Other·January 19, 2017

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 Department of Public Health during a RECERTIFICATION survey and one Entity Reported Incident (ERI). ERI Complaint Number:CA00511297 Substantiated Representing the Department of Public Health: Surveyor: 36926, RN, HFEN Surveyor: 17013, RN, Senior HFEN Surveyor: 17019, RN, HFEN Surveyor: 31333, Pharmacist Consultant Surveyor: 38108, RN, HFEN Surveyor: 37198, RN, HFEN Surveyor: 37989, RN, HFEN Surveyor: 37662, RN, HFEN Surveyor: 37990, RN, HFEN Total Resident Population: 156 + 2 Bed holds Total Sample: 24 Six Randomly Selected Residents (RSRs) Highest Severity and Scope:G

F154 SS=D INFORMED OF HEALTH STATUS, CARE, & TREATMENTS

F154 12/16/2016 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: 1MGY11 Facility ID: CA940000015 If continuation sheet 1 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 CFR(s): 483.10(b)(3), 483.10(d)(2) The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. The resident has the right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's staff failed to obtain an informed consent from one (Resident 3) of seven residents, who were taking psychotropic medications (medications capable of affecting the mind, emotions, and behavior), out of 24 sample residents. This deficient practice had the potential for residents and/or responsible parties to not get informed of the possible adverse reactions/side effects and their right to refuse these types of medications. Findings: A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 11/8/16, with diagnoses that included depression (a persistent feeling of sadness, loss, anger, or frustration that interferes with everyday life). The Minimum Data Set (MDS, a resident assessment and care screening tool) indicated Resident 3 required extensive assistance (weight bearing support) with daily activities, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 2 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 such as bed mobility, dressing, toilet use and personal hygiene. A review of Resident 3's physician's order, dated 11/8/16, indicated to administer Zoloft (a medication used to treat depression), 100 milligrams (mg) daily at bedtime. There was no documented evidence in Resident 3's clinical record that an informed consent was obtained from Resident 3 and/or the responsible party prior to its administration. During an interview and record review on 11/16/16, at 7:20 a.m., the Minimum Data Set Nurse (MDS Nurse 2) stated that there was no informed consent obtained from Resident 3 and/or the responsible party for the use of the antidepressant medication. The facility's policy and procedures titled, "Psychotherapeutic Drug Use - CA," revised 8/2012, indicated, "Upon change of condition or initiation of a new order for psychoactive medications (same as psychotropic medications), the Licensed Nurses shall complete the Verification of Informed Consent form prior to the initiation of the new medication."

F164 SS=D PERSONAL PRIVACY/CONFIDENTIALITY OF F164 RECORDS CFR(s): 483.10(e), 483.75(l)(4) 12/16/2016 The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 3 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide privacy during personal care and services for one of six randomly selected resident (RSR 26). Resident 26's physician was observed assessing the resident's health condition in the hallway, while Resident 26 sat in the wheelchair, in the presence of other residents, while the nursing staff watched. This deficient practice resulted in Resident 26's privacy being denied while the physician used a stethoscope (an acoustic medical device for auscultation, or listening to the internal sounds of an animal or human body) placed on the resident's chest wall and was listening to her lungs. Findings: On 11/17/16, at approximately 12:15 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 4 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 an interview with the Minimum Data Set nurse (MDS Nurse 1), Resident 26's physician was observed examining the resident with a stethoscope. The physician was listening to Resident 26's lung sounds, while Resident 26 was sitting in the wheelchair in the hallway next to other residents, in front of the nurse's station. The MDS Nurse 1 was asked what the physician was doing and she immediately went to intervene and pushed Resident 26 into her room, while the physician followed. Resident 26 was heard saying, "Why? What's wrong? " MDS Nurse 1 closed Resident 26's curtains, once in the room. On 11/17/16 at 1:55 p.m., Resident 26 was observed in bed and was asked where does the physician usually examine her. RSR 26 stated, " Anywhere, depending on where I am when he comes. If I am in the hallway,then he does it there." At 2:10 p.m., on 11/17/16, MDS Nurse 1 stated, "The resident's (RSR 26) physician denied the resident of privacy by examining her in the hallway and that should never be done. MDS Nurse 1 stated, "Most physicians usually visit the residents early morning when they are still in the bed, but this physician only had two residents here. He is a nephrologist (a physician who specialized in kidney care and treating diseases of the kidneys), but I did speak to him about it." A review of the facility's undated policy titled, "Dignity, Respect and Privacy," indicated residents shall be examined and treated in a manner that maintained the privacy of their bodies. The policy also stipulated a closed door or drawn curtain would shield the resident from passers-by and the people not involved in the care of the resident shall not be present without the resident's consent while they are being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 5 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 examined or treated.

F226 SS=E DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.13(c)

F226 02/23/2017 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policies related to abuse prevention, by not conducting an investigation when they were informed about an allegation of abuse between one of 24 sampled residents (Resident 19) by a family member. Also, during the abuse and emergency preparedness interviews, two of five certified nursing assistants (CNAs 4 and 8) regarding abuse protocols were unable to identify all types of abuse. These deficient practices resulted in the facility not following its policy regarding reporting abuse allegations and had the potential for staff's inability to identify abuse incidents with residents. Findings: a. On 11/15 /16, at 10 a.m., during a quality of life (QOL) group interview, in the presence of 11 alert residents, the residents were asked if they were aware of any instances when a resident was abused and/or neglected. Resident 23 stated, "Yes a resident (Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 6 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 19) was seen being abuse by the resident's family member, just yesterday." Resident 23 stated the incident occurred during activities in the presence of the activity's staff, while Resident 19 was playing. The family member pulled Resident 19's chair out of the circle. Resident 23 stated, "It did not feel good seeing it." Another Resident (Resident 24) stated Resident 19's family member (the same family member) had been seen before shaking Resident 19's wheelchair. At 7:35 a.m., on 11/17/16, during an interview, the facility's activity director (AD) stated Resident 19's family member (FM) visited Resident 19 every day and was really involved in Resident 19's care/activities. The AD stated one of the residents (Resident 23) told her three days prior (Monday, 11/14/16) that Resident 19's FM was being mean toward Resident 19. The AD stated Resident 23 stated Resident 19 was participating in an activity where she would toss rings and she could not do it, and the FM took Resident 19 out of the circle of the activity and scolded her. The AD stated she did not report the incident to anyone, but should had because it was the facility's policy. The AD stated she did not think anything of it, because she did not think Resident 19's FM would abuse her. The AD stated Resident 19's FM became upset because Resident 19 did not understand the game. On 11/17/16 at 9:05 a.m., during an interview, Resident 24 stated she saw Resident 19's family member shake her wheelchair with the resident in it at the nurse's station. Resident 24 was asked if she reported the incident to anyone and she replied, "No, because the resident's family member gets away with everything." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 7 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of Resident 24's Admission Face Sheet indicated the resident was admitted to the facility on 5/2/14, and readmitted on 6/13/14. Resident 24's diagnoses included shortness of breath ([SOB] a feeling of difficulty or labored breathing), peripheral neuropathy (weakness, numbness, and pain due to nerve damage, usually in the hands and feet), congestive heart failure ([CHF] a chronic condition in which the heart does not pump blood as well as it should), coronary artery disease ([CAD] an impedance or blockage of one or more arteries that supply blood to the heart, usually due to arteriosclerosis [hardening of the arteries]). A review of Resident 24's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/10/16, indicated Resident 24 was able to make needs known, understand others and cognition was intact. On 11/17/16 at 9:30 a.m., the activity assistance (AA), stated she was in the room conducting the activity during the incident between Resident 19 and the FM. The AA stated initially Resident 19 refused to play the ring toss game and then she played, but could not toss the ring well and one of the rings struck her (AA). The FM took Resident 19 out of the circle and turned her wheelchair around and told Resident 19 her behavior was not acceptable. The AA stated Resident 19 did not throw the ring purposely to strike her. The AA stated she reported the incident to her supervisor (AD) that same day, because a resident (Resident 23) complained that the FM was being rude and aggressive toward Resident 19. The AA stated the AD told her she would follow-up and report the allegation to the administrator. At 9:59 a.m., on 11/17/16, during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 8 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Resident 23 stated she was in the activity room on Monday, 11/14/16, and saw Resident 19's FM take her out of the activity circle, turned her wheelchair around and was face to face with Resident 19 and "scolded" her. Resident 23 stated the FM scolded Resident 19 because she could not do the ring toss. Resident 23 stated Resident 19's FM visited the resident every day. Resident 23 stated, "So maybe she is just tired and stressed out." Resident 23 stated she felt bad seeing the incident, especially since this was not the first time the FM had been rude and aggressive toward Resident 19. Resident 23 stated she felt it was necessary to report the incident to the AD. A review of Resident 23's Admission Face Sheet indicated Resident 23 was admitted to the facility on 3/17/04. Resident 23's diagnoses included multiple sclerosis (disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, complete paraplegia (complete paralysis of the lower half of the body), orthostatic hypotension (low blood pressure when standing up), generalized anxiety disorder (feelings of fear), major depressive disorder (persistent feelings of sadness), and gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and caused heartburn). A review of Resident 23's Minimum Data Set (MDS), an assessment and care screening tool, dated 8/15/16, indicated Resident 23 had a Brief Interview for Mental Status (BIMS) score of 14 ([cognition intact] ability to make decisions). According to the MDS, Resident 23 had the ability to understand and be understood. A review of Resident 19's Admission Face Sheet indicated the resident was originally FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 9 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 admitted to the facility on 12/19/13 and readmitted on 11/8/14. Resident 19's diagnoses included urinary tract infection ([UTI] an infection in any part of the kidneys, ureters, bladder and urethra), chronic kidney disease (progressive loss in kidney function over a period of time), Alzheimer's disease (most common cause of dementia, a gradual decrease in the ability to remember), anemia (deficiency of red blood cells or of hemoglobin in the blood, resulting in pale skin and weariness), falling with syncope (a short loss of consciousness and muscle strength, and muscle weakness). A review of Resident 19's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/17/16, indicated Resident 19 had memory problems, impaired decision-making, but was able to make needs known and understand others. According to the MDS, Resident 19 was assessed as being dependent with bed mobility, transferring, locomotion on and off the unit, requiring extensive assistance with eating and with personal hygiene. A review of the facility's abuse in-services, dated 7/8/16 and 8/11/16, indicated the AD attended the inservices. On 11/17/16, at 11:23 a.m., during an interview, the administrator stated the AD was supposed to report the alleged verbal abuse immediately, as per the facility's policy. The administrator stated she started the abuse investigation regarding the allegation. The administrator presented a "Counseling/Disciplinary Notice," dated 11/17/16, indicating the AD was written-up and suspended for violation of the facility's policy and procedure of not reporting the alleged abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 10 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of the facility's policy, revised on 2/2008, titled "Abuse Prevention," indicated under the Protection; if a resident incident was reported, discovered or suspected, where the health, welfare or safety of the resident was involved, the facility should follow steps to prevent further potential abuse while the investigation is in progress. The policy also stipulated all alleged abuse, mistreatment or neglect should be reported to the State Licensing Agency immediately or within 24 hours. b. On 11/16/16 at 7:02 a.m., a certified nursing assistant (CNA 4) was asked to name the different types of abuse, but CNA 4 was only able to name four types of abuse: physical, emotional, sexual, and financial and stated she could not remember the other types. c. On 11/16/16 at 11:45 a.m., CNA 8 was asked to name the different types of abuse, CNA 8 was only able to name one type, verbal abuse. CNA 8 stated she did not know the other types of abuse. A review of the facility's policy, revised on 2/2008 and titled, "Abuse Prevention," indicated the facility's training/orientation program will include review of facility's policy on what constitutes abuse, neglect, and misappropriation of resident property.

F241 SS=G DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.15(a) 02/15/2017 The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 11 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 respect in full recognition of his or her individuality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of 24 sampled residents (Resident 21) and one of six randomly selected residents (RSR [Resident 27]). Resident 21, who was continent of bowel and bladder (ability to control), but wore diapers at night, was told by the staff to urinate (act of urinating) in her diaper and was not assisted to the bathroom (Cross referenced to F 315 a). Resident 27, who used the bedpan (a receptacle used by a bedridden patient as a toilet) complained the staff would leave her on the bedpan for long periods of time, which resulted in Resident 27 having back pain. These deficient practices resulted in Residents 21 and 27's dignity and respect being denied and expressed that they felt pain, unimportant, and discomfort, and wanted to go home. Findings: a. On 11/15 /16, at 10 a.m., during a quality of life (QOL) group interview, with 11 alert residents, three (Residents 20, 21, and 22) of the 11 residents stated their call lights were not being answered timely. Resident 21 stated the facility's nursing assistants (CNAs), during the nightshift, would tell her on several occasions to urinate in her diaper when she put her call light on for assistance to go to the bathroom. Resident 21 stated an unidentified CNA told her because she was at risk for falls and did not want Resident 21 to stand up. Resident 21 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 12 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 stated when she urinated in her diaper it made her feel uncomfortable and unhappy. A review of Resident 21's Admission Face Sheet and clinical records indicated Resident 21 was admitted to the facility on 2/26/16. Resident 21's diagnoses included Stage 4 chronic kidney disease (advanced kidney damage), hypertension (high blood pressure), and a history of multiple urinary tract infections ([UTIs] an infection of the urinary tract that caused urgency, pain, and a burning feeling upon urination). A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21 had a Brief Interview for Mental Status (BIMS) score of 9 (8 -15=interviewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use. On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she urinated a lot, and had to wait long periods of time for the CNAs to come and assist her to the bathroom, which resulted in Resident 21 holding her urine and having pain. On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated the CNAs put diapers on her at night, " just in case." Resident 21 also stated at night the CNAs would encourage her to urinate in her diaper, because they do not want her to get up and fall. Resident 21 stated she felt hopeless and bad. At 10:35 a.m., on 11/17/16 a registered nurse (RN 3) was interviewed regarding what his thoughts were on telling a resident, who was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 13 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 continent (had control) and goes to the bathroom, to urinate in their diaper. RN 3 replied that it was not right and the residents had the right to choose whether they want to go to the bathroom, use a bedpan, and/ or bedside commode (portable toilets). On 11/17/16 at 10:41 a.m., CNA 7 was asked if she was familiar with Resident 21. CNA 7 stated that she was familiar with Resident 21 and her preferences. CNA 7 was asked if she would ever encourage a resident to urinate in their diaper, CNA 7 stated, "No because it was inappropriate, especially if a resident was alert, and can go to the bathroom." On 11/17/16 at 12:29 p.m., during an interview with a physician (Physician 1), a nephrologist (a physician who specialized in kidney care and treating diseases of the kidneys), was asked if holding urine can result in UTI. Physician 1 stated, " It is advisable to void (urinate) frequently and older residents may have stress incontinence (the involuntary leakage of urine) so they may want to train the resident to void timely at least every four hours. Holding urine can be a complicating factor to develop a UTI. " On 11/18/16 at 9:48 a.m., the director of staff development (DSD) was asked if certified nursing assistants would encourage a resident to urinate in their diaper if they normally go to the bathroom. The DSD replied, "They would get in trouble. It's not appropriate." The DSD also stated that it would be an automatic write up. When the DSD was asked if residents that go to the bathroom during the day, should go to the bathroom during the night, the DSD replied, "Definitely." A review of an article by the American Urological Association, titled, " What Causes a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 14 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 UTI? " indicated holding urine in the bladder can increase the risks of UTI at <http://www.urologyhealth.org/urologicconditions/urinary-tract-infections-inadults/causes> b. On 11/14/16 at 7:31 a.m., during the facility's initial tour, Resident 27 was observed lying on the bed. Resident 27 was alert, talking about her daily activities and expressing concerns regarding her care. Resident 27 stated, "It's always cold in this room, and they don't come fast enough to change my diaper." A review of Resident 27's Admission Face Sheet indicated Resident 27 was newly admitted to the facility on 11/5/16. Resident 27's diagnoses included urinary tract infection (when bacteria enters the urinary tract), generalized muscle weakness, hypertension (abnormal high blood pressure) difficulty walking, cerebral vascular accident ([CVA] death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) with right sided weakness, and congestive heart failure ([CHF] severe failure of the heart to function properly). A review of Resident 27's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/5/16, indicated Resident 27 was alert with cognition intact and had a Brief Interview for Mental Status (BIMS) score of 13 (9-15 score is interviewable). According to the MDS, Resident 27 was assessed as requiring extensive assistance with personal hygiene, dressing, bathing, and toileting. The MDS indicated Resident 27 was frequently incontinent (inability to control) of bowel and bladder. A review of Resident 27's physician's orders, dated 11/5/16, indicated Resident 27 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 15 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 receiving Aldactone 50 milligrams (mg), as well as Lasix 20 milligrams (mg) daily, both are diuretic medications, which results in increased urinary output. During an interview on 11/17/16 at 7:35 a.m., Resident 27 tearfully stated, "They take a long time to change my diaper. They come much later after being called. The certified nurse assistants (CNA) leave me on the soiled bed pan for a long time, which resulted in my back hurting. I feel bad about it, I feel like a bother. I don't want to stay here, I want to go home." On 11/17/16 at 7:42 a.m., Resident 27 gestured for the surveyor to come to her bedside and she stated, "Please, I need my diaper changed." A licensed vocational nurse (LVN 5) was called into Resident 27's room and was told that Resident 27 was requesting a diaper change. LVN 5 was observed changing Resident 27's diaper and a bath towel was observed in between Resident 27's legs and the diaper. The towel was soiled, but the diaper was dry. LVN 5 stated, "A towel is not supposed to be there (between the legs) and I will speak to the CNA immediately." On 11/17/16 at 8:32 a.m., during a subsequent interview, LVN 5 stated that bed pans are to be taken immediately after use and it was not normal to put a towel between a resident's legs at any time. At 1:05 p.m., on 11/17/16, during an interview, CNA 9 initially denied placing a towel between Resident 27's legs, but then stated, "It is a habit of mine to place a towel on top or between the resident's legs to prevent the urine from leaking onto the diaper. I should not have put a towel there." A review of the facility's policy titled, "Dignity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 16 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 and Respect," with a revision date of 5/2007, indicated that all residents should be treated with kindness, dignity, and respect and that staff should display respect for the resident when caring for them as a constant encouragement of their individuality and dignity as human beings.

