Health inspection·June 4, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when: Residents Affected - Few 1. The facility did not complete a follow-up investigation report (FIR) after a resident-to-resident altercation (RRA) within five days for two of seven sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have another altercation, and to develop distress and injuries. 2. The facility did not report an allegation of financial abuse to California Department of Public Health (CDPH) within 24 hours of an allegation for one of seven sampled residents (Resident 3). This failure had the potential for emotional distress for Resident 3. Findings: 1. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 5/20/25, the SBAR indicated, Resident (1) states he woke up and saw (Resident 2) sitting on the end of the bed, (Resident 2) grabbed (Resident 1's) pillow from behind his head and starting to hit him with the pillow multiple times, then (Resident 2) proceeded to go around the bed, grabbed the water pitcher threatening to hit (Resident 1). During a review of Resident 2's Brief Interview for Mental Status (BIMS), dated 5/16/25, the BIMS indicated Resident 2 had a score of 3 (score 0-7 indicates severe cognitive impairment). During a review of Resident 1's BIMS, dated 5/17/25, the BIMS indicated Resident 1 had a score of 15 (score of 13-15 indicates cognitively intact). During an interview on 6/4/25 at 12:48 p.m. with Resident 1, Resident 1 stated Resident 2 went to his room while he was asleep and hit him with a pillow. During a concurrent interview and record review on 6/4/25 at 2:55 p.m. with the Administrator, the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022 was reviewed. The P&P indicated, Findings of all investigations are documented and reported. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The Administrator stated he did not complete the FIR after Resident 1 and Resident 2's RRA on 5/20/25 and the P&P was not followed. The Administrator stated the FIR should have been submitted to CDPH by 5/25/25. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555170 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 555170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arvin Post Acute 323 Campus Drive Arvin, CA 93203 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)