Inspection·December 11, 2024

F 0658 units subcutaneously (under the skin) after meals for DM notify MD if below 60 or higher than 400 . LVN 1 stated, the following was physician ' s order for sliding scale: Level of Harm - Minimal harm or potential for actual harm HumalOG 100 Unit/ML (Insulin Lispro (Human) Inject as per sliding scale: Residents Affected - Few If 0-150=0 units 151-200=2 units 201-250=4 units 251-300=6 units 301-350=8 units 351-400=10 units Subcutaneously before meals for diabetes, Notify MD if below 60 or higher than 400. During an interview on 11/26/24, at 10:10 am with LVN 1. LVN 1 stated, Resident 1 had an order for 10 units of Humalog after every meal and a sliding scale order before meals. LVN 1 stated, we checked her blood sugar about fifteen minutes before her meal arrived. LVN1 stated, physician order for the sliding scale insulin was indicated to be administered before her meals. LVN 1 stated, when Resident 1 needed insulin from her sliding scale order, LVN 1 was combining the required sliding scale insulin with the scheduled order of 10 unit. LVN 1 stated, for example on 11/02/2024, Resident 1 needed four units from her sliding scale and ten units from her scheduled order. LVN 1 stated, she administered fourteen units of Humalog using one insulin pen after Resident 1 was finished eating. LVN 1 stated, she administered the combined units of insulin after meals to Resident 1 on following days: 11/2/24,11/5/24,11/6/24.11/7/24,11/8/24,11/14/24,11/18/24,11/19/24,11/20/24,11/29/24, 11/30/24, and 12/2/24. LVN 1 stated, her signature on the MAR indicated, she administered the insulin. LVN 1 stated, she did not follow physician orders and Resident 1 could have experienced adverse reactions affecting her health and wellness. LVN 1 stated, We were to follow physician orders at all times, and I did not. During a concurrent interview and record review on 11/26/24, at 10:50 a.m., with LVN 2, Resident 1's Medication Administration Record (MAR) dated 11/2024 and 12/11/2024 was reviewed. LVN 2 stated, her signature on the MAR indicated she administered insulin to Resident 1. LVN 2 stated she administered the combined units of insulin using one insulin pen after the meal to Resident 1 on the following dates: 11/3/24,11/4/24,11/9/24, 11/10/24,11/15/24, 11/16/24,11/21/24,11/22/24,11/27/24, 11/28/24, 12/3/24,12/4/24,12/9/24, and 12/10/24. LVN 2 stated, We were not following physician orders for the sliding scale insulin to be administered prior to Resident 1 ' s meals. LVN 2 stated, she was combining the scheduled dose of ten units with the sliding scale units using one insulin pen and administering after Resident 1 ' s meals. During a review of Resident 1's Physician Orders (PO), dated 12/01/2024, the PO indicated, .HumalOG Kwik pen SolutionPen-injector100 UNIT/ML Milliliters (Unit of measure) (Insulin) Lispro Unit Dial) Inject 10 units subcutaneously (under the skin) after meals for DM notify MD if below 60 or higher than 400 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056225 If continuation sheet Page 2 of 4 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 12/11/2024 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 During a review of Resident 1's PO, dated 12/01/2024, the PO indicated, .HumalOG Solution 100 Units/ML (Insulin Lispro(Human) Inject as per sliding scale If 0-150=0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, Subcutaneously before meals for diabetes, Notify MD if below 60 or higher than 400 . During a concurrent interview on 11/26/24, at 11:25 a.m., with Assistant Director on Nursing (ADON), ADON stated, Resident 1 had two separate orders for Humalog insulin. ADON stated, Resident 1 had a scheduled order for ten units of insulin after meals. ADON stated, Resident 1 had a sliding scale order for insulin before meals. ADON stated, the physician order indicated sliding scale Humalog be administered before meals. ADON stated I am aware the LVN ' s are using one insulin pen to administer both insulin orders. ADON stated, LVN ' s were not following physician order to administer sliding scale insulin to Resident 1 prior to meals. ADON stated, Resident 1 could have episodes of hypoglycemia or hyperglycemia if physician orders were not followed. During a concurrent interview on 11/26/24, at 11:45 a.m., with Director of Nursing (DON), [NAME] stated, Resident 1 had two separate orders for insulin. DON stated, LVNs should be administering two separate insulin shots if sliding scale insulin were needed, DON stated, she was not aware LVNs were administering insulin using one insulin pen after meals. DON stated, LVNs were not following physician orders for sliding scale insulin. DON stated, it was out of the scope of the LVNs to deviate from a physician order without consulting the physician. DON stated, Resident 1 ' s blood sugar could become unstable causing harm and affecting her health and wellness. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration dated 2001, the P&P indicated. Purpose .to provide guidelines for the safe administration of insulin to residents with diabetes .Types of insulin, dosage requirements, strength and method of administration must be verified before administration, to assure that it corresponds with the order on the medication order on the medication sheet and physician ' s order During a review of the facility's document titled Job Description LPN/LVN, dated 02/2024 the job description indicated, .The primary purpose of your job position is to provide direct care to the residents .Prepare and administer medications as ordered by the physician During a review of the facility's (P&P) titled, Administering Medication dated 2001, the P&P indicated, .Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified example before and after meals .The individual administering the medications checks the label THREE(3) times to verify the right resident, right medication, right dosage, right time, and right method(route) of administration before giving the medication . During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056225 If continuation sheet Page 3 of 4 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 12/11/2024 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 communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056225 If continuation sheet Page 4 of 4