F246 SS=E REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES CFR(s): 483.15(e)(1)

F246 12/16/2016 A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach at all times and answered in a timely manner for two of 24 sampled residents (Resident 14 and Resident 21) and one of six randomly selected resident (RSR 27). These deficient practices had the potential to delay the provision of services and residents' needs not being met. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 17 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 a. During a quality of life (QOL) group interview, conducted on 11/15/16 at 10 a.m., with 11 alert residents in attendance, Resident 21 stated the staff does not answer her call light timely resulting in holding her urine for long periods of time, having accidents, and not getting changed on time. During the QOL interview, the ombudsman (a patient advocate) in attendance stated on her many visits to the facility she would see the certified nursing assistants (CNAs) huddled in one area talking amongst themselves. The ombudsman stated she spoke to the staff about it. A review of Resident 21's Admission Face Sheet and clinical record indicated Resident 21 was admitted to the facility on 2/26/16. Resident 21's diagnoses included Stage IV chronic kidney disease (advanced kidney damage), hypertension (high blood pressure), and a history of multiple urinary tract infections ([UTI] an infection of the urinary tract that causes urgency, pain, and a burning feeling upon urination). A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21's Brief Interview for Mental Status (BIMS) score was 9 (8-15=interviewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use. On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she had a history of UTIs and she urinated a lot. Resident 21 stated that she waits a long time for the CNAs to respond FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 18 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 to the call light. Resident 21 stated it hurts her abdomen when she had to wait long to urinate. Resident 21 stated sometimes she had to wait so long for the CNA to come and assist her to the bathroom she would wet herself. Resident 21 stated during her eight month stay at the facility the CNAs would sometimes come in and turn off the call light and not assist her. Resident 21 stated the CNAs would say, "I'll get your nurse, but no one ever comes back." When Resident 21 was asked how she felt when it happened she stated, "It doesn't make me feel too good." On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated that she waits 10-15 minutes at least for a CNA to come take her to the bathroom. On 11/17/16 at 10:35 a.m., during an interview with a registered nurse (RN 3), RN 3 stated that a resident's call light should be answered as soon as possible and even if it was not that staff's resident. On 11/17/16 at 10:41 a.m., a certified nursing assistant (CNA 7) was asked how long should it take for a resident's call light be answered after they push the button, CNA 7 stated the resident should not wait longer than one minute. When asked if 10-15 minutes was a long time to wait for assistance, CNA 7 stated, "Fifteen minutes is too long. Five minutes is too long. My coworkers should go, if I can't answer it." On 11/18/16 at 9:22 a.m., during a telephone interview, Resident 21's family member stated that he had witnessed the staff take a long time to take Resident 21 to the bathroom. Resident 21's family member stated the resident would wait up to 15 minutes sometimes. Resident 21's family member stated, "There's a trick to it. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 19 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 When the light goes on, they (staff) come and turn it off, because it's on a timer and leave and no one comes back to assist her (Resident 21). I have seen it." On 11/18/16 at 9:48 a.m., during an interview, the facility's director of staff development (DSD) stated that the call lights are on a timer and when the resident pushes the call light, the timer starts. A review of the facility's policy titled, "Call Light/Bell," with a revision date of 5/2007, indicated the call light/bell should be answered within a reasonable time (3-5 minutes). The policy also stipulated to listen to the resident's request/need and to respond to the request. b. On 11/15/2016 at 8 a.m., Resident 14 was observed in her room sitting in the wheelchair eating breakfast. Resident 14 was alert and responsive. The call light was observed located at the head of Resident 14's bed and not within the resident's reach. On 11/15/2016 at 9 a.m., Resident 14 was observed in her room sitting on her wheelchair and the call light was not within the resident's reach. During a concurrent interview, a certified nursing assistant (CNA 2) was asked where the call light should be located. CNA 2 stated call lights must be within the resident's reach at all times, especially when there was no staff around. A review of Resident 14's Admission Face Sheet indicated Resident 14 was admitted to the facility on 7/16/07. Resident 14's diagnoses included other specified rheumatoid arthritis (a disease that causes inflammation and deformity of the joints), unspecified osteoarthritis (gradual loss of cartilage of the joints), gastro esophageal reflux disease ([GERD] a disorder where the stomach's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 20 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 digestive juices flows back up and causes heartburn), and unspecified dementia (a brain disease that causes a gradual decrease in the ability to remember). A review of Resident 14's Minimum Data Set (MDS), an assessment and care screening tool, dated 9/16/16, indicated Resident 14 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe impairment of cognitive status. According to the MDS, Resident 14 had the ability to usually understand and be understood. The MDS, under Section G0110 B., for Functional Status (ADL Self Performance), indicated Resident 14 required extensive assistance with a two-plus person physical assist for bed mobility and transferring. A review of the facility's policy and procedure titled, "Call light/Bell," with a revised date of 5/2007, indicated to place the call device within the resident's reach before leaving the room. c. On 11/14/16 at 7:31 a.m., during the facility initial tour, Resident 27 was observed lying on her bed. During an interview on 11/17/16 at 7:35 a.m., Resident 27 stated, "They take a long time to come to my room when I call them, they take a long time to change my soiled diaper. They come way later." A review of Resident 27's Admission Face Sheet indicated the resident was admitted to the facility on 11/5/16. Resident 27's diagnoses included urinary tract infection (infection in kidneys, ureters, bladder and urethra), generalized muscle weakness, difficulty with walking and heart failure (severe failure of the heart to function properly). A review of Resident 27's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 21 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 (MDS), a standardized assessment and care screening tool, dated 11/5/16, indicated Resident 27 required extensive assistance with personal hygiene and dressing using a oneperson physical assist. A review of Resident 27's Medication Administration Record, for the month of 11/2016 dated 11/5/16 to 11/18/16, indicated Resident 27 was administered Lasix (a medication used to treat fluid build-up due to heart failure) which results in urinary frequency. According to the facility's policy and procedure, titled "Call Light/Bell," with a revision date of 5/2007, indicated the residents call light will be answered within a reasonable time (3-5 minutes), and stipulated the staff should listen to the resident's needs, respond to the request, and leave the resident comfortable, with the call device within reach.

F250 SS=E PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.15(g)(1)

F250 12/16/2016 The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility's social service failed to follow its policy regarding loss/theft of personal belongings and hearing aids recommendations for two of 24 sampled residents (Residents 12 and 23). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 22 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 These deficient practices resulted in the facility not following its policy and had the potential to put Resident 23 at risk for identity theft and decrease Resident 12's quality of life. Findings: a. A review of Resident 23's Admission Face Sheet indicated Resident 23 was admitted to the facility on 3/17/04. Resident 23's diagnoses included multiple sclerosis (disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, complete paraplegia (complete paralysis of the lower half of the body), orthostatic hypotension (low blood pressure when standing up), generalized anxiety disorder (feelings of fear), major depressive disorder (persistent feelings of sadness), and gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and causes heartburn). A review of Resident 23's Minimum Data Set (MDS), an assessment and care screening tool, dated 8/15/16, indicated Resident 23 had a Brief Interview for Mental Status (BIMS) score of 14 ([cognitively intact] ability to make decisions). According to the MDS, Resident 23 had the ability to understand and be understood. The MDS, under Section G0110 B., for Functional status (ADL Self Performance), indicated Resident 23 required an extensive assistance of a two-plus person physical assist in bed mobility and transferring. Resident 23 was incontinent (inability to control) of bowel/bladder and had a supra pubic catheter (a thin, sterile flexible tube that is used to drain urine from the bladder inserted through a cut in the abdomen, a few inches below the navel). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 23 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 11/17/16 at 7:30 a.m., during an interview, Resident 23 stated she lost her wallet which contained her identification card, social security card, medicare/medical card, and $25.00 in cash on 10/20/16. Resident 23 stated she had not received any police report follow-up regarding the loss of her personal belongings from the facility social services. On 11/17/16 at 8:37 a.m., the director of social services (SSD 2) was interviewed regarding Resident 23's theft/loss of personal belonging (wallet). SSD 2 stated the reported incident was recorded in Resident 23's progress note and a "Missing Items Report" was completed. SSD 2 stated a police report was done by the resident's family member. A review of the documentation and the investigation report regarding Resident 23's theft/loss indicated there were no records of the incident in Resident 23's progress note. There was also no documented evidence of a police report or follow-up conducted by the facility's social services. On 11/17/16 at 8:55 a.m., an interview with the social services (SS 1) was conducted regarding Resident 23's police report follow-up. SS 1 stated Resident 23's family member was the one who reported the incident. When asked whether the police report should have been acquired and followed-up by social services, SS 1 stated a record of the police report should have been followed-up and filed along with the rest of the investigation reports regarding the resident's theft/loss of personal belonging (wallet). On 11/17/16 at 9:55 a.m., a telephone interview was conducted with Resident 23's family member. Resident 23's family member was asked about Resident 23's theft/loss of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 24 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 wallet, she stated that the incident occurred on 10/20/16. Resident 23's family member stated she was told by the social services to report the incident to the police, which was five days after the incident occured (10/25/16). She stated that she reported the incident to the police but the facility social services did not follow up on the police report. A review of the facility's policy and procedure titled, "Theft & Loss" with a revised date of 4/2013, indicated that loss or theft of residents property worth $25.00 or more will be documented and reported to the administrator for investigation, police reporting, or other appropriate action. The policy further stipulated that the documentation of lost or stolen resident's property with a value of $25.00 or more, shall include a description of the lost or stolen article, estimated value, date and time the loss or theft was discovered, if determinable, the date and time the loss or theft occurred, and action taken. b. A review of Resident 12's Admission face sheet indicated Resident 12 was admitted to the facility on 6/20/16, with diagnoses that included hypertension (abnormally high blood pressure), dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance, and acute kidney failure (abrupt loss of kidney function). A review of Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/7/16, indicated Resident 12 usually understands and had the ability to be understood by others. According to the MDS, Resident 12 does not have hallucinations (apparent perception of something not present) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 25 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 11/15/16, at approximately 8:47 a.m., Resident 12 was observed sitting in his wheelchair at the side of the bed, with eyes closed. Resident 12 did not respond upon approach and required a loud voice before the resident responded. Resident 12 stated, "Sorry, I could not hear you." On 11/17/16 at 8:10 a.m.,during an interview, Resident 12 stated "My hearing is poor. I do not understand what people tell me." A review of Resident 12's audiology evaluation, dated 7/29/16, indicated Resident 12 had hearing loss in both ears (mild to moderate). On 11/17/16 on 10:24 a.m., an interview was conducted with Social Services (SS 1). She stated, "The family member had requested the hearing aids, I made an appointment with a hearing aid company on 9/9/16, but the family member cancelled it because she was not available to take Resident 12 and it was too much money. The facility does not provide a ride to the appointments if the family is around." On 11/17/16 on 10:35 a.m., during an interview regarding residents transportation, the director of nurses (DON) stated, "The facility provides transportation for appointments, if the family is unable to take the resident." On 11/17/16 on 1:58 p.m., during a telephone interview, Resident 12's family member stated,"The social worker said that Resident 12's insurance will not cover all the cost and we have to come up with the rest of the payment. I do not think I can afford it, so I cancelled the appointment. Is there anyway insurance can cover it? I would really like for him to have the hearing aids. I feel it is really important FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 26 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 because it is his way of communicating. They told me to provide a pen and paper for him to communicate with. So I did, but when I visit him, it was not even being used." A review of the essential duties and responsibilities of a social worker indicated the social worker will assist in arranging transportation to other facilities when necessary; provide information to resident/families as to Medicare/Medicaid, and other financial assistance programs available to the resident, assist in providing solutions for social and practical environmental problems including seeking financial assistance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 27 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F253 HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.15(h)(2)

F253 12/16/2016

F257 12/16/2016 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to clean two bathroom toilet seats (Rooms 312 and 318) out of 45 resident-shared bathrooms. This deficient practice had the potential to expose the residents to disease-causing organisms that could cause infection. Findings: During a facility tour with the licensed vocational nurse (LVN 8) on 11/14/16, at 9:10 a.m., the toilet seat in the bathroom of Rooms 312 and 318 were observed with brown substance on it. During a concurrent interview, LVN 8 stated the toilet seats were dirty and needed cleaning. LVN 8 called the housekeeping staff (HS 1) and HS 1 stated the toilet seats were dirty. A review of the facility's policy titled, "Rooms, Cleaning Residents," dated 5/2007, indicated it was the facility's policy to provide a clean, comfortable, homelike and sanitary living area.

F257 SS=E COMFORTABLE & SAFE TEMPERATURE LEVELS CFR(s): 483.15(h)(6) The facility must provide comfortable and safe temperature levels. Facilities initially certified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 28 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 after October 1, 1990 must maintain a temperature range of 71 - 81° F This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that residents' rooms and hallways were at comfortable temperature levels at 71-81 Fahrenheit (F) for one of 24 sampled residents (Resident 24), and one randomly sampled resident ([RSR] 27) during an environmental tour of the facility. During a quality of life (QOL) meeting on 11/15/16, at 10 a.m., four of 11 alert residents stated they felt it was too cold in the facility. This deficient practice had the potential to put residents at risk for being too cold or susceptible to respiratory ailments and/or colds. Findings: a. On 11/16/16, at approximately 3:20 p.m., during an interview with Resident 24, the resident stated her room was too cold. On 11/16/16, at approximately 4:10 p.m. the maintenance supervisor (MS) came to check Residents 24's room temperature. The MS validated Resident 24's room being too cold by using a " temperature wand." The temperature measured at 69 degrees F. Resident 24, who was observed wearing a heavy knit sweater, stated she had complained of the room being too cold for the last two winters. The MS stated he had recalled Resident 24 requesting a heating window, which was recently denied. A review of Resident 24's Admission Face FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 29 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Sheet indicated the resident was admitted to the facility on 5/2/14, and readmitted on 6/13/14. Resident 24's diagnoses included shortness of breath ([SOB] a feeling of difficulty or labored breathing), peripheral neuropathy (weakness, numbness, and pain due to nerve damage, usually in the hands and feet), congestive heart failure ([CHF] a chronic condition in which the heart does not pump blood as well as it should), coronary artery disease ([CAD] an impedance or blockage of one or more arteries that supply blood to the heart, usually due to arteriosclerosis [hardening of the arteries]). A review of Resident 24's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/10/16, indicated Resident 24 was able to make needs known, understand others, and cognition was intact. b. On 11/14/16 at 7:31 a.m., during the facility's initial tour, Resident 27 stated her room was always cold. A review of Resident 27's Admission Face Sheet indicated the resident was admitted to the facility on 12/5/16. Resident 27's diagnoses included urinary tract infection ( [UTI] an infection in kidneys, ureters, bladder and urethra) generalized muscle weakness, with difficulty in walking, and heart failure( failure of the heart to pump effectively) A review of Resident 27's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/5/16, indicated Resident 27 was able to make needs known and understand others. c. During the facility's environmental tour, conducted with the maintenance director (DM), on 11/16/16, at approximately 1:50 p.m., the following temperatures were observed in various areas of the facility using an infrared thermometer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 30 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 gun: 1. Along the hallway in front of the case manager's office, the DM checked the temperature and the thermometer read 70 degrees Fahrenheit (F). 2. Inside of Room 424, the DM checked the temperature and the thermometer read 70 degrees F. 3. Along the hallway in front of the director of nursing's office (DON), the DM checked the temperature and the thermometer read 68 degrees F. 4. Along the hallway in front of Room 402, the DM checked the temperature and the thermometer read 65 degrees F. 5. Along the hallway in front of Room 304, the DM checked the temperature and the thermometer read 67 degrees F. 6. Inside of Room 304, the DM checked the temperature and the thermometer read 68 degrees F. During an interview on 11/16/16, at 2:35 p.m., the DM stated, "It is cold and the temperature should be 72 degrees F." A review of the facility's policy and procedure titled, "Physical Environment: Comfortable and Safe Air Temperatures," with a revision date of 11/2007, indicated to maintain comfortable and safe temperature levels throughout the facility, and in resident rooms (between the range of 71 -81 degrees Fahrenheit). The policy stipulated the maintenance director will regularly inspect temperatures throughout the facility and keep a log, and individual resident preferences may be met as possible/practicable/reasonable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 31 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F279 DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d), 483.20(k)(1)

