Health inspection·August 28, 2024

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 an abbreviated standard survey. Complaint Number: 909785 and 909286 Representing the Department: 51042, HFEN 34510, HFES The inspection was limited to the specific complaint's investigated and does not represent the findings of a full inspection of the facility. No deficienes were issued for complaint number 909286. One deficiency was issued for complaint number 909785.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(b)(5)(i)(A)(B)(c)(1)(4)

F609 08/18/2024 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the 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: 8W3D11 Facility ID: CA050000320 If continuation sheet 1 of 4 PRINTED: 05/13/2026 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: _______________ 555702 (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARDS POST-ACUTE 730 34th St Bakersfield, CA 93301 (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 allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled, "Abuse, Neglect, Exploitation, or Misappropriation-Reporting Investigating " for one of the six sampled residents (Resident 1), when the facility did not report an allegation of abuse to the California Department of Public Health (CDPH) and did not complete an investigation of the allegation of abuse. These failures had the potential to result in Resident 1 experiencing continued abuse, feeling unsafe, and having feelings of fear. Findings: During a concurrent observation and interview on 7/17/24 at 2:20p.m. with Resident 1, in Resident 1's room, Resident 1 was sitting in bed. Resident 1 stated Resident 2 threw a tray lid at her and bounced off the wall and few minutes later Resident 2 threw a glass plate from the food tray and shattered by Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8W3D11 Facility ID: CA050000320 If continuation sheet 2 of 4 PRINTED: 05/13/2026 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: _______________ 555702 (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARDS POST-ACUTE 730 34th St Bakersfield, CA 93301 (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 1's foot. Resident 1 stated, "I don't feel safe." During a review of Residents 1's "Minimum Data Set (MDS-Assessment Tool), " dated May 9, 2024. The MDS indicated Resident 1 had a Brief Interview for Mental Status BIMS score of 15 (score of 13-15 means cognitive intact). During a review of Resident's 2's "Situation, Background, Assessment, and Recommendation (SBAR)," dated 7/15/24, the SBAR indicated, "This morning resident [2] behavior was out of hand. Resident [2] was reported and seen by other residents and team members throwing out hazardous things towards her roommate [Resident 1]. Resident [2] was shouting at her roommate [Resident 1] and was trying to hit her [Resident 1] with plate and hard bowl cover. Resident [1] said that she doesn't want to see her roommate [Resident 2]. " During a review of Resident 2's "Social Services Notes " (SSN), dated 7/15/2024, the SSN indicated, "SS was informed this morning resident [2] was having aggressive behaviors. Resident [2] was throwing items of her tray and food towards her roommates [Resident 1 and Resident 3]. Resident [2] then got up and threw her tray missing roommate [Resident 1], both roommates [Resident 1 and Resident 3] then exited room at this time. " During an interview on 7/17/24 at 5:20 p.m. with Social Services Assistant (SSA), SSA stated, "Yes, I was able to see [Resident 1] had high anxiety because [Resident 2] had shattered a glass plate by her [Resident 1] feet. She [Resident 1] did mention to me she was scared for her life because [Resident 2] is aggressive. " FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8W3D11 Facility ID: CA050000320 If continuation sheet 3 of 4 PRINTED: 05/13/2026 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: _______________ 555702 (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARDS POST-ACUTE 730 34th St Bakersfield, CA 93301 (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 During concurrent interview and record review on 7/30/2024 at 4:10 p.m. with Director of Nursing (DON), DON stated, "She [Resident 2] threw a plate. No report was filed [to CDPH]." During an interview on 7/31/2024 at 3:51 p.m. with SSA, SSA stated the alleged abuse was not reported to the CDPH and no summary of investigation was completed. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" dated April 2021, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin), neglect exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8W3D11 Facility ID: CA050000320 If continuation sheet 4 of 4