Resident 2's] eyes was looking at [her].? During the same interview and concurrent record review on 7/11/2025 at 11:58 AM with MN, MN stated the Initial admission Record (IAR), dated 5/15/2025, indicated the resident had impaired vision. MN stated she did not refer to the IAR when she conducted Resident 2's assessment to complete the MDS assessment. MN stated Resident 2's medical records from the GACH such as the Occupational Therapy Evaluation (OTE), dated 5/13/2025, indicated the resident had no visual tracking. MN stated she was not aware of the OTE from the GACH. MN stated Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment record, dated 5/16/2025, indicated the resident had bilateral (both sides) eye blindness. MN stated she did not review and was not aware of the OTE and Occupational Therapy OT Evaluation & Plan of 055706 Page 12 of 13 055706 07/11/2025 The Orchard - Post Acute Care 12385 E. Washington Blvd Whittier, CA 90606

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Treatment records.? During an observation and interview on 7/11/2025 at 12:55 PM with Resident 2, Resident 2 was observed in the facility's dining room. Resident 2 stated her vision had been blurry even before she was admitted to the facility. During a concurrent interview and record review on 7/11/2025 at 2:10 PM with the Occupational Therapist (OTR), Resident 2's Occupational Therapy OT Evaluation & Plan of Treatment notes, dated 5/16/2025, was reviewed. OTR stated the note indicated the resident was blind on both eyes. The OTR stated when Resident 2 was evaluated, the resident could not read regardless of the distance. The OTR stated Resident 2 informed her that she could not see and that the resident would only focus on the OTR's voice. During a concurrent interview and record review on 7/11/2025 at 2:33 PM with the Director of Nursing (DON), Resident 2's entire medical records and the facility's policy and procedure for completing the MDS titled, CMS RAI Version 3.0 Manual (RAI Manual) were reviewed. The DON stated Resident 2's records, including the Occupational Therapy OT Evaluation & Plan of Treatment notes, dated 5/16/2025, the IAR, dated 5/15/2025, and the OTE from GACH prior to the admission to the facility, all indicated the resident did not have adequate visual acuity. The DON stated the RAI Manual indicated the assessment for the resident's MDS included asking other direct care staff about the resident's visual acuity. The DON stated MN should have taken into account other direct care staff's documentation and assessment of the resident when completing Resident 2's MDS.? During the same interview on 7/11/2025 at 2:33 PM, the DON stated having an accurate FRE was important to identify the type of care needs for the resident otherwise the FRE would not identify the correct score and potentially affect the resident's interventions for a fall. The DON stated Resident 2's FRE was not accurate and without the correct information the facility staff would not know how to care for the resident without a proper assessment. During a review of the facility's policy and procedure (P&P) titled, Fall Management System dated June 2018, the P&P indicated It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. During a review of the facility's P&P for completing the MDS, titled CMS RAI Version 3.0 Manual, dated 10/2024, indicated steps to assess the resident's vision included to ask family, caregivers, and/or direct care staff over all shifts, if possible, about the resident's usual vision patterns and to ask the resident about their visual abilities. The P&P also indicated the following regarding a resident's vision:? Adequate vision indicates the resident can see fine detail, such as regular print in newspapers/books.? Impaired vision indicates that the resident can see large print, but no regular print in newspapers/books.? Moderately impaired vision indicates that the resident has limited vision; not able to see newspaper headlines but can identify objects.? Highly impaired vision indicates the resident's ability to identify objects is questionable, but the resident's eyes appear to follow objects.? Severely impaired vision indicates that the resident has no vision or sees only light, colors of shapes; eyes do not appear to follow object. 055706 Page 13 of 13