F279 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/16/2016 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop a comprehension plan of care for three of 24 sampled residents (Residents 7, 8, and 14). Resident 7, who had hyperlipidemia (abnormally elevated levels of any or all lipids [fats] and/or lipoproteins in the blood), and was receiving medication for the condition, care plan indicated the staff's interventions included to encorage low fat and salt intake that was not implemented. Resident 8, who had a Stage IV pressure sore FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 32 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 (a wound that occurs as a result of prolonged pressure on a specific area of the body / very deep, reaching into muscle and bone and causing extensive damage) and was receiving oxygen via a nasal cannula (a device used to deliver supplemental oxygen), care plan did not address the need for a pressure relieving device around the resident's ears. Resident 14's plan of care did not address the need to assess the resident's respiratory rate, although there was an order to assess the respiratory due to receiving around the clock (ATC) Norco medication (a narcotic pain medication). These deficient practices resulted in residents not receiving individualized care or interventions and had the potential to result in harm to the residents. Findings: a. A review of Resident 7's Admission Face sheet indicated the resident was admitted to the facility on 3/1/14 and readmitted on 5/1/14. Resident 7's diagnoses included hypertension ( high blood pressure), hyperlipidemia, dementia (a broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember), and a history of falls. A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/5/16, indicated Resident 7's cognition was severely impaired and rarely had the ability to understand or be understood. According to the MDS, Resident 7 required extensive assistance to being total FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 33 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 dependent with her activities of daily living. Resident 7 was incontinent (inability to control) of bowel and bladder. A review of Resident 7's physician's orders, dated 6/16/15, indicated for Resident 7 to receive a regular pureed (mashed/blended food) textured, high protein, nectar thickened, with large portions. A review of Resident 7's care plan, dated 5/2/14, indicated Resident 7 had altered cardiovascular status related to hypertension and hyperlipidemia. The staff's intervention included encouraging Resident 7 to take a low fat and salt intake. On 11/17/16 at 8:02 a.m., during an interview, the Minimum Data Set (MDS) nurse (MDS Nurse 1) stated, while reviewing Resident 7's care plan, stated according to the care plan the resident should be receiving a low fat diet due to Resident 7's diagnosis of hyperlipidemia. MDS Nurse 1 reviewed Resident 7's diet order, which did not indicate a low fat/salt diet, as stipulated in the care plan. The MDS Nurse stated the care plan should have been specific for Resident 7. b. During a wound care observation on 11/15/16, at 9:15 a.m., Resident 8 was observed receiving oxygen via nasal cannula at two liters per minute (LPM) with no pressure relieving device around both ear lobes. A review of Resident 8's Admission Face Sheet indicated Resident 8 was most recently readmitted to the facility on 10/25/16. Resident 8's diagnoses included heart failure, dysphagia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 34 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 (difficulty swallowing), Stage IV pressure sore in the sacrum (a large, triangular bone at the base of the spine), and clostridium difficile (C. difficile - a bacterium that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon [large intestine]) infection in the stool. A review of Resident 8's Minimum Data Set ([MDS], an assessment and care screening tool), dated 11/1/16, indicated Resident 8 was severely impaired and unable to understand others. A review of Resident 8's physician orders, dated 10/25/16, indicated for Resident 8 to receive continuous oxygen at two LPM via nasal cannula. During an interview on 11/15/16, at 9:30 a.m., a licensed vocational nurse (LVN 5) was asked about Resident 8's ear lobes without any pressure relieving device, LVN 5 stated she would check the physician's orders. LVN 5 she would obtain an order if there was not one. A review of Resident 8's physician's orders indicated that staff obtained an order on 11/15/16, at 9:51 a.m., for Resident 8 to have cannula ear covers placed on both ears for protection and prevention of pressure sore. A review of Resident 8's Braden scale (an assessment tool for predicting the risk for pressure sore) indicated Resident 8 had a score of 11 which indicated that Resident 8 was a high risk for pressure sores. A review of Resident 8's care plan dated 11/16/16, which was initiated on 11/15/16, indicated that the care plan was incomplete. The care plan only addressed Resident 8's right ear for potential pressure sore FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 35 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 development and not both ears. There were no staff interventions indicated on the care plan. During an interview on 11/17/16, at 7:39 a.m., LVN 2 stated both registered nurses and licensed vocational nurses are able to do the residents' care plans. LVN 2 stated the care plan for Resident 8 was not properly completed to include both ears and it should have been. A review of the facility's policy and procedure, titled, "Resident Assessment: Nursing Care Plan," with a revision date of 5/2007, indicated to review comprehensive care plan and evaluate interventions for goal appropriateness. Address all high risk areas on form and identify changes that may have occurred since last review. c. A review of Resident 14's Admission Face Sheet indicated Resident 14 was admitted to the facility on 7/16/07. Resident 14's diagnoses included other specified rheumatoid arthritis (a disease that causes inflammation and deformity of the joints), unspecified osteoarthritis (gradual loss of cartilage of the joints), gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and causes heartburn), and unspecified dementia (a brain disease that causes a gradual decrease in the ability to remember). A review of Resident 14's Minimum Data Set (MDS), an assessment and care screening tool, dated 9/16/16, indicated Resident 14 had a Brief Interview for Mental Status (BIMS) score of four (which indicated severe impairment of cognitive status). According to the MDS, Resident 14 had the ability to usually understand and be understood. The MDS, under Section G0110 B., for Functional Status (ADL Self Performance), indicated Resident 14 required extensive assistance with a two-plus FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 36 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 person physical assist in transferring and bed mobility. On 11/15/16 at 10:30 a.m., a review of Resident 14's physician's order, dated 10/17/16, indicated to hold the administration of Norco (a pain medication) tablet 5-325mg if Resident 14's respiratory rate was under 12 or if the resident was sedated. On 11/16/16 at 10:10 a.m., a review of Resident 14's care plan, did not indicate the need to monitor the resident's respiratory rate every eight hours for the administration of Norco 5-325mg tablet as stipulated in the physician's orders. The plan of care also had no staff interventions regarding the need for respiratory assessment or to monitor for signs of sedation prior to giving the medication (Norco). On 11/18/16 at 8:20 a.m., during an interview, a registered nurse (RN 3) was inteviewed regarding Resident 14's plan of care updates. RN 3 stated the care plan should be updated if there are any changes in the resident's medical status, any new or updated physician's orders, and with each resident's specific needs. A review of the facility's policy and procedure titled, "Nursing Care Plan," with a revised date of 5/2007, indicated to address all high risk areas and identify changes that may have occurred since the last review. Areas of assessment included medication use, special treatments, and procedures.

F309 SS=E PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 12/16/2016 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 37 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: d1. Resident 7 was observed on several occasions, on 11/14/16 at 9:15 a.m., 11/14/16 at 3:30 p.m., 11/15/16 at 8:45 a.m., 11/15/16 at 3:26 p.m., and 11/16/16 at 9:52 a.m., not wearing heel protectors and/or heels being off loading, as per the physician's orders and the Resident 7's plan of care. A review of Resident 7's admission Face sheet indicated the resident was admitted to the facility on 3/1/14 and readmitted on 5/1/14. Resident 7's diagnoses included hypertension ( high blood pressure), hyperlipidemia (abnormally elevated levels of any or all lipids [fats] and/or lipoproteins in the blood), dementia (a broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember), and a history of falls. A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/5/16, indicated Resident 7's cognition was severely impaired and rarely had the ability to understand or be understood. According to the MDS, Resident 7 required extensive assistance to being total dependent with her activities of daily living. Resident 7 was incontinent (inability to control) of bowel and bladder. A review of Resident 7's physician's orders, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 38 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 dated 9/15/16, indicated to off load (float/suspend) heels with pillows and the use of heel protectors at all the times for protection and prevention of pressure sores. A review of Resident 7's care plan, dated 10/29/14, indicated Resident 7 had potential for pressure ulcer development related to disease process and immobility. The staff's interventions included to follow the facility's policies/protocols for prevention and treatment. On 11/16/16 at 9:22 a.m., during an interview, the Minimum Data Set (MDS) nurse (MDS Nurse 1) stated, while reviewing Resident 7's clinical record, the physician's order for the resident's heels to be floating and the heel protectors worn should be followed. She stated she will call the physician to clarify the order. On 11/16/16 at 9:52 a.m., while at Resident 7's bedside, the resident's primary certified nursing assistant (CNA 1) was interviewed about Resident 7 not wearing heel protectors and off loading of the heels. CNA 1 stated Resident 7 should be wearing the heel protectors and heels off loaded, but she had forgotten for the last two days. d2. A review of Resident 7's physician's order, dated 9/3/15, indicated a lipid panel (a blood test that measures lipids-fats and fatty substances used as a source of energy in your body) should be drawn yearly on the first Monday of September. The first Monday in September 2016 was 9/5/16. A review of Resident 7's laboratory results, indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 39 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 lipid panel was not drawn until 9/13/16. On 11/15/16 at 7:15 a.m., during an interview, a MDS Nurse (1) stated the lipid panel was not done as ordered by the physician. MDS Nurse 1 stated it should had been done on 9/5/16, but was not done until 9/13/16. The MDS Nurse stated it should have been done as ordered and stated, "Maybe the nurse got confused." The MDS nurse stated she was going to call the physician to possibly change the order to prevent future confusion. Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for four of 24 sampled residents (Residents 3, 4, 7, and 15) . For Resident 3, the treatment nurse applied triple antibiotic ointment to a scab without a physician's order. For Resident 4, laboratory tests were not done as ordered. For Resident 15, insulin was given, but the resident did not have anything to eat until 40 minutes later. Resident 7 had a physician's order to off load heels (suspend heels) and to have a lipid panel (a blood test that measures lipids-fats and fatty substances used as a source of energy in your body) drawn every September on the first Monday that was not implemented. These deficient practices of not following physician's orders and standard of preactice, put the residents at risk of not attaining the highest practicable well-being and at risk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 40 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 adverse consequences. Findings: a. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 11/8/16, with diagnoses that included Stage II (a partial thickness skin loss) pressure area (an area of damaged skin caused by staying in one position for too long) to the coccyx (tail bone area). The Minimum Data Set (MDS, a resident assessment and care screening tool) indicated Resident 3 required extensive assistance (weight bearing support) with daily activities, such as bed mobility, dressing, toilet use and personal hygiene. On 11/15/16, at 9 a.m., a licensed vocational nurse (LVN 3) was observed during treatment to Resident 3 (including to a scab located on the area above the upper lip and below the nose). LVN 3 stated that she usually applies A & D ointment to the scab, but since today the scab appeared moist, she would apply triple antibiotic ointment (and she did). After the procedure, at 9:15 a.m., LVN 3 stated there was no doctor's order to apply the triple antibiotic and acknowledged her failure for using the medication without an order. The facility's undated policy and procedures titled, "Physician's Orders, Telephone Orders and Recapitulation Process," indicated, "Physician's orders shall be obtained prior to the initiation of any medication or treatment." b. A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on 2/4/15, with diagnoses that included hypertension (high blood pressure) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 41 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 hypothyroidism (also known as underactive thyroid, a condition when the thyroid gland does not make enough thyroid hormone, which, in turn, causes the body to have slower metabolism). A review of Resident 4's MDS, dated 10/7/16, indicated the resident had severe impairment in decision making skills and required extensive assistance with daily activities, such as transfers, bathing and personal hygiene. A review of Resident 4's physician's order, dated 11/9/16, indicated to obtain laboratory tests for the following: 1) Complete blood count (CBC, a test used to evaluate anemia and infection), 2) Basic metabolic panel (BMP, a test to evaluate current status of kidneys as well as electrolyte and acid/base balance and level of blood sugar), and 3) Thyroidstimulating hormone (TSH, a hormone that stimulates the thyroid gland for body metabolism). A review of Resident 4's clinical records on 11/16/16 revealed no laboratory test results. During an interview, review of Resident 4's clinical record, and laboratory requisition review on 11/17/16, at 7:35 a.m., a licensed nurse (MDS 2) stated that the laboratory tests were not done, and that the physician will be notified. The facility's policy and procedures titled, "Lab Tests Protocol," revised 11/2007, indicated, "1. The Nurse noting the order for the lab test will make out the proper requisition form and plan it in the lab book, 2. The Nurse noting the order will document the order in the 24-hour Report sheet, 3. The Nurse noting the order will add it to the Diagnostic Test & Lab Log. It is kept in the Lab Book, 4. The night shift will check verify that the slip is made out and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 42 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 test requisition is entered into the Lab Book and on the Diagnostic Test & Lab Log while doing the 24-hour check off of all charts." c. A review of Resident 15's Admission Face Sheet indicated Resident 15 was admitted to the facility on 11/3/16, with diagnoses that included diabetes (a metabolism disorder that affects the body's ability to use blood sugar resulting to high levels of sugar in the blood) with diabetic neuropathy (problems with sensation in the feet). A review of Resident 15's MDS, dated 10/19/16, indicated Resident 15 was alert and oriented, required extensive assistance from one-two persons with positioning, transfers, bathing and dressing. A review of Resident 15's physician' s order, dated 11/3/16, indicated an order for Novolog (a fast-acting mealtime insulin that helps lower mealtime blood sugar spikes) flex pen solution pen-injector 100 unit/ml (milliliter) Insulin, per sliding scale (a predetermined amount of insulin to be given based on blood sugar test result), subcutaneously (given by injection into fatty tissue) before meals and at bedtime for diabetes. The care plan for Resident 15, dated 11/3/16, indicated the resident was at risk for hypo (low blood sugar) /hyperglycemia (high blood sugar) episodes. The goal was for Resident 15 to be free from any signs and symptoms of hypoglycemia. On 11/14/16, at 12:51 p.m., during a medication pass observation and interview, licensed vocational nurse (LVN 6) was observed preparing and administering Resident 15's medications that included Novolog insulin which was injected subcutaneously into his left FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 43 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 lower stomach area. LVN 6 stated Resident 15's lunch tray had not arrived and should be delivered in 10 to 15 minutes. On 11/14/16, at 1 p.m., during an interview, Resident 15 stated he had not been given a snack or received his lunch and his last meal was at 8 a.m. that morning. Resident 15 stated he usually receives a lunch tray between 12:30 p.m. and 1 p.m., but does not receive a daily snack. At 1:03 p.m., on the same day (11/14/16), LVN 6 stated that Resident 15 had not eaten or received his lunch and ordered Resident 15 a snack that arrived at 1:14 p.m. (23 minutes after Novolog insulin injection) and at 1:20 p.m. his lunch tray arrived (29 minutes after insulin injection). Resident 15's meal was delayed for over 20 minutes after his Novolog insulin injection. A review of the manufacturer's package insert for insulin Novolog Flex Pen solution peninjector, indicated that the medication should be given immediately (within 5-10 minutes) prior to the start of a meal. During an interview with the registered dietitian (RD), on 11/17/16, at 10 a.m., he stated that nurses may request an early meal tray or snack for diabetic residents, by completing a pink slip, titled, " Nursing-Dietary Communication Form". The RD stated that he interviews each resident at admission to ask them their preferences for meals and snacks; he indicated that a resident can change their preferences at any time and the kitchen also had sugar-free snacks and diabetic-type snacks available. On 1/17/16, at 10:20 a.m., during a record review and interview, licensed vocational nurse (LVN 2), stated that the facility's sliding scale FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 44 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 schedule for insulin administration was 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. LVN 2 stated that ideally, a resident should eat 30 minutes after receiving insulin, although the insulin can be given one hour before or after the scheduled time, so it could be given closer to the meal. A review of Resident 15's medication administration history for Novolog Flex Pen solution pen-injector, insulin was administered to Resident 15 at 12:15 p.m., on 11/14/16 ; 12:05 p.m., on 11/15/16; and 12:15 p.m. on 11/16/16. A review of the facility's meal service cart delivery schedule indicated that lunch trays were to be delivered to Station 4 (where Resident 15 was located) at 12:50 p.m. and 1 p.m. daily. At 2:15 p.m., on 11/17/16, LVN 1 stated that Resident 15 had a snack with his insulin today, but he usually does not receive a snack unless it is ordered with the sliding scale. LVN 1 stated that Resident 15 only received a snack today because he had other medication administered that is ordered with food. LVN 1 stated that some residents have sliding scale orders to give with food. LVN 1 stated, "If the order indicates with food, then we give it [medication] with food". LVN 1 stated, "He (Resident 15) does not have that type of sliding scale order, so he does not usually receive food with his insulin". LVN 1 was asked if she had access to the packet insert (instructions for use) for Resident 15's insulin pen-injector, LVN 1 stated that only the insulin pen-injector was stocked in the medication cart; she did not have access to the package insert or original container. LVN 1 stated the pharmacist would have that information. On 11/17/16, at 3 p.m., during an interview, the pharmacist (PD) stated that for the type of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 45 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 insulin pen-injector that Resident 15 had ordered, food should be given to the resident within 5-10 minutes, according to the package insert. PD stated, "I don't think it should be delayed more than 30 minutes." At 3:20 p.m., on 11/17/16, LVN 1 stated, "I guess it shouldn't be so long before the food comes; it could be a problem. I understand now." On 11/17/16, at 3:25 p.m., during an interview, the director of nursing (DON) stated according to the facility's meal service cart delivery schedule, the lunch meal trays arrive at 12:50 p.m. and 1 p.m. for residents at Station 4. The DON was asked if she thought it was appropriate to administer insulin at 11:30 a.m. and have the lunch trays arrive at 1 p.m. for residents on Station 4, DON stated, "No, nursing practice and nursing judgement tells me it should be within 30 minutes. I'm seeing something doesn't jive here; there's a problem with communication between the departments." The DON stated that she saw an opportunity to improve the situation. According to the facility's policy, titled, "Medication Administration", dated 5/2007, indicated that medications are administered as prescribed in accordance with good nursing principles and practices. A review of the facility policy, titled, "Diabetes Mellitus Resident, Nursing Care of", indicated it is the policy of the facility to assist the resident to establish a balance between diet, exercise, and insulin; prevent recurrence of hypoglycemia (low blood sugar), and to assist in determining approaches to special dietary problems.

