Health inspection·November 5, 2024

F 0658 Level of Harm - Minimal harm or potential for actual harm for Resident 1 when he was admitted on [DATE]. MR stated, there was no inventory list in the EMR for the re-admissions on 10/4/24 and 10/28/24. MR stated, Resident 1 should have had an inventory list completed for each admission. MR stated, the CNA was responsible for filling out the inventory paper form, and the LVN was responsible to input the items from the inventory form into the computer and get a signature of the resident or the Residents RP. Residents Affected - Few During a concurrent observation and interview on 11/5/24 at 1:21 p.m. with CNA 1 in Resident 1's room, CNA 1 went through Resident 1's bedside cabinet and was unable to find his wallet, checkbook or bank card. CNA 1 went through Resident 1's pants and jackets that were hung up in the closet and went through Resident 1's closet drawers and was unable to find his check book, wallet or bank card. CNA 1 looked through two pink bags, one white bag and one [retail store] bag that were stored in the closet and was unable to find Resident 1's check book, wallet or bank card. CNA 1 stated, she was not able to find Resident 1's wallet, check book or bank card in his belongings. During an interview on 11/5/24 at 1:48 p.m. with the Social Services Director (SSD), the SSD stated, an outside agency social worker filed a grievance that Resident 1's wallet and check book were missing. The SSD stated, she checked Resident 1's inventory list and did not find the wallet and check book on the inventory list. The SSD stated, Resident 1's wallet, checkbook and bankcard were found in the back of the dining room. The SSD stated, she did not know how Resident 1's items ended up in the dining room. The SSD stated, the CNA and the LVN admitting the resident were responsible for inventorying the resident's belongings. The SSD stated, the LVN was responsible for entering the resident's inventory into the residents EMR. The SSD stated, it was important for resident's belongings to be inventoried to ensure personal items and reimbursement to a resident if something went missing. During an interview on 11/5/24 at 2:54 p.m. with the LVN, the LVN stated, when a resident was admitted to the facility, the CNA or the LVN would make a list of the resident's inventory on paper. LVN stated, it was the LVN's responsibility to enter the inventory into the EMR and make a copy for medical records. LVN stated, if the CNA made the list of items, the LVN had to verify everything on the list was physically present. The LVN stated, the resident or their RP needed to sign the inventory form. The LVN stated when a resident was admitted they had to have an inventory list completed. The LVN stated, if a resident came in with no belongings, they would still had to do an inventory list and document there was no belongings. The LVN stated, it was important to complete an inventory list in case something went missing. During an interview on 11/7/24 at 2:03 p.m. with the Director of Nursing (DON), the DON stated, it was her expectation that an inventory list be completed when a resident was admitted and re-admitted to the facility. The DON stated the process of completing the inventory was that the LVN or CNA would fill out the inventory form and the nurse would enter it into the EMR. The DON stated, Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/28/24. The DON stated, she was unable to find documentation that an inventory list had been completed on 7/12/24, 10/4/24 or 10/28/24 in the EMR or in Resident 1's hard chart (physical medical record). The DON stated, it was important for resident's belongings to be inventoried when they were admitted to ensure their personal belongings were tracked. The DON stated, when inventories were not completed on admission there was a potential for resident's personal belongings to get lost. The DON stated, the facility's P&P for Personal Property required for an inventory to be completed upon admission. The DON stated, the P&P for Personal Property was not followed. During a review of RESIDENT GRIEVANCE FORM, dated 10/14/2024, the RESIDENT GRIEANCE FORM indicated, . [Resident 1] . DESCRIBE THE NATURE OF THE GRIEVANCE: Patient lost items wallet / checkbook Last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056225 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056225 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Post Acute 4840 E.Tulare Avenue Fresno, CA 93727 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seen in 8/02/24 per email on 10/14/24 . INVESTIGATION: FINDINGS: . looked for items [at] bedside no findings writer added to communications to be on the look out for items . 10/18/2024 writer put on communications again . 10/21/2024 staff member [initials] looked through all Patient belongings no tracings of items . 10/22/24 Items Found [and] Placed in Social [services] Safe . During a review of the facility's (P&P) titled, Personal Property dated 2001, the P&P indicated, . Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits . The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary . During a review of Job Description LVN dated 2/2024, the Job Description LVN indicated, . Essential Duties . Charting and Documentation . Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge . During a review of Resident 1's Clinical Census (CC) dated, 11/5/24, the CC indicated, Resident 1 was admitted [DATE], discharged on 10/3/24, readmitted on [DATE], discharged on 10/21/24 and re-admitted on [DATE]. During a review of professional reference from https://canhr.org/nursing-home-admission-agreements/#:~:text=Personal%20Possessions,current%20and%20save%20a% NURSING HOME admission AGREEMENTS dated, 9/4/2024, indicated, . When you are admitted to a nursing home, you will be asked to sign an admission agreement that explains your rights and responsibilities and those of the nursing home . Signing Other Documents at admission . Personal Possessions . At admission, the nursing home must establish a personal property inventory and give you or your representative a copy. (California Health & Safety Code §1289.4) . During a review of professional reference from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483 titled REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES dated 11/4/24, indicated, . Resident Rights . Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide . A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings . The facility shall exercise reasonable care for the protection of the resident's property from loss or theft . Admission, transfer, and discharge rights . Admissions policy . The facility must establish and implement an admissions policy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056225 If continuation sheet Page 3 of 3