F313 TREATMENT/DEVICES TO MAINTAIN FORM CMS-2567(02-99) Previous Versions Obsolete

F313 Event ID: 1MGY11 12/16/2016 Facility ID: CA940000015 If continuation sheet 46 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D HEARING/VISION CFR(s): 483.25(b) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to coordinate and ensure arrangements, per physician's orders were implemented for auditory services for one of 24 sampled residents (Resident 12). Resident 12's physician's order was not followed-up for three months (cross referenced to F250 b). This deficiency practice had the potential to result in Resident 12's decline in quality of life. Findings: A review of Resident 12's Admission Face Sheet indicated Resident 12 was admitted to the facility on 6/20/16. Resident 12's diagnoses included hypertension (high blood pressure), dementia (a disorder that effects the brain) without behavioral disturbance, and acute kidney failure (abrupt loss of kidney function). A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/7/16, indicated Resident 12 usually had the ability understand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 47 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 and be understood. According to the MDS, Resident 12 required extensive assistance with a one-person physical assist for walking, dressing, and toilet use. On 11/15/16, at approximately 8:47 a.m., Resident 12 was observed sitting in his wheelchair at the side of the bed, with his eyes closed. Resident 12 was greeted and Resident 12 responded, "Sorry, I could not hear you." On 11/17/16, at 8:10 a.m., during an interview, Resident 12 stated, "My hearing is poor. I don't understand what people tell me." A review of Resident 12's audiology (the study of hearing disorders) evaluation, dated 7/29/16, indicated Resident 12 had hearing loss in both ears (mild to moderate). A review of Resident 12's physician's order summary report, dated 8/24/16, indicated an audiology evaluation for hearing aids and to obtain authorization from Resident 12's insurance for the hearing aids. On 11/17/16 at 10:24 a.m., an interview was conducted with the social services director (SSD 1). SSD 1 stated, "The family member had requested the hearing aids, I made an appointment with a company on 9/9/16, but the family member cancelled it, she was not available and it was too much money, and the facility does not provide a ride to the appointments if the family is around." On 11/17/16, at 11:35 a.m., during an interview, the director of nurses (DON) was asked about residents' transportation for appointments. The DON stated, "The facility provides transportation for residents' appointments, if the family is unable to take the resident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 48 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 11/17/16, at 1:58 p.m., during a telephone interview, Resident 12's family member stated, "The social worker said that Resident 12's insurance will not cover all the cost of the hearing aids and we have to come up with the rest of the payment. I do not think I can afford it, so I cancelled the appointment. Is there anyway insurance can cover it? I would really like for him to have the hearing aids. I feel it is really important because it is his way of communicating. They told me to provide a pen and paper so I did, but when I visit him, it was not even being used." A review of Resident 12's care plan, dated 7/19/16, titled, "At risk for a communication problem related to hearing deficit," indicated the staff's interventions included to anticipate and meet needs, be conscious of resident position when in groups, activities, dining room to promote proper communication with others, discuss with resident resident/family concerns or feelings regarding communication difficulty, encourage resident to continue stating thoughts even if resident is having difficulty, focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation. According to the facility's undated Social Services Policy and Procedure Manual, Social services will coordinate and maintain a system to monitor the Dental, Optometry, Audiology and Podiatry evaluations. Social services staff member will obtain consent to evaluation(s) prior to scheduling appointments.

F314 SS=E TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(c) FORM CMS-2567(02-99) Previous Versions Obsolete

F314 Event ID: 1MGY11 12/16/2016 Facility ID: CA940000015 If continuation sheet 49 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment to promote healing and/or to prevent the development of new pressure ulcers (injury to the skin and underlying tissue due to prolonged pressure to the area) for three of five sampled residents (Residents 3, 7 and 8), who had pressure uclers or were at risk of developing pressure ulcers, in a total sample of 24 residents. Resident 3, who had a Stage II pressure ulcer (the outer layer of skin and part of the underlying layer of skin is damaged or lost) on the coccyx (tailbone) area, was observed numerous times on a flat-lying position (the affected coccyx area pressing against the mattress). Resident 7 had no heel protectors/offloading heels, despite having a physician's order to do both in order to prevent pressure ulcer development. Resident 8, who was receiving continuous oxygen inhalation by nasal cannula (a thin, plastic tube that delivers oxygen directly into the nose through two small prongs), did not have a pressure-relieving device to prevent the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 50 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 development of pressure ulcer(s) behind the earlobes where the nasal cannula is placed. These deficient practices put the residents at risk for developing pressure sores and for adequate wound healing of the current pressure sores. Findings: a. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 11/8/16, with diagnoses that included Stage II pressure area to the coccyx and multiple sclerosis (a progressive autoimmune disorder that wears away at the coverings that protect the nerve cells, gradually weakening bodily function by attacking the cells of the brain and spinal column). The Minimum Data Set (MDS, a resident assessment and care screening tool) indicated Resident 3 required extensive assistance (weight bearing support) with daily activities, such as bed mobility, dressing, toilet use and personal hygiene. During the course of the survey (including on 11/14/16, at 9:30 a.m., 11/15/16, at 9 a.m., and 11/16/16, at 7:14 a.m.), Resident 3 was observed numerous times on a flat-lying position, with the affected coccyx area pressing directly on the mattress. According to Medical Surgical Nursing, 9th Edition, pages 186-187, "Prevention remains the best treatment for pressure sores. Reposition the patients frequently to prevent pressure sore at least every two hours and every hour when in chair. Never position the patient directly on the pressure sore." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 51 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of Resident 3's care plan, dated 11/15/16, indicated the resident had a Stage II pressure ulcer on the coccyx area upon admission to the facility. The goal was for the pressure ulcer to show signs of healing and to remain free from infection. There was no indication to offload the affected area and/or to reposition Resident 3 every two hours. During an interview on 11/16/16, at 7:20 a.m., a licensed nurse (MDS 2) stated it is the facility's failure for having Resident 3's pressure ulcer directly on the mattress. MDS 2 stated that staff should be turning Resident 3 side to side every two hours. The facility's policy and procedures, Nursing Administration, Subject: Pressure Ulcers, revised 05/2007, indicated, "1. Relieve the underlying cause of pressure, addressing pressure, shear, other physical friction and maceration (skin is softened, turns white, and broken down by extended exposure to wetness or moisture), /moisture factors. 2. Encourage mobility/ambulation. Reposition/turn at least every two (2) hours. 3. Position body with pillows, foam wedges, and/or other support devices turning the resident at 30 degrees oblique angles to avoid pressure over body prominences." b. Resident 7 was observed on several occasions, on 11/14/16 at 9:15 a.m., 11/14/16 at 3:30 p.m., 11/15/16 at 8:45 a.m., 11/15/16 at 3:26 p.m., and 11/16/16 at 9:52 a.m., not wearing heel protectors and/or heels being off loading, as per the physician's orders and the Resident 7's plan of care. A review of Resident 7's Admission Face Sheet indicated the resident was admitted to the facility on 3/1/14 and readmitted on 5/1/14. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 52 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Resident 7's diagnoses included hypertension ( high blood pressure), hyperlipidemia (abnormally elevated levels of any or all lipids [fats] and/or lipoproteins in the blood), dementia (a broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember), and a history of falls. A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/5/16, indicated Resident 7's cognition was severely impaired and rarely had the ability to understand or be understood. According to the MDS, Resident 7 required extensive assistance to being total dependent with her activities of daily living. Resident 7 was incontinent (inability to control) of bowel and bladder. A review of Resident 7's Braden Score for Predicting Pressure Sores, dated 9/14/16, indicated Resident 7 had a score of 11 (high risk). A review of Resident 7's physician's orders, dated 9/15/16, indicated to off load the resident's feet with pillows and use heel protectors at all the times for protection and prevention. A review of Resident 7's care plan, dated 10/29/14, indicated Resident 7 had potential for pressure ulcer development related to disease process and immobility. The staff's interventions included to follow the facility's policies/protocol a for prevention and treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 53 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 11/16/16 at 9:22 a.m., during an interview, the Minimum Data Set (MDS) nurse (MDS Nurse 1) stated, while reveiwing Resident 7's clinical record, the physician's order for the resident's heels to be floating and the heel protectors worn should be followed. She stated she will call the physician to clarify the order. On 11/16/16 at 9:52 a.m., while at Resident 7's bedside, the resident's primary certified nursing assistant (CNA 1) was asked about Resident 7 not wearing heel protectors and the off loading of the heels. CNA 1 stated Resident 7 should be wearing the heel protectors and heels off loaded, but she had forgotten for the last two days. c. During a wound care (Stage IV pressure sore) observation on 11/15/16, at 9:15 a.m., Resident 8 was observed receiving oxygen via nasal cannula at two liters per minute (LPM) with no pressure relieving device around both ear lobes. A review of Resident 8's Admission Face Sheet indicated Resident 8 was most recently readmitted to the facility on 10/25/16. Resident 8's diagnoses included heart failure, dysphagia (difficulty swallowing), Stage IV pressure sore in the sacrum (a large, triangular bone at the base of the spine), and clostridium difficile (C. difficile [a bacterium that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon {large intestine}]) infection in the stool. A review of Resident 8's Minimum Data Set ([MDS], an assessment and care screening tool), dated 11/1/16, indicated Resident 8 was severely impaired and unable to understand others. A review of Resident 8's care plan initiated on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 54 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 10/25/16, indicated Resident 8 had pressure sore to sacralcoccyx (area at the bottom portion of the spine) and had potential for pressure sore development related to history of ulcers, immobility (inability to move), frail, poor clinical condition, bowel incontinence (inability to control bowel movements), friction, shear. A review of Resident 8's Braden scale (an assessment tool for predicting the risk for pressure sore development), dated 11/8/16, indicated Resident 8 had a score of 11, which indicated that Resident 8 was a high risk for pressure sores. A review of Resident 8's physician orders, dated 10/25/16, indicated for Resident 8 to receive continuous oxygen at two LPM via nasal cannula. During an interview on 11/15/16, at 9:30 a.m., a licensed vocational nurse (LVN 5) was asked about Resident 8's ear lobes not having any pressure relieving device, LVN 5 stated she would check the physician's orders and obtain an order if there is not one. During an interview on 11/15/16, at 2:49 p.m., the MDS nurse (MDS Nurse 1) stated it was the responsibility of the staff from central supply to put on the protective covering when the oxygen nasal cannula tubing needs to be changed. MDS Nurse 1 stated that it was not done and that it should have been done. A review of Resident 8's physician's orders on 11/15/16, and timed at 9:51 a.m., indicated the physician ordered for Resident 8 to have cannula ear covers on both ears for protection and prevention of pressure sores. A review of the facility's policy titled, "Care and Treatment: Pressure Injury," with a revision FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 55 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 date of 5/2007, indicated that it was the policy of the facility that a resident having pressure injury received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The purpose of the policy was to promote the prevention of pressure injury development and prevent development of additional pressure injury.

F315 SS=E NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(d)

F315 12/16/2016 Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. This REQUIREMENT is not met as evidenced by: c. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 11/8/16, with diagnoses that included multiple sclerosis (a progressive autoimmune disorder that wears away at the coverings that protect the nerve cells, gradually weakening bodily function by attacking the cells of the brain and spinal column) and Stage II pressure ulcer (the outer layer of skin and part of the underlying layer of skin is damaged or lost due to prolonged pressure) to the coccyx (tail bone area). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 56 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 The Minimum Data Set (MDS, a resident assessment and care screening tool) indicated Resident 3 required extensive assistance (weight bearing support) with daily activities, such as bed mobility, dressing, toilet use and personal hygiene. A review of Resident 3's physician's order, dated 11/8/16, indicated for the resident to have an indwelling urinary catheter for the following reason: wound management (Stage II pressure ulcer to the coccyx area). During an interview on 11/16/16, at 7:20 a.m., a licensed nurse (MDS 2) stated that an indwelling urinary catheter was indicated for pressure ulcers that were at Stage III or Stage IV (full thickness skin loss), but not for Stage II pressure ulcers. A review of Resident 3's care plan, dated 11/15/16, indicated the resident had a Stage II pressure ulcer on the coccyx area upon admission to the facility. The goal was for the pressure ulcer to show signs of healing and to remain free from infection. Interventions included to administer treatments as ordered and to assess/record/monitor wound healing. There was no indication for care for the use of an indwelling urinary catheter. The facility's policy and procedures, Pressure Ulcer Management Protocol, revised 5/2007, indicated that an indwelling urinary catheter may be used for wound management of Stage III or Stage IV pressure ulcer, per physician's order. Based on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 57 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 prevent urinary tract infections ([UTIs] an infection of the urinary tract that causes urgency, pain, and a burning feeling upon urination) and were catheterized (placement or insertion of a latex or silicone tube known as a urinary catheter into the urinary bladder through the urethra, allowing urine to drain freely) only when necessary for three of 24 sampled residents (Residents 3, 21, and 23). Resident 23, who had a history of UTIs requiring antibiotic (used to treat infections) therapies, had a supra-pubic urinary catheter (a thin sterile flexible tube that is used to drain urine from the bladder inserted through a cut in the abdomen, a few inches below the navel) with the bag lying on Resident 23's chest/abdomen area while the urine was observed back flowing toward the bladder. Resident 21, who waited for periods of time, holding her urine, while waiting for assistance to go to the bathroom, developed four UTIs with abdominal pain within a six month period requiring antibiotic therapy. Resident 3 had no clinical indication for the need to have an indwelling urinary catheter. These failures resulted in the residents developing recurrent UTIs and having pain, which had the potential to result in urosepsis (a life-threatening bacterial infection, a complication of urinary tract infections). Findings: a. During a quality of life (QOL) group interview, conducted on 11/15/16, at 10 a.m., with 11 alert residents in attendance, Resident 21 stated the staff does not answer her call light timely resulting in her holding her urine for long periods of time, having accidents, and not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 58 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 getting changed on time. During the QOL interview, the ombudsman (a patient advocate) in attendance stated on her many visits to the facility she would see the CNAs (certified nurse assistant) huddled in one area talking amongst themselves. A review of Resident 21's Admission Face Sheet and clinical record indicated Resident 21 was admitted to the facility on 2/26/16. Resident 21's diagnoses included Stage IV chronic kidney disease (advanced kidney damage), hypertension (high blood pressure), and a history of multiple urinary tract infections. A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21's Brief Interview for Mental Status (BIMS) score was 9 (8-15=interviewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use. On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she urinated a lot and had a history of UTIs. Resident 21 stated she waits a long time for the certified nursing assistants (CNAs) to respond to the call light when she wanted to go to the bathroom. Resident 21 stated it hurts her abdomen when she had to wait long to urinate. Resident 21 stated sometimes she had to wait so long for the CNA to come and assist her to the bathroom she would wet herself. Resident 21 stated during her eight month stay at the facility, the CNAs would sometimes come in and turn off the call light and not assist her. Resident 21 stated the CNAs would say, "I'll get your nurse, but no one ever comes back." When Resident 21 was asked how she felt when it happened she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 59 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 stated, "It doesn't make me feel too good." A review of Resident 21's nurse's notes/clinical record indicated Resident 21 had four UTIs over a six month period from (4/2016-10/2016), on 4/21/16, 6/1/16, 8/21/16, and 10/10/16. A review of Resident 21's Medication Administration Record (MAR), for the month of 4/2016, from 4/1/16-4/30/16, indicated Resident 21's antibiotic therapy was started on 4/21/16 at 2:21 p.m., of Ciprofloxacin ([Cipro] an antibiotic used to treat a number of bacterial infections) 250 milligram (mg) two times a day (BID) for 10 days for UTI. A review of Resident 21's laboratory urinalysis ([UA] analysis of urine to detect the presence of disease) results, dated 6/1/16, and timed at 11:41 a.m., indicated the leukocyte esterase (a type of enzyme produced by white blood cells [indicative of UTI]) result was out of range at 2+ (normal reference range [NRR] results should be negative). Resident 21's white blood cell ([WBC] indicative of the presence of an infection if elevated) count on the same date was elevated at 11-20 (NRR should be 0-5). A review of Resident 21's physician orders, dated 6/1/16, and timed at 9 p.m., indicated Resident 21 was started on another antibiotic. The physician ordered ceftriazone sodium (an antibiotic used to treat bacterial infections) solution one (1) gram (one thousand milligrams) intravenously ([IV] into the vein) for 10 days at bedtime for UTI. A review of Resident 21's laboratory UA results, dated 8/20/16, and timed at 6:02 p.m., indicated the leukocyte esterase was 3+ (NRR=should be negative), the WBC count was >50 (greater than 50 ), and the bacteria was moderate (NRR should be negative). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 60 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 According to a nurses' note, dated 8/20/16, and timed at 10:29 p.m., Resident 21 complained of lower abdominal discomfort and had dysuria (pain while urinating). According to Resident 21's MAR, for the month of 8/2016, Resident 21 received a new order for medication on 8/21/16 at 1 p.m., for Augmentin (an antibiotic used to treat a bacterial infections) 500 mg three times (TID) a day for 10 days. A review of Resident 21's laboratory UA results, dated 10/3/16, and timed at 8:58 a.m., indicated nitrite was present (which is indicative of a UTI ) was positive (NRR=should be negative), leukocyte esterase was 3+, WBC count was >50, and the bacteria was few. Resident 21's MAR, for the month of 10/2016 indicated Resident 21 received Augmentin (an antibiotic used to treat a number of bacterial infections) 250-125 mg TID. A review of Resident 21's UA results, dated 10/24/16, and timed at 9:49 a.m., the leukocyte esterase was noted as trace, the WBC count was elevated at 11-20, and the bacteria was few. Resident 21's urine culture (a test to find and identify germs [usually bacteria] that may be causing a urinary tract infection), dated 10/27/16, and timed at 3:32 p.m., indicated that two organisms were present in Resident 21's urine, Escherichia coli (a germ, or bacterium, that lives in the digestive tracts of humans and animals) and Providencia stuartii (a bacterial species isolated from urinary tract infections and from small outbreaks and random cases of diarrheal disease). A review of Resident 21's MAR, for the month of 10/2016, indicated Resident 21 received Pyridium (a medication used to treat pain, burning, increased urination, and the increased urge to urinate) tablet 100 mg TID for dysuria (painful urination). The MAR, also indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 61 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Resident 21 was started on cranberry tablets (is acidic and can interfere with unwanted bacteria in the urinary tract) 450 mg, every day for prophylaxis (prevention of UTI), started on 10/26/16 at 2:38 p.m. On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated she waited at least 10-15 minutes for a CNA to assist her to the bathroom. Resident 21 stated she had pains in her abdomen sometimes and it started since she had been in the facility. Resident 21 stated, "I think my pain is happening because they make me wait so long." A review of an article by the American Urological Association, titled, " What Causes a UTI? " indicated holding urine in the bladder can increase the risks of UTI at <http://www.urologyhealth.org/urologicconditions/urinary-tract-infections-inadults/causes> On 11/17/16 at 10:35 a.m., during an interview, a registered nurse (RN 3) stated a resident's call light should be answered as soon as possible, even if it was not that CNA's resident. When RN 3 was asked what could happened if a resident hold their urine for long periods of time, RN 3 stated, "A backflow of urine could happen, which could cause an infection [sic]." On 11/17/16 at 10:41 a.m., CNA 7 was asked how long should it take for a resident's call light to be answered after it was activated; CNA 7 stated the resident should not wait longer than one minute. CNA7 was asked if 10-15 minutes was a long time to wait for assistance, CNA 7 stated, "Fifteen minutes is too long. Five minutes is too long. My coworkers should go, if I can't answer it (the call light)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 62 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of Resident 21's care plan, dated 8/20/16, and titled, "At risk for UTI related to dysuria, abdominal discomfort and scanty urine," indicated the staff's interventions included to check Resident 21 for incontinence (a loss of control of the bladder), encourage adequate fluid intake, monitor intake and output, and obtain vital signs as ordered per the facility's protocol. A review of Resident 21's care plan, dated 10/10/16, titled, "On antibiotic therapy related to UTI," indicated the staff's interventions included to administer medication as ordered, and noted that any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions, to monitor every shift for adverse (harmful) reaction, observe for possible side effects every shift, and report pertinent lab results to the physician. On 11/17/16 at 12:29 p.m., during an interview with a physician (Physician 1), a nephrologist (a physician who specialized in kidney care and treating diseases of the kidneys), was asked if holding urine can result in UTI and Physician 1 stated, "It is advisable to void (urinate) frequently and older residents may have stress incontinence (the involuntary leakage of urine) so they may want to train the resident to void timely at least every four hours. Holding urine can be a complicating factor to develop a UTI. " On 11/18/16 at 9:22 a.m., during a telephone interview, Resident 21's family member stated Resident 21 told him that she had been holding her urine. Resident 21's family member stated that he had witnessed the staff take a long time to take Resident 21 to the bathroom. Resident 21's family member stated Resident 21 would wait up to 15 minutes sometimes. Resident 21's family member stated, "There's a trick to it. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 63 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 When the light goes on, they (staff) come and turn it off, because it's on a timer and leave and no one comes back to assist her (Resident 21). I have seen it." On 11/18/16 at 9:48 a.m., during an interview, the facility's director of staff development (DSD) stated that the call lights are on a timer and when the resident pushes the call light, the timer starts. A review of the facility's policy titled, "Call Light/Bell," with a revision date of 5/2007, indicated the staff should answer the call light within a reasonable time (3-5 minutes), listen to the resident's request/need, and to respond to the request. b. On 11/17/16 at 9:59 a.m., Resident 23 was observed in bed with the urinary catheter bag with straw-colored urine draining in the bag and tubing. The catheter's bag was lying on top of Resident 23's chest/abdomen area. Resident 23 stated she was waiting for the certified nursing assistant (CNA 6) to come back with the lift to transfer her to the wheelchair. The urine was observed in the catheter tubing back flowing upward toward Resident 23's bladder. Resident 23 stated the CNAs always placed the catheter bag on top of her for transferring. A review of an article by Drugs.com, titled "Foley Catheter Placement and Care," indicated the drainage bag should be below the level of the waist, which helps the urine from moving back up the tubing and into the bladder. The article indicated the tubing should not be looped or kinked, because it can also cause urine to back up and collect into the bladder <https://www.drugs.com/cg/foley-catheterplacement-and> care.html. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 64 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 At 10:03 a.m., on 11/17/16, a registered nurse (RN3) was called into Resident 23's room to see the resident's catheter bag placement above her bladder. RN 3 came to Resident 23's bedside and stated the catheter should not be higher than the bladder. Resident 23 stated, "It's okay, this is how we do the transfer to the wheelchair." RN 3 stated Resident 23 had a history of UTIs and was receiving prophylaxis (prevention) antibiotics for recurrent UTIs. On 11/17/16 at 11:05 a.m., during an interview, CNA 6 stated she had cared for Resident 23 for over three years, because the resident was particular what CNA cared for her due to the resident's pickiness and routine. CNA 6 stated she knew Resident 23's habits and how the resident liked things. CNA 6 stated she gets Resident 23 up in the wheelchair every day and she understands the importance of the urinary catheter bag placement being below the bladder to prevent backflow and UTIs, because she was just in-serviced by RN3. A review of Resident 23's Admission Face Sheet indicated Resident 23 was admitted to the facility on 3/17/04. Resident 23's diagnoses included multiple sclerosis (disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, complete paraplegia (complete paralysis [loss of muscle function] of the lower half of the body), orthostatic hypotension (low blood pressure when standing up), generalized anxiety disorder (feelings of fear), major depressive disorder (persistent feelings of sadness), and gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and caused heartburn). A review of Resident 23's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 65 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 (MDS), an assessment and care screening tool, dated 8/15/16, indicated Resident 23 had a Brief Interview for Mental Status (BIMS) score of 14 ([cognition intact] had the ability to make decisions). According to the MDS, Resident 23 had the ability to understand and be understood. The MDS, under Section G0110 B., for Functional Status (ADL Self Performance), indicated Resident 23 required an extensive assistance of a two-plus person physical assist with bed mobility and transferring. The MDS indicated Resident 23 was incontinent (inability to control) of bowel/bladder and had a supra pubic catheter. The following are Resident 23's urine culture results: 1. On 12/29/15, a urine culture was positive for the organism Morganella Morganii. Resident 23 started on Ertapenem 1 gm IV (into the vein [used to treat severe infections of the skin, lungs, stomach, pelvis, and urinary tract]) piggy back given for seven days. 2. On 2/9/16, a urine culture was positive for the organisms Proteus mirabilis > (greater than) 100,000 colonies/ml. A handwritten note on the lab results indicated 10 doses of oral Amoxil 500mg were ordered until culture and sensitivity results. 3. On 3/8/16, a urine culture was positive for Proteus mirabilis (>100,000 colonies/ml) and an Enterococcus species (50,000 colonies/ml). According to the handwritten note on the UA report, Resident 23 was started on Zosyn (an antibiotic) 3.375g every six hours for 10 days. 4. On 5/10/16, a urine culture was identified to have many bacteria and was positive for the organism Klebsiella pneumoniae (>100,000 colonies/ml) and Staphylococcus aureus FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 66 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 (50,000 colonies/ml). 5. On 6/24/16, a urine culture/chemistry indicated Resident 23's urine was positive for 3+ Leukocyte Esterase (indicative of a UTI), turbid in appearance (cloudy, opaque or thick), red blood cell >30, white blood cell >50, bacteria few, and budding yeast. The urine culture was positive for Proteus mirabilis. On 6/27/16, Amoxicillin (an antibiotic) 500 mg was started TID for 10 days. A review of Resident 23's physician's orders via a telephone order, dated 6/27/16, indicated Amoxicillin capsule 250 milligrams (mg) was ordered by the physician to be administered by mouth once a day for UTI prophylaxis (prevention) for 60 days. Another physician's order, dated 9/8/16, indicated to continue the Amoxicillin 250 mg for a total of 90 days. A review of Resident 23's care plan, initiated on 6/27/16, identified Resident 23 at risk for a potential problem with receiving antibiotic therapy related to UTI prophylaxis. The goal indicated Resident 23 would be free of any discomfort or adverse side effects of the antibiotic therapy through a review date of 11/24/16. The staff interventions included to administer medication (antibiotic) as ordered. A review of a medication regimen review (MRR) for Resident 23, conducted by the facility's pharmacist consultant (PC), dated 8/8/16, indicated that an antibiotic used for prophylaxis was not recommended due to the risk of bacteria developing resistance to the antibiotic. The PC documented, "Please evaluate for a stop date." A review of Resident 23's Medication Administration Records (MARs) for the months FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 67 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 of 8/2016, 9/2016, and 10/2016, indicated Resident 23 continued to receive the prophylaxis Amoxicillin every day until 10/8/16, two months after the PC recommended discontinuing the antibiotic. On 11/17/16 at 2:15 p.m., during an interview, the Minimum Data Set Nurse (MDS Nurse 1) stated they provided teaching to Resident 23 regarding the level of the indwelling urinary catheter bag placement. MDS Nurse 1 stated Resident 23 was adamant about placing the catheter bag on her chest/abdomen area, since it was her routine throughout the years. MDS Nurse 1 stated Resident 23 stated, "I have been here for over 13 years doing the same thing, and I am not going to change anything!" The MDS Nurse 1 stated the staff met and decided to have Resident 23's urinary catheter clamped during transfer to avoid the urine backflow into Resident 23's bladder. A review of the facility's undated policy, titled, "Prevention of Urinary Tract Infection/Indwelling Urinary Catheter," indicated an unobstructed downward flow will be maintained at all times unless the catheter is clamped for a procedure. The policy also indicated the urine collection bag will be maintained below the level of the bladder.

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 12/16/2016 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 68 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the residents' shared bathroom floor was free of potential hazards, by not replacing a burnedout lightbulb resulting to inadequate lighting and by not cleaning up spilled fluid on the floor in one of 45 shared residents' bathrooms (Room 312). This deficient practice had the potential to place the residents at risk for falls. Findings: On 11/14/16, at 9:30 a.m., during the facility's initial tour with a licensed vocational nurse (LVN 8), one of the lightbulbs in the residents' bathroom (Room 318) was observed burned out and there was a clear substance (water) on the bathroom floor, below the sink to the pathway of the toilet. LVN 8 called the housekeeping staff (HS) to clean the floor. HS stated, "Oh I see it, I will clean it up." At 10 a.m., on 11/14/16, during an interview, LVN 8 stated, "Each morning the professional staff have a meeting (including the maintenance staff [MS]), during that time, we report to MS if something is wrong." LVN 8 stated, "We also have a maintenance log at the Nurses' Station to report things." A review of the maintenance log book indicated there was no record of a work order to replace the burned-out lightbulb in the bathroom of Room 318. On 11/14/16, at 10:15 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 69 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 interview, the director of maintenance (DM) was asked how do staff report burned-out lightbulbs or broken equipment, the DM stated that staff can tell him by using their radio headset or the evening shift can write a note and leave it in the maintenance shop and he will review the notes the next day. DM was asked what is the process for reviewing maintenance orders placed in the maintenance log book, DM stated, "We don't work with that anymore." DM stated that he did not know how long it had been since he and his staff stopped reviewing the maintenance log book. DM was asked what is the process to communicate to staff, once a maintenance request has been completed, DM stated, "We respond on the radio that it was fixed." DM was asked if there is a facility policy on maintenance requests/repairs, DM stated that he was not sure if there was a policy. According to the facility policy titled, "Rooms, Cleaning Residents," dated 5/2007 indicated that staff are to report any maintenance repairs needed. According to the facility's undated policy titled, "Repair of non-functioning items," indicated it is the policy of the facility to repair anything in the facility that is not functioning correctly that can be repaired. When there is something that needs to be repaired, facility employees inform the maintenance department via one of the following methods: a) verbally - either in person or through the communication radios, b) maintenance logs-employees can write a brief description of the repair that needs to be completed in the maintenance log books, or c) Nursing 24-hour report - the following day during stand-up (a meeting with professional staff) for any repairs that are written in the report, they are communicated to the maintenance department. When the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 70 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 maintenance department is informed of the necessary repairs, someone from maintenance will perform the repair.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(k)

F328 12/16/2016 The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility's staff failed to ensure that one (Resident 3) of four residents with oxygen inhalation therapy, in a total sample of 24 residents, was provided the correct amount of oxygen flow rate as ordered by the physician. Resident 3 was receiving oxygen at 3 liters per min (L/min), but the physician's order was 2 L/min. This deficient practice puts the resident at risk of getting more oxygen than the body required, which may result in untoward reactions (anxiety, dizziness, difficulty in breathing, damage to the eyes). Findings: A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 11/8/16, with diagnoses that included pneumonia (lung infection). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 71 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 The Minimum Data Set (MDS, a resident assessment and care screening tool) indicated Resident 3 required extensive assistance (weight bearing support) with daily activities, such as bed mobility, dressing, toilet use and personal hygiene. On 11/14/16, at 9:30 a.m., in the presence of the licensed nurse (MDS 2), Resident 3 was observed in bed receiving oxygen at 3 L/min through a nasal cannula (a thin, plastic tube that delivers oxygen directly into the nose through two small prongs). A review of Resident 3's physician's order, dated 11/8/16, indicated to administer 2 L/min of oxygen continuously until 11/17/16. During an interview and review of Resident 3's clinical record on 11/14/16, at 9:55 a.m., MDS 2 stated the facility staff's failure of setting Resident 3's oxygen flow rate at 3 L/min and stated it should only be at 2 L/min. A review of Resident 3's care plan, dated 11/14/16, indicated the resident had oxygen therapy related to respiratory illness/pneumonia. Interventions included administering medication (oxygen) as ordered by the physician. The facility's policy and procedures, Oxygen Administration (Mask, Cannula, Catheter), revised 5/2007, indicated, "Check oxygen flowmeter for correct liter flow."

F329 SS=E DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l)

F329 12/16/2016 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 72 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 12 and 14) and one of six randomly selected residents (RSR 28), were free from unnecessary drugs. Resident 12 was receiving increasing doses of four psychotropic medications, Risperdal (an atypical antipsychotic), Depakote (a moodstabilizing medication), Zoloft (an antidepressant medication), and Ativan ([Lorazepam] a sedating antianxiety medication). There was no documented evidence of non-pharmacological interventions, and no documented attempt for gradual dose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 73 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 reductions (GDR). Resident 14 was receiving a narcotic pain medication (Norco Tablet 5-325 mg) for chronic pain every eight hours around the clock. The pharmacist consultant (PC) recommended and the physician ordered for Resident 14's respiratory rate to be assessed prior to administering that was not followed. These deficient practices resulted in the physician's orders and the PC consultants recommendation not being followed and had the potential to result in an adverse effects to Residents 12 and 14. Findings: a. According to the admission record, Resident 12 was re-admitted to the facility on 6/20/16 from a general acute care hospital (GACH) with diagnoses that included chronic kidney disease (a progressive loss in kidney function over a period of time), difficulty walking, muscle weakness, presence of a cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions), hypertension (abnormally high blood pressure), Alzheimer's disease (a type of dementia that causes problems with memory, thinking and behavior over time) without behavioral disturbance, anxiety ( feeling of worry, nervousness, or unease), and osteoarthritis (degeneration of joint cartilage). A review of the GACH's Patient Transfer/Referral Record indicated Resident 12 was admitted to the GACH on 6/18/16 with a chief complaint of generalized weakness, possible fall; and discharged from the GACH on 6/20/16 with discharged prognosis documented as can improve and be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 74 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 discharged; current needs as skilled nursing care and rehabilitation; rehabilitation potential was marked yes; activity limitations indicated ambulatory with assistance; mental status as disoriented; and disabilities and impairments documented as hearing and vision. According to the Minimum Data Set (MDS), a standardized assessment tool, dated 10/7/16, indicated that Resident 12's speech was clear; had the ability to hear with minimal difficulty; sometimes understood and sometimes understands; adequate vision; no hallucinations or delusions; no physical or verbal behavioral symptoms directed toward others; no rejection of evaluation or care. The MDS indicated the resident required supervision and one person physical assistance for eating; and extensive assistance for ambulation, transfer, walk in room, dressing, toilet and personal hygiene with one person physical assistance. A review of Resident 12's physician order summary report for the month of 10/16 included but not limited to the following medication orders: 1. Norvasc 5 mg by mouth once a day for hypertension, hold for systolic blood pressure ([SBP] the pressure when the heart beats while pumping blood) less than 110 millimeters of mercury with an order date of 6/20/16. 2. Oxygen as needed for shortness of breath with an order date of 6/30/16. 3. Risperdal one milligram (mg) by mouth twice a day for psychosis manifested by aggressive behavior toward others with an order date of 8/22/16 (which was increased from Risperdal 0.5 mg twice a day with an initial order date of 7/20/16). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 75 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 4. Depakote 250 mg by mouth twice a day for mood stabilization manifested by angry verbal outburst with an order date of 10/10/16 (which was increased from Depakote 125 mg twice a day with an initial order date of 8/24/16). 5. Zoloft 50 mg by mouth once a day at bedtime for depression manifested by verbalization of sadness with an order date of 10/17/16 (which was increased from Zoloft 25 mg once a day with an initial order date of 7/18/16). 6. Ativan 1 mg by mouth every morning after breakfast for anxiety with an order date of 11/1/16 (which was changed from Ativan 0.5 mg as needed for wanting to get out of bed with an order date of 8/10/16). During an interview and observation on 11/17/16 at 8 a.m. in the presence of two restorative nurse assistants (RNA 2 and RNA 3) in Resident 12's room, the resident was observed sitting in the wheelchair awake, alert, calm, and quiet. RNA 2 stated Resident 12 was hard of hearing, but did not have any hearing aids. Resident 12 stated in a very low, soft voice, "I am hard of hearing." During a concurrent interview in the presence of RNA 3, RNA 2 stated Resident 12 was always calm with her and she has never observed the resident strike out at staff. RNA 3 agreed with RNA 2 and stated, "He (Resident 12) is always calm with us (RNA 2 and RNA 3). During an interview on 11/17/16 at 8:10 a.m., with Resident 12's certified nurse assistant (CNA 10), CNA 10 stated, "He (Resident 12) is very approachable. He cooperates and helps me with his own care; never have a problem. " FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 76 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 a concurrent observation and interview while waiting to receive his breakfast, Resident 12 stated, " Not that enthusiastic about getting breakfast. Do not like the food. " Resident further stated, " My hearing is slowly dissipating. Hearing aids would be a great help. My right ear is sharper than my left ear. I hear quite a bit, but what is actually being said I have to guess at it. " Resident 12 stated that no one has talked to him about his medications and did not know what medications he was on. On 11/17/16 at 8:25 a.m., during an interview, the activities assistant (AA 3) stated, Resident 12 participates in group games and likes going outside for stimulation. AA 3 stated Resident 12 has always been calm and she has never seen the resident aggressive and that he does not appear to hear voices. On 11/17/16 at 9:33 a.m., during an interview and record review with social services director (SSD 1) after looking through Resident 12's clinical records stated the resident had an episode of behavior that was reported to her on 7/12/16. SSD 1 stated the behavior was reported to the resident's family member who thought the behavior may have been related to his inability to hear what was being said to him and the family member wanted Resident 12's hearing evaluated. SSD 1 further stated she had not observed Resident 12 display any aggressive behavior and no aggressive behavior has been reported to her or social services since the original incident on 7/12/16. According to Resident 12's clinical record titled, "Visit Note Report," dated 7/12/16, documented, "Patient has been having episodes of delusion and paranoia, would not let go of butter knife. RN supervisor convinced patient to put butter knife down. Charge nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 77 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 and staff afraid patient may hurt himself or someone else due to increased episodes of confusion. Physician provided new telephone prescription orders for Ativan 1 mg SL (sublingually, under the tongue) every morning after breakfast. Called orders into pharmacy. Patient received lying in low bed, patient is confused, stated he was hard of hearing ...Patient is confused although calm." A review of Resident 12's physician's orders, dated 7/12/16 indicated Ativan 1 mg SL every morning after breakfast. However, there was no documentation on the resident's eMAR of any non-pharmacological interventions attempted for Resident 12 prior to the administration of Ativan, or after the documented behavior that was reported to SSD 1 and noted on the Visit Note Report, dated 7/12/16. Another physician's orders for Resident 12, dated 7/13/16 indicated, an order for a hearing aid evaluation. A review of Resident 12's electronic Medication Administration Records (eMAR) for 6/2016 and 7/2016 , indicated Resident 12 received four doses of Ativan 0.5 mg on 6/21/16, 6/24/16, 6/25/16, 6/27/16, and the dose was increased and Resident 12 received four additional doses of Ativan 1 mg on 7/1/16, 7/5/16, 7/8/16, and 7/12/16. A review of Resident 12's nursing notes indicated the following: On 6/30/16, indicated Resident 12 had episodes of anxiety, manifested by inability to relax and getting up unassisted twice. Ativan was given. On 7/1/16, Ativan 1 mg was administered to Resident 12, due to being very restless and attempting to get out of bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 78 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 7/2/16, at 11:59 p.m., Resident 12 exhibited episodes of anxiety manifested by inability to relax; getting up unassisted twice; was administered Ativan. After one hour of sleep, Resident 12 stayed in bed after dinner. On 7/5/16, Ativan 1 mg was administered to Resident 12 for anxiety manifested by inability to relax; was restless. On 7/8/16, Ativan 1 mg was administered to Resident 12 after Resident 12 appeared very restless, attempting to get out of bed. A review of the Consultant Pharmacist Medication Regimen indicated the following recommendations for Resident 12: Dated 7/27/16, medication evaluation, OBRA regulations limit the dose of Ativan in the elderly to 2 mg/day. This resident has order for Ativan 0.5 mg every 4 hours as needed and could potentially receive greater than 2 mg per day. Dated 7/27/16, Please clarify behavior of "Continuously getting out of bed" for lorazepam (Ativan) as needed to an appropriate, objective anxiety related behavior based on Resident 12's words or actions. Dated 9/28/16, behavioral clarification, please clarify behavior of " Irritability" for Zoloft to an objective depression related behavior based on Resident 12's words or actions. A review of Resident 12's care conference note, dated 6/30/16, indicated Resident 12 was admitted from an acute hospital for continuance of care and rehabilitation with skilled services. According to the nurse's notes, Resident 12 remained cooperative with others and staff and was able to get along well with everyone. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 79 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A care plan, dated 7/19/16, for at risk for a communication problem due to hearing deficit and indicated the facility staff were instructed to anticipate and meet the needs of Resident 12. The goals included respond to the feeling resident is trying to express. A care plan, dated 6/21/16, for needs of antianxiety (Ativan) medication for anxiety disorder, indicated Resident 12 was at risk for side effects from the medication. The goals included no discomfort or adverse reactions related to antianxiety therapy. The interventions included monitor/document side effects and effectiveness. Antianxiety side effects included, drowsiness, clumsiness, confusion, disorientation, impaired thinking and judgement, memory loss, forgetfulness, blurred or double vision and hostility, rage, aggressive or impulsive behavior, hallucinations. However the care plan was not reevaluated or updated after documented behavior on 7/12/16 or reviewed to ensure Resident 12 was free from side effects or adverse reactions from the Ativan medication. A care plan, dated 7/18/16, for Resident 12's need of an antipsychotic (Risperdal), indicated the resident was at risk for side effects from the medications and at risk for falls. The resident's goals included no drug related complications, including movement disorder, gait disturbance, constipation, cognitive or behavioral impairment. The staff interventions included to monitor, record, report to MD (physician) side effects and adverse reactions of psychoactive medications that included unsteady gait, shaking, falls, depression, refusal to eat, blurred vision, behavioral symptoms not usual to the person. The facility failed to include a care plan for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 80 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Resident 12's need of Depakote (anticonvulsant) or Zoloft (antidepressant). A review of Resident 12's psychiatric evaluation, dated 7/16/16, indicated Resident 12 was confused and oriented to name only, aware of his facility placement, mood was calm and cooperative, speech was coherent, thought process is slow possibly due to hard of hearing but was goal oriented. Resident 12 denied having paranoia, denies auditory and visual hallucinations, and denies suicidal ideations. Indicated neurological findings, of dementia. A review of the facility's policy titled, "Dementia Care," dated 12/1/13, indicated the physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia based on pertinent clinical guidelines and regulatory expectations. The medications should be targeted to specific symptoms and should be used in the lowest possible doses for the shortest time, unless a clinical rationale for higher doses or longer-term use is documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 81 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 According to Daily Med, the Food and Drug Administration (FDA) approved manufacturer label for Seroquel included a black boxed warning (the strongest warning that the FDA requires and indicates the drug carries a significant risk of serious or even lifethreatening adverse effects), indicated a black boxed warning for the drug Risperidal (risperidone) with increased mortality in elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. According to Daily Med, Risperidal (risperidone) was not approved for the treatment of patients with dementiarelated psychosis. According to DailyMed, the manufacturer label for Zoloft, included a black boxed warning that indicated, all patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Caregivers should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and to report such symptoms FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 82 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 immediately to health care providers. Such monitoring should include daily observation by caregivers. Prescriptions for Zoloft should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of adverse symptoms and overdose. On 11/17/2016 at 3:02 p.m., during a telephone interview, Resident 12's family member (FM 1) stated communication was really important and thinks his behavior is due to his inability to hear what is being said or asked of him; and the facility keeps increasing his medication. FM 1 stated, " (Resident 12) told me when he takes a shower they are very rough with him. " FM 1 stated a facility staff called and said they were increasing Resident 12's medications, FM 1 was concerned that the resident would become like a zombie and noticed him getting weaker, a decline in his ability to walk, and his speech is slower; and would like him to have some physical therapy;. FM 1 stated the facility staff assured FM 1 that Resident 12's medication dosages were not as high as other residents medications. FM 1 stated, " What can you do when you trust in them (the facility staff) to give good care and you are not there to see it." On 11/18/16 at 9:53 a.m., Resident 12 was observed in a wheelchair being pushed by CNA 11, and Resident 12's hands were observed with tremors covered with a towel. CNA 11 was asked why Resident 12's hands were covered and CNA 11 stated, "The resident's right hands shakes, so I did not want him to be embarrassed, since he was going to activities." At 9:56 a.m., on 11/18/16, during an interview, the facility's psychiatrist ([physician 2] a physician who specializes in the branch of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 83 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders), who was part of the psychotropic committee of the facility, stated dementia asymptomatic residents should not receive psychotropic medications first. Physician 2 stated nonpharmalogicals interventions should be tried first and if used then a GDR should be done as resident improved. According to the American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults, indicated all benzodiazepines, which include Ativan, increase risk of cognitive impairment, delirium, and falls in older adults and should be avoided for the treatment of insomnia, agitation, or delirium. According to DailyMed, Clinically Significant Drug Interactions, Ativan produced increased CNS-depressant effects when administered with other CNS-depressants such as antipsychotic (e.g. Risperdal), anticonvulsants (e.g. Depakote) ...Concurrent administration of lorazepam with Depakote results in increased plasma concentrations and reduced clearance of lorazepam. Lorazepam dosage should be reduced to approximately 50 % when coadministered with Depakote. A review of the facility's policy and procedure titled, "Care and Treatment Psychotherapeutic Drug Use," indicated It was the policy of the facility to maintain every residents' right to be free from psychotherapeutic drugs. The facility shall ensure that these drugs are used to treat a specific condition as diagnosed by a physician, and that behavioral interventions shall be attempted in an effort to discontinue these drugs ...Psychotherapeutic medications shall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 84 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms and will be considered only after other measures have been attempted. b. A review of Resident 14's Admission Face Sheet indicated Resident 14 was admitted to the facility on 7/16/07. Resident 14's diagnoses included other specified rheumatoid arthritis (a disease that causes inflammation and deformity of the joints), unspecified osteoarthritis (gradual loss of cartilage of the joints), gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and causes heartburn), and unspecified dementia (a brain disease that causes a gradual decrease in the ability to remember). A review of Resident 14's Minimum Data Set (MDS), an assessment and care screening tool, dated 9/16/16, indicated Resident 14 had a Brief Interview for Mental Status (BIMS) score of four (severe impairment of cognitive status). According to the MDS, Resident 14 had the ability to usually understand and be understood. The MDS, under Section G0110 B., for Functional Status (ADL Self Performance), Resident 14 required an extensive assistance with bed mobility and transferring indicated the resident required an extensive assistance with a two-plus person physical assist. A review of Resident 14's Physician's order summary report, with a start date of 10/17/2016, indicated to hold the administration of Norco (a narcotic pain medication) tablet 5325 mg if the respiratory rate was under 12 or if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 85 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Resident 14 was sedated. A review of Resident 14's Medical Administration Record (MAR) for the month of October 2016 indicated Resident 14's respiratory rate was not being recorded prior to the administration of Norco tablet 5-325 mg. A review of the pharmacy consultant monthly medication regimen review (MRR) for Resident 14, dated 9/1/16-9/28/16, indicated to consider updating the order of Norco 5-325 mg to include a hold parameter, such as hold if respiratory rate is under 12 or if the resident was sedated. A review of the pharmacy consultant MRR for the month of 10/1/16-10/21/16 for Resident 14, indicated there were no recommendations, although the nurses were not assessing Resident 14's respiratory rate and documenting it. On 11/15/16 at 1:25 p.m., during an interview and a concurrent review of Resident 14's MAR, a licensed vocational nurse (LVN 1) was asked what was being assessed for Resident 14 before giving Norco 5-325 mg tablet every eight hours. LVN 1 stated only pain assessment was being performed and recorded before medication administration of Norco, since it was given every eight hours. On 11/17/16 at 3 p.m., during an interview, MDS Nurse 1 stated that if the resident's physician's order was on the Physician's order summary report, the resident's physician approved the order. MDS Nurse 1 stated it was usually the nurses who monitors and inputs the physician's orders that are approved by the physicians. A review of the facility's policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 86 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 titled, "Medication Administration," revised on 5/2007, indicated to obtain and record any vital signs, as necessary, prior to the medication being administered. A review of Dailymed, an online drug reference, indicated Norco (Hydrocodone/Acetaminophen) 5-325 mg may produce dose-related respiratory depression by acting directly on the brain stem respiratory center. The article stipulated Hydrocodone also affected the center that controls respiratory rhythm, and may produce irregular and/or periodic breathing. https://dailymed.nlm.nih.gov/dailymed/drugInfo. cfm?setid=aaef2d01-126d-4aab-9b2aeee31a769150

F332 SS=E FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.25(m)(1)

F332 02/15/2017 The facility must ensure that it is free of medication error rates of five percent or greater. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of four medication errors out of 27 opportunities for error, to yield a cumulative error rate of 14.8% for one of 24 sample residents (Resident 15) and two randomly selected residents (RSR 28 and 29). This deficient practice had the potential for the residents to not receive their medication as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 87 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 prescribed to achieve therapeutic effectiveness and increased the potential for adverse reactions. For Resident 15, a licensed vocational nurse (LVN 6) failed to administer Pentoxifylline extended release (helps blood flow more easily through narrowed arteries in legs and arms) and Novolog injectable insulin (to treat diabetes [high blood sugar]) with food which increased Resident 15's risk for medication side effects and adverse reactions. For RSR 28, a licensed vocational nurse (LVN 9) failed to check the resident's heart rate prior to the administration of a blood pressure medication, metoprolol tartrate as ordered by the physician as a required parameter used to determine if the medication should be held (not given). For Resident 29, a licensed vocational nurse (LVN 1) failed to administer potassium chloride with sufficient fluids or a meal to minimize the potential for stomach irritation. Findings: a. A review of Resident 15's Admission Face Sheet indicated Resident 15 was initially admitted to the facility on 10/6/16 and readmitted on 11/3/16, Resident 15's diagnoses included difficulty walking, muscle weakness, diabetes mellitus (low or high blood sugar levels), hypertension (high blood pressure), esophagitis (irritation or inflammation of the esophagus [tube that carries food from the throat to the stomach], gastro-esophageal reflux disease (GERD) a condition in which the contents of the stomach backs up into the esophagus), and a gastric ulcer (break in the normal tissue that lines the stomach). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 88 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of Resident 15's Minimum Data Set (MDS), a standardized resident assessment tool, dated 10/19/16, indicated Resident 15 had adequate hearing, clear speech with clear comprehension and was able to make needs known. According to the MDS, Resident 15 required extensive staff assistance with a oneperson physical assist with eating and bathing; a two-plus person assist for transferring and dressing. During a medication pass observation on 11/14/16, at 12:51 p.m., LVN 6 was observed preparing and then administering Resident 15's medications that included, but not limited to, Novolog insulin which was injected subcutaneously (under the skin) into Resident 15's lower left stomach area and an oral administration of Pentoxifylline 400 mg extended release (ER), one tablet. During a concurrent interview LVN 6 stated Resident 15's lunch tray had not arrived and should be delivered in 10 to 15 minutes. On 11/14/16, at 1 p.m., during an interview, Resident 15 stated he had not been given a snack or received his lunch and his last meal was at 8 a.m. that morning. Resident 15 stated he usually received his lunch tray between 12:30 p.m. and 1 p.m., but does not receive a daily snack. At 1:03 p.m. on 11/14/16, LVN 6 acknowledged that Resident 15 had not eaten or received his lunch after the insulin was given. LVN 6 ordered Resident 15 a snack that arrived at 1:14 p.m. (23 minutes after Novolog insulin injection). At 1:20 p.m., on same day (11/14/16), Resident 15's lunch tray arrived (29 minutes after insulin injection). Resident 15's meal was delayed for over 20 minutes after receiving Novolog insulin injection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 89 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of Resident 15's physicians' orders, dated 10/12/16, indicated an order was written for Pentoxifylline ER 400 mg, to give one tablet by mouth three times a day with meals. Resident 15's dose was not given with food. A review of Resident 15's physicians' orders, dated 11/3/16, indicated an order was written for Novolog Flex Pen solution pen-injector 100 unit/ml (milliliter) Insulin, inject as per sliding scale, subcutaneously (into fatty tissue) to be given before meals and at bedtime for diabetes. A review of Resident 15's care plan, dated 11/3/16, indicated Resident 15 was at risk for hypo/hyperglycemia (low or high blood sugar) episodes. The goal indicated Resident 15 would be free from any signs and symptoms of hypoglycemia. According to DailyMed, a Food and Drug Administration (FDA) approved manufacturer label indicated " Novolog has a more rapid onset of action and a shorter duration of activity than regular human insulin. An injection of Novolog should immediately be followed by a meal within five to ten minutes." b. A review of Resident 28's (RSR 28) Admission Face Sheet indicated the Resident 28 was admitted to the facility on 10/3/16. Resident 28's diagnoses included difficulty walking, muscle weakness, diabetes mellitus (low or high blood sugar levels), hypertension (high blood pressure), and heart failure. A review of Resident 28's MDS, dated 10/10/16, indicated RSR 28 had minimal difficulty hearing, clear speech with clear comprehension and was able to make needs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 90 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 known, but required supervision and setup for eating, and extensive staff assistance with one person physical assist with transferring, toileting, and bathing. During a concurrent medication pass observation and interview, on 11/14/16, at 9:44 a.m., LVN 9 was observed preparing RSR 28's medications that included, but not limited to metoprolol tartrate and then administering by mouth two tablets of 25 mg for a total dose of 50 mg of metoprolol tartrate. LVN 9 was not observed checking the Resident 28's heart rate or pulse prior to the administration of the medication. During a concurrent interview, LVN 9 acknowledged that RSR 28's heart rate had not been checked prior to the administration of Metoprolol. LVN 9 stated, "Physician order says to take the blood pressure and pulse prior to the administration of the blood pressure medication. The pulse should have been taken, because it could go against the physician's order, and the medication may not need to be given." A review of the RSR 28 ' s physician's order, dated 10/3/2016, indicated to give Metoprolol Tartrate, 50 mg by mouth once a day for hypertension. The order had parameters to hold the medication if RSR 28's systolic blood pressure was less than 110 millimeters mercury (mmHg) and/or for a heart rate less than 60 beats per minute (bpm). According to DailyMed the Food and Drug Administration (FDA) approved manufacturer label included a warning that indicated, "Metoprolol tartrate tablets are contraindicated in patients with a heart rate less than 45 beats per minute; and systolic blood pressure less than 100 mmHg." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 91 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 c. A review of RSR 29's Admission Face Sheet indicated Resident 29 was readmitted to the facility on 7/21/16. Resident 29's diagnoses included developmental disorder of scholastic skills (specific and significant impairment in learning), heart failure, atrial fibrillation (an irregularity in heartbeat), history of falling, and gastro-esophageal reflux disease (GERD). A review of Resident 29's MDS, dated 9/19/16, indicated RSR 29 had unclear speech, rarely able to make needs known or be understood by others, and required limited staff assistance and one person physical assistance for eating and bathing, ambulation, dressing and toileting. During a concurrent medication pass observation and interview on 11/14/16, at 8:33 a.m., LVN 1 was observed preparing RSR 29's medications that included, but not limited to, potassium chloride extended release (ER) 10 millequivalents (mEq). LVN 1 then administered the medication to RSR 29 with a sip of another medication Liquacel (a concentrated liquid protein). RSR 29 received three more medications furosemide (water pill), phenytoin (seizure medication), and a multivitamin with minerals each were followed with a sip of Liquacel 9 (not water). Once the Liquacel was finished LVN 1 provided four ounces of water to RSR 29. LVN 1 was not observed administering the potassium chloride with food or a full glass (eight ounces) of water, which may caused stomach irritation. During a concurrent interview, LVN 1 stated if she had questions about medications she could ask the pharmacist, but so far LVN 1 stated she has not had to call the pharmacist to ask about medications. When questioned, LVN 1 was not aware of the need to administer potassium with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 92 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 a full glass of water or food to minimize stomach irritation to RSR 29 who had a history of GERD. A review of the facility's policy titled, "Medication Administration," with a revised date of 5/2007, indicated it was the policy of the facility to accurately prepare, administer and document medications. The policy also indicated medications are administered as prescribed in accordance with good nursing principles and practices. According to DailyMed the Food and Drug Administration (FDA) approved manufacturer label included a warning that indicated because of the potential for gastric irritation, potassium chloride extended-release capsules 10 millequivalents (mEq) should be taken with meals and with a full glass of water or other liquid.

F368 SS=E FREQUENCY OF MEALS/SNACKS AT BEDTIME CFR(s): 483.35(f)

F368 12/16/2016 Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided below. The facility must offer snacks at bedtime daily. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 93 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 meal span, and a nourishing snack is served. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility's staff failed to ensure that residents received their meals timely. This deficient practice puts residents at risk of not meeting the body's needs. Findings: On 11/14/16, at 11:55 a.m., approximately 4550 residents were observed in the dining room waiting for their lunch trays to be served. At 12:21 p.m., the first cart was delivered, checked by staff for accuracy, and then served to the residents. The last cart was delivered at 12:40 p.m.; trays were checked for accuracy and served to the rest of the residents, who have been waiting for at least 45 minutes. An information in the dining room wall indicated that lunch trays were to be served starting at 12 p.m. On 11/14/16, at 12:55 p.m., Resident 4 and Resident 20, who were waiting for their lunch trays in their shared room, both stated that they were "starved." Resident 4 and Resident 20 stated that they were told their trays would be delivered around 12:30 p.m. Resident 4 and Resident 20 were upset and stated that all meals always came late. On 11/15/16, at 7:10 a.m., there were eight residents waiting for their breakfast trays to be delivered. At 7:27 a.m., the meal cart was delivered; trays were checked by staff for accuracy, and then served to the residents. The last tray was served to the last resident at 7:42 a.m. An information in the dining room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 94 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 wall indicated that breakfast trays were to be served starting at 7 a.m. During an interview on 11/15/16, at 7:45 a.m., with one of the eight residents eating breakfast in the dining room, the alert and oriented randomly-selected resident (RSR 25) stated that meal trays always came late. RSR 25 stated that he was an early person and usually gets to the dining room around 6:50 a.m., but does not get his breakfast tray until about 30 minutes later. During the group interview on 11/15/16, at 10 a.m., six of 11 alert and oriented residents stated that meal trays always came late. During an interview on 11/17/18, at 11:43 a.m., the Dietary Supervisor acknowledged the facility's failure to meet the expected time of the delivery of meal trays and stated the facility will work on improving the timeliness of delivery of meal trays in order to meet the residents' needs.

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.35(i) 12/16/2016 The facility must (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 95 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 review, the facility failed to take temperatures of individual food items in the steam table prior to serving to the residents. This deficient practice puts residents at high risk for foodborne illnesses. Findings: On 11/14/16, at 8:04 a.m., kitchen staff were observed during the tray line at the steam table preparing the breakfast trays for the residents. When asked if food temperatures were taken prior to preparing the trays, the cook stated that food temperatures were not taken this morning because they ran a little late this morning. The temperature log was reviewed where only the temperatures of the milk, juice and coffee were documented. During an interview on 11/14/16, at 8:10 a.m., the facility's Registered Dietitian stated that it was very important that food temperatures be taken prior to distributing to the residents. The facility's policy and procedures, Food, Reheating and Cooling during Tray line, revised 5/2007, indicated, "It is the policy of this facility that potentially hazardous foods shall be served and held at the required temperatures on the tray line or during meal service... Hot Foods will be prepared per recipe and cooked to specified temperature. Food will be kept for service at greater than 140 degrees F (Fahrenheit). If the temperature drops below 140 degrees F, stop service and reheat."

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.60(a),(b)

F425 12/16/2016 The facility must provide routine and emergency drugs and biologicals to its FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 96 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 residents, or obtain them under an agreement described in §483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's staff failed to ensure that treatment medication was available for one (Resident 5) of four residents who had orders for treatment procedures, in a total sample of 24 residents. Resident 5's Santyl ointment was not available prior to the treatment procedure. This deficient practice has the potential to cause delay of services to the residents. Findings: Resident 5 was admitted to the facility on 9/3/16 with diagnoses that included status-post surgical procedure to the left knee (placement of left artificial knee joint), heart failure, endstage renal disease, anxiety disorder, hypertension and diabetes mellitus. The Minimum Data Set (MDS, a standardized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 97 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 assessment and care screening tool) dated 9/10/16 indicated the resident was cognitively intact but required extensive assistance with daily activities, including transfers, ambulation, dressing, personal hygiene and bathing. The resident had developed a wound to the left heal (which, then, affected also the lateral and top of the foot) as a result from arterial insufficiency (secondary to diabetes mellitus). A physician's order dated 11/2/16 indicated to apply Santyl ointment to two open wounds on the left foot and to apply Calazime cream on the lateral side. On 11/15/16, at 10:30 a.m., a licensed nurse (LVN 3) was observed as she prepared the treatment supplies prior to the actual treatment procedure. In the middle of the preparation, LVN 3 stated that the Santyl ointment was not available (Calazime cream was available), that she faxed the requisition to the pharmacy yesterday (11/14/16) for a replacement because she used the last of the ointment and already discarded the empty tube yesterday. During an interview on 11/15/16, at 11:40 a.m., a licensed nurse (MDS 1) stated that after going through fax records sent on 11/14/16, there was no record of a requisition to the pharmacy regarding Resident 5's Santyl ointment, and, therefore, the pharmacy did not send a new ointment to the facility. The facility's policy and procedures, Pharmacy Services - Physician Orders, revised 5/2007, indicated, "Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to assure that refills are on hand." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 98 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 b. On 11/16/16 at 9:15 a.m., during a medication area inspection of Nursing Stations 2 and 3, and a concurrent interview with a registered nurse (RN 3), RN 3 was asked for the emergency kit (Ekit) usage log for the two stations. RN 3 stated the Ekit usage log was filled out and returned to the pharmacy with the used Ekit. RN 3 further stated she could not determine which licensed nurse last accessed the Ekit, what medication may have been removed and/or for which resident. RN 3 stated the facility did not keep a copy of the medications removed from the Ekit and administered to residents. During the inspection, a white container was observed on the floor filled approximately halfway with multiple tablets and capsules of different medications. The container was marked, "For Incineration Only." RN 3 stated discontinued and expired medications were dropped through the round opening in the top of the container and the pharmacy comes regularly to pick it up and dispose of the medications. At 9:46 a.m., on 11/16/16, during a review with RN 3 of the facility's Drug Disposal Log and Medication Disposition Log of Non-Controlled Medications, the log listed the medication Renvela 800 mg (used to control serum phosphorus in patients with chronic kidney disease [loss of kidney function] on dialysis [a process of filtering waste from the blood, when the kidneys no longer work adequately]). However, the quantity to be disposed was not documented and the medication was also observed to be in the white container. RN 3 stated the Drug Disposal Log did not include the quantity for each medication being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 99 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 disposed and that she could not determine how many Renvela 800 mg were disposed since no quantity was documented. While looking at the disposition log, RN 3 stated, "Medications documented on the Drug Disposal Log should include a quantity and two nurses should sign off for the non-controlled disposal. I do not see two nurses' signatures. All the medications are mixed up (in the white container for incineration). Each medication should have been logged." On 11/17/16 at 11:50 a.m., during an interview, in the presence of the assistant director of nursing (ADON), the director of nurses (DON), stated the non-controlled medications are logged and disposed of by the charge nurses in the medication room on each nursing station. The DON stated the medications are either returned to the pharmacy for credit or placed in the container for incineration; however, all medications must be logged. On 11/17/16 at 12:06 p.m., during a concurrent medication area inspection (Station 4), and an interview, the DON and ADON stated the facility did not have documentation or a log to indicate what medications were placed in the container marked, "For Incineration Only." The DON acknowledged she did not know what medications were in the container. During Station 4's continued medication room inspection and concurrent interview, a tote was observed inside the medication room filled with bubble packs of medications labeled individually for multiple residents. The ADON stated inside the tote were discontinued resident's medications prepared for return to pharmacy for credit. The ADON stated she did not know if every medication in the tote prepared for the pharmacy to pick up had been logged. A Novolog Insulin FlexPen labeled for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 100 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 two separate residents were pulled from the tote to reconcile with the return medication disposition log. After reviewing the log, the DON stated the two insulin (Novolog) pens were not documented and that she would have the entire tote checked and logged correctly. A review of the facility's undated policy and procedure titled, Emergency Drug Supply Referenced the State Regulation - Title 22 Section 72377, indicated, "The use of the emergency drug supply will be recorded in the emergency drug supply logbook...Separate records of use shall be maintained for drugs administered from the supply. Such records shall include the name of the resident, the name and dose of the drug administered, the date and time the dose was withdrawn from the supply, and the signature of the person administering the dose, or opening the supply if no items were used." A review of the facility's undated policy and procedure titled, "Disposal of Non-Controlled Medications," indicated all drugs disposed of or returned to the pharmacy for credit are to be entered onto an appropriate medication disposition record. These records are to be maintained for at least three (3) years. Information that must be entered into the records included: 1. Prescription number 1. Pharmacy name 2. Drug name and strength 3. Quantity of doses remaining 4. Resident's name 5. Date of disposal or return to the pharmacy 6. Signatures of two licensed nurses

F428 SS=D DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON FORM CMS-2567(02-99) Previous Versions Obsolete

F428 Event ID: 1MGY11 12/16/2016 Facility ID: CA940000015 If continuation sheet 101 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 CFR(s): 483.60(c) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's pharmacy consultant failed to ensure that the medication regimen review (MRR) and recommendations were being followed for one of 24 sampled residents (Resident 14). This deficient practice resulted in the facility not implementing the respiratory assessment for Resident 14 before the administration of Norco (a narcotic pain medication) 5-325 mg tablet every eight hours around the clock (ATC). Findings: A review of Resident 14's Admission Face Sheet indicated Resident 14 was admitted to the facility on 7/16/07. Resident 14's diagnoses included other specified rheumatoid arthritis (a disease that causes inflammation and deformity of the joints), unspecified osteoarthritis (gradual loss of cartilage of the joints), gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and causes heartburn), and unspecified dementia (a brain disease that causes a gradual decrease in the ability to remember). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 102 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 A review of Resident 14's Minimum Data Set (MDS), an assessment and care screening tool, dated 9/16/16, indicated Resident 14 had a Brief Interview for Mental Status (BIMS) score of four (which indicated severe impairment of cognitive status). According to the MDS, Resident 14 had the ability to usually understand and be understood. Resident 14's MDS, under Section G0110 B., for Functional Status (ADL Self Performance), indicated Resident 14 required an extensive assistance in bed mobility and transferring with a two-plus person physical assist. A review of Resident 14's Physician's order summary report, with a start date of 10/17/16, indicated to administer Norco (a narcotic pain medication) tablet 5-325 mg every eight hours ATC for chronic pain management and to hold administration of medication if respiratory rate was under 12 and/or if the resident was sedated. A review of Resident 14's Medical Administration Record (MAR) indicated Resident 14's respiratory rate was not being recorded prior to administration of Norco tablet 5-325 mg. A review of the facility's monthly pharmacy consultant MRR for Resident 14, dated between 9/1/16-9/28/16, indicated to consider updating the order of Norco 5-325 mg to include a hold parameter, such as hold if respiratory rate was under 12 and/or the resident was sedated. A review of the pharmacy's consultant MRR for the month of 10/1/16-10/21/16 for Resident 14, indicated there was no further recommendations, although the nurses were not assessing Resident 14's respiratory rate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 103 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 and documenting it, as per the pharmacist recommendations. On 11/17/16 at 8:52 a.m., during a telephone interview, the facility's pharmacist consultant (PC) stated he did not have any further recommendations for Resident 14 the following month (10/2016) because implementation of Resident 14's respiratory assessment was under the nurse's professional judgement. However, the PC stated he should have updated the current pharmacy recommendation and followed through for the month of October 2016. On 11/17/16 at 3 p.m., during an interview, the Minimum Data Set nurse (MDS nurse 1) stated that if the resident's physician's order was on the order summary, the physician approved the orders. MDS Nurse 1 stated it was usually the nurses who monitors and inputs the orders approved by the physician. A review of Dailymed, an online drug reference, Norco ([hydrocodone/acetaminophen] a pain medication) may produce dose-related respiratory depression by acting directly on the brain stem respiratory center. The article stipulated that Hydrocodone also affected the brain center that controls respiratory rhythm, and may produce irregular and/or periodic breathing. https://dailymed.nlm.nih.gov/dailymed/drugInfo. cfm?setid=aaef2d01-126d-4aab-9b2aeee31a769150 According to the facility's undated policy titled, "Pharmacist Medication Regimen Review," the consultant pharmacist documents potential or actual medication therapy problems and communicates them to the responsible physician and the director of nursing within ten FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 104 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 working days of the review.

F431 SS=E DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.60(b), (d), (e)

F431 12/16/2016 The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 105 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 review, the facility failed to ensure that medications, emergency kits, and specimen/medications refrigerators were properly monitored and labeled. This deficient practice had the potential to negatively affect the medications and specimens stored in the refrigerator, lead to administration of expired medication, and improper documentation of medication and medical supplies used in the facility. Findings: a. On 11/16/16 at 8:30 a.m., the medication refrigerator inside the medication room on Station 4 was observed to have dripping water from the freezer compartment on two medications (IV Cefazolin and Novolog Flexpen). The medication refrigerator temperature was 40 degrees Fahrenheit (F). On 11/16/16, at 8:33 a.m., an interview was conducted with a registered nurse (RN 1). RN 1 stated that she checked the refrigerator at 6:55 a.m., that morning, before her shift, and it was 38 degrees F and did not see dripping water. A review of the medication refrigerator log attached to the medication refrigerator indicated the temperature was 38 degrees F for the a.m. shift. At 8:55 a.m. on 11/16/16, during an interview, the Minimum Data Set Nurse (MDS Nurse 1) was asked what the facility's protocol was for checking the medications refrigerator. MDS Nurse 1 stated the nurses should have seen the dripping water and should have reported it to maintenance in order to get it replaced. A review of the undated facility's policy and procedure titled, "Medication Storage in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 106 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 Facility," indicated medication storage areas should be kept clean, well lit, and free of clutter and extreme temperatures. It also indicated medication storage conditions are monitored on a regular basis and corrective action taken if problems are identified. b. On 11/16/16 at 8:50 a.m., an observation was made of the facility's specimen refrigerator, located inside the utility room on Station 4. The refrigerator temperature was 52 degrees F. A review of specimen refrigerator's temperature log indicated the temperature was recorded as 40 degrees F for the a.m. shift. On 11/16/16 at 9 a.m., MDS Nurse 1 stated the refrigerator's temperature has to be between 35-45 degrees F. MDS Nurse 1 stated the nurses should have reported the high temperature. On 11/16/16 at 9:30 a.m., MDS Nurse 1 stated the thermometer in the specimen refrigerator was not working properly and was replaced immediately. According to the facility's policy and procedure titled, "Refrigerator at Nursing Station," dated 3/2009, refrigerators must maintain temperatures at or below 45 degrees Fahrenheit and should contain an accurate thermometer at all times. c. On 11/16/16 at 8:40 a.m., Ativan ([Lorazepam] an anti-anxiety medication) 2 mg/ml 10 ml vial was observed in the medication refrigerator in Station 4 without a complete date when it was opened it read "DO 10/12" on the vial. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 107 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 11/16/16 at 8:42 a.m., during a concurrent interview, a registered nurse supervisor (RN 1) stated, "DO, means date opened, and we forgot to put the year, which should be 2016. RN 1 stated it should had read " DO 10/12/2016." According to an undated facility's policy and procedure titled, "Medication Storage in the Facility," medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.65 12/16/2016 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 108 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow its Infection Control Program for one of 24 sampled residents (Resident 8) and for urinals (plastic container for urination) observed unlabeled in a shared bathroom during the facility's initial tour. A registered nurse (RN 1) was observed in Resident 8's isolation room for clostridium difficile (C. diff [a bacterium that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon {large intestine}]) infection in the stool, using her own pulse oximeter (a device that measures the amount of oxygen in the blood by using a sensor attached to a finger, toe, or ear) which she failed to disinfect after using on Resident 8 who was on contact isolation. Resident 8's family member was observed in the isolation room (C-Diff.) and had her purse and lunch bag exposed and unprotected on top of Resident 8's bedside table. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 109 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 On 11/14/16, at approximately 8:50 a.m., during the facility initial tour, unlabeled urinals were observed in a shared bathroom. These deficient practices had the potential to result in cross contamination and spread of infection between residents, staff, and visitors. Findings: a1. During an observation on 11/15/16, at 7:45 a.m., RN 1 pulled out, with the contaminated gloved hand, her personal pulse oximeter from her jacket pocket, took it out of its case, and placed the sensor on Resident 8's finger. After RN 1 read the oxygen saturation (an estimate of the amount of oxygen in the blood), while using her contaminated gloved hands, she put the pulse oximeter back in the case, and placed it in her jacket pocket without disinfecting it, washing her hands, and/or changing the gloves. A review of Resident 8's Admission Face Sheet indicated Resident 8 was re-admitted to the facility on 10/25/16. Resident 8's diagnoses included heart failure, dysphagia (difficulty in swallowing), Stage IV pressure sore (very deep wound, reaching into muscle and bone and causing extensive damage, that occurs as a result of prolonged pressure on a specific area of the body) in the sacrum (a large, triangular bone at the base of the spine), and C-diff in stool. A review of Resident 8's Minimum Data Set ([MDS], an assessment and care screening tool), dated 11/1/16, indicated Resident 8 was severely impaired and was unable to understand and be understood. During an interview on 11/15/16, at 8:01 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 110 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 in the presence of the MDS nurse (MDS Nurse 1), RN 1 stated there was no pulse oximeter in Resident 8's isolation room and that each staff used their own pulse oximeter to check oxygen saturation. RN 1 then stated she should have gotten a pulse oximeter from the isolation cart outside Resident 8's room. MDS Nurse 1 stated RN 1 should have used a pulse oximeter specifically assigned to Resident 8 and that she also should have used a wipe to disinfect the pulse oximeter after she used it. A review of the facility's undated policy titled, "Isolation Measures: General Policy Statement," indicated when possible, the staff should dedicate the use of non-critical patientcare equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient. a2. During a wound care observation for Resident 8's Stage IV pressure sore on 11/15/16, at 9:15 a.m., a family member (FM) was observed in Resident 8's isolation room, properly gowned and wearing gloves. However, Resident 8's FM had her purse and lunch bag, exposed and unprotected, sitting on top of Resident 8's bedside table in the isolation room. At 2:49 p.m., on 11/15/16, during an interview, the director of staff development (DSD) stated the family member's belongings should not have been in the isolation room. During an interview with Resident 8's family member on 11/15/16, at 3:04 p.m., she stated she was never told by the staff to protect her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 111 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 belongings. The FM stated she was only told to wear a gown and gloves. On 11/16/16, at 2:20 p.m., during an interview, in the presence of the director of nursing (DON), the family member again stated that no one told her or really explained to her that her personal property in the isolation room should be covered or not be there. A review of the facility's undated policy titled, "Isolation Measures: General Policy Statement," indicated, the resident, family, visitors, and health care workers should be provided with an explanation of the reason for isolation and the proper procedures that will be followed. The policy stipulated the nursing department will ensure that education is provided, as necessary, and will monitor to ensure precautions are appropriately followed. According to an online article by Center for Disease Control and Prevention (CDC) about transmission of C. difficile, indicated it was shed in feces. Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to residents mainly via the hands of healthcare personnel who have touched a contaminated surface or item. According to the article, Clostridium difficile can live for long periods on surfaces. http://www.cdc.gov/hai/organisms/cdiff/cdiffpatient.html b. On 11/14/16, at approximately 8:50 a.m., during the facility's initial tour, accompanied by MDS Nurse 1, two urinals were observed unlabeled (no name or date) hanging from the towel rack in Bathroom 419. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 112 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 a concurrent interview conducted with MDS Nurse 1 stated "No, they should not be there without any labels. I will throw them away."

F465 SS=B SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.70(h) 12/16/2016 The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a clutterfree and safe environment, which had the potential to cause hazards and accidents to residents, staff, and visitors. Findings: On 11/16/16, at 2:45 p.m., during the facility's environmental tour, conducted with the maintenance director (DM), a hot water pipe that led into the facility from the boiler room was observed partly exposed and with torn and tattered insulation. There were durable medical equipment (DME), including three Geri-chairs (geriatric chairs), three bedside commodes, one medication cart, one hospital bed, three mattresses, and one dresser visible in the back patio. During an interview on 11/16/16, at 2:50 p.m., the DM stated they will repair the hot water pipe insulation and clean up the clutter. A review of the facility's policy and procedure titled, "Environmental Conditions," with a revision date of 11/2007, indicated it was the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 113 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 policy of the facility to maintain the residents' environment free of accident hazards as possible, over which the facility has control. The policy stipulated the residents' environment included the physical surroundings to which the resident has access (e.g. room, unit, common use areas and facility grounds).

F514 SS=E RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.75(l)(1)

F514 02/15/2017 The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's staff failed to ensure clinical records were complete and accurately documented for five of 24 sampled residents (Residents 3, 5, 10, 12, and 18). For Residents 3 and 5, some of the physician's orders that were in the computer were not printed and filed in the clinical records. For Resident 10, the Physician Orders for LifeSustaining Treatment ([POLST] a form that gives seriously-ill patients more control over their end-of-life care, including medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 114 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR (cardiopulmonary resuscitation) was not signed by the physician. For Resident 12, the POLST did not have the date of the physician's signature, and was not signed by the resident's responsible party. For Resident 18, the POLST was not signed by the physician until after the resident's death. These deficient practices had the potential for physician's orders to not be implemented; clinical records to have inaccurate information and a delay in services. It also had the potential in denying residents' of their rights regarding health care decision and/or wishes. Findings: a. A review of Resident 3's and 5's clinical records indicated that there were physician's orders (from the computer) that were not printed and filed in the residents' clinical records. Resident 3 had treatment orders for a wound to the tailbone area and Resident 5 had treatment orders for the wound on the left foot, but the treatment orders were not printed and filed in Resident 3's and Resident 5's clinical records. During an interview and record review on 11/16/16, at 7:20 a.m., and 9:30 a.m., the minimum data set nurse (MDS Nurse 2), responsible for comprehensive assessments of residents, stated that all of the physician's orders for both Resident 3 and Resident 5 were not filed in the clinical records (and signed) by the physicians. MDS Nurse 2 stated that all physician orders are to be printed and filed in all residents' clinical records. The physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 115 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 orders that were not printed and filed in Resident 3 and Resident 5 clinical records had not been electronically signed by the physicians. The facility's undated policy and procedures titled, "Physician's Orders, Telephone Orders and Recapitulation Process", indicated "Printing of the Physician Orders for the facility will take place the last day of the current month. If the last day falls on a weekend, then the printing will take place the business day prior to the weekend. Note: If physicians have access to electronically sign orders, they can also electronically sign the Order Reviews each month, the Monthly Orders do not need to be printed for residents of these physicians as long as the reviews are eSigned each month." b. A review of a Resident 10's Physician Orders for Life-Sustaining Treatment (POLST), signed by Resident 10's family member and dated 7/19/16, but was not signed and dated by the physician. A review of Resident 10's Admission Face Sheet indicated Resident 10 was admitted to the facility on 7/18/16. Resident 10's diagnoses included Parkinson's disease (a progressive disorder of the nervous system that affects movement), dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning), and generalized muscle weakness. A review of Resident 10's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 10/19/16, indicated Resident 10 was rarely/never understood by others and rarely/never understands others. According to the MDS, Resident 10 required extensive assistance with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 116 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 a one-person physical assist for dressing, transferring, and hygiene/bathing. A review of the facility's policy titled, "Physician Orders for Life-Sustaining Treatment (POLST)," with a revision date of 12/2009, indicated that once the POLST form was completed, it must be signed by the resident, or if the resident lacks decision-making capacity the resident's legally recognized health care decision maker and the attending physician. c. A review of Resident 12's Admission Face Sheet indicated Resident 12 was admitted to the facility on 6/20/16. Resident 12's diagnoses included hypertension (high blood pressure), dementia without behavioral disturbance, and acute kidney failure (abrupt loss of kidney function). A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/7/16, indicated Resident 12 usually had the ability to understand and be understood by others. According to the MDS, Resident 12 does not have hallucinations (apparent perception of something not present) or, delusions (misconceptions or beliefs that are firmly held, contrary to reality). A review of of Resident 12's POLST indicated "Do Not Resuscitation (DNR) [no life saving measure]," was ordered with a physician signature, but was not dated. On 11/17/16, at 10:38 a.m., during an interview, a licensed vocational nurse (LVN 8). LVN 8 stated, "Yes, there should be a date with the signature and the family should also sign the POLST." We need to make sure that the doctors date it and the family signature is needed. " FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 117 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (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 d. A review of Resident 18's Admission Face Sheet indicated Resident 18 was originally admitted to the facility on 1/18/11, and readmitted on 4/11/16. Resident 18 diagnoses included pleural effusion (excess fluid that accumulates in the chest cavity and surrounds the lungs), thoracotomy with chest tube (surgical incision with a flexible plastic tube inserted through the chest wall that allows fluid to flow to a drainage unit), pneumonia (infection that inflames the air sacs in lungs), muscle weakness and dysphagia (difficulty in swallowing). According to the nurses' notes, Resident 18 was placed on hospice care on 4/29/16. A review of the nurses' note, dated 10/23/16, indicated Resident 18 expired that day. A review of Resident 18's POLST indicated it was prepared on 10/20/16, and signed by Resident 18's recognized decision maker, but was not signed by the physician until 10/27/16, four days after Resident 18 expired. On 11/15/16 at 3:32 p.m., during an interview with MDS Nurse 1 regarding Resident 18's POLST being signed by the physician after Resident 18 expired. MDS Nurse 1 stated, " It should have been done sooner, especially since the resident was placed on hospice six months prior." According to the facility's undated policy and procedure, titled " Physician Orders for Life Sustaining Treatment (POLST)," indicated once the POLST was completed, it must be signed by the resident, or if the resident lacks decision-making capacity the resident's legally recognized health care decision maker, AND the attending physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1MGY11 Facility ID: CA940000015 If continuation sheet 118 of 119 PRINTED: 05/14/2026 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: _______________ 055706 (X3) DATE SURVEY COMPLETED 11/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE ORCHARD - POST ACUTE CARE 12385 Washington Blvd Whittier, CA 90606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 1MGY11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000015 (X5) COMPLETE DATE If continuation sheet 119 of 119