Other·February 6, 2019

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 an investigation of a facility reported incident during an annual recertification visit. Facility reported incident number: 614188 Representing the Department of Public Health: Surveyor ID: 27785 Surveyor ID: 25219 Surveyor ID: 31331 Surveyor ID: 33690 Surveyor ID: 39642 Total Resident Population: 149 Total Resident Sample: 30 Highest Scope and Severity: E No deficiencies were issued for facility reported incident number 614188

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 01/17/2019 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. 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: 90EO11 Facility ID: CA940000015 If continuation sheet 1 of 37 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 12/21/2018 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 a bedside commode for one of 30 sampled residents (Resident 141) was within the resident's reach. Resident 141's bedside commode was stored in the restroom. This deficient practice had the potential for the resident to not make it to the restroom in time and also placed the resident at risk for falls. Findings: A review of Resident 141's Admission Record, indicated the resident was admitted to the facility on 9/4/18, with diagnoses that included history of falling and dementia (is the name for a group of symptoms caused by disorders that affect the brain, it is not a specific disease). A review of Resident 141's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 12/3/18, indicated that the resident usually made self-understood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance (resident involved in activity, staff provided weightbearing support) from staff for transferring, dressing, toileting, and personal hygiene. During an observation and concurrent interview, on 12/18/18, at 1:50 p.m., Resident 141's Family Member 1 (FM 1) stated, the resident did not have enough space in the room so the facility had to keep the resident's bedside commode in the restroom. Resident 141 had three other resident's sharing the room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 2 of 37 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 12/21/2018 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 the resident's bedside commode was stored in the restroom. During an observation and concurrent interview, on 12/20/18, at 2 p.m., the Director of Nursing (DON) stated, the resident's bedside commode should not be stored in the restroom. The DON stated, it should be kept at the bedside so that the resident would not have to walk to the restroom. The DON stated, that it put the resident at risk for falls. A review of the facility undated policy and procedure titled, "Bedpan, Urinals and Bed Side Commode, Cleaning of," dated 5/2007, indicated that after cleaning item, return to the resident's bedside.

F559 SS=D Choose/Be Notified of Room/Roommate Change CFR(s): 483.10(e)(4)-(6)

F559 01/17/2019 §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. §483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. §483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 3 of 37 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 12/21/2018 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 observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 141) was provided with advanced notification of a room change. Resident 141 was moved from a twobed room to a four-bed room without notification and/or permission from the designated power of attorney (POA a document you can use to appoint someone to make decisions on your behalf). This deficient practice violated the resident's rights to be informed and/or consent to the room change. Findings: A review of Resident 141's Admission Record, indicated the resident was admitted to the facility on 9/4/18, with diagnoses that included history of falling and dementia (is the name for a group of symptoms caused by disorders that affect the brain, it is not a specific disease). A review of Resident 141's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 12/3/18, indicated that the resident usually made self-understood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance (resident involved in activity, staff provided weightbearing support) from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 141's Advance Health Care Directive, dated 3/1/14, indicated that the POA was family member 1 (FM 1). During an observation and concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 4 of 37 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 12/21/2018 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, on 12/18/18, at 1:50 p.m., Resident 141's FM 1 stated, that the resident did not have enough space in the room so the facility had to keep the resident's bedside commode in the restroom. FM 1 also stated, the resident's bedside table was kept at the foot of the bed and it would hit the resident's privacy curtain. FM 1 stated, that Resident 141 used to be in a two-bed room and had more space and did not understand why Resident 141 was moved into a four-bed room. FM 1 stated, that she was not asked for consent for the move and was told that they were moving Resident 141. Resident 141 had three other resident's sharing the room and the resident's bedside commode was stored in the restroom. During an interview and concurrent record review, on 12/20/18, at 1:44 p.m., the Director of Nursing (DON) stated, that Resident 141 was originally in a two-bed room. The DON stated, that Resident 141's Social Service note dated 11/21/18, indicated the resident was moved to Room 425 D and no indication of why the resident was moved. The DON stated, that the facility needed to notify the resident and/or representative, of the room change and provide a reason for the room change in advance. The DON stated, that the facility should try not to change the resident's room because it could cause the resident to be disoriented. During a follow up interview and concurrent record review, on 12/20/18, at 2 p.m., the DON stated, that there was no documentation indicating the resident and/or representative was given written notice of the room change in advance. A review of the facility undated policy and procedure titled, "Social Services Policy and Procedure," indicated that the resident had the right to notification of room or roommate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 5 of 37 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 12/21/2018 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 changes and to a agree prior to the change taking place. A Notification of Room or Roommate Change form was to be completed and used to document that the resident had been given advanced notification of the room or roommate change. This form was to be filed in the Social Services section of the resident's clinical record, and in a Room Change.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 01/17/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 12) was coded accurately on the Minimum Data Set (MDS, a standardized assessment and care-screening tool) Under Section O (Special Treatments, Procedures, and Programs) for hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness). This deficient practice had the potential for the resident to not receive appropriate treatment and/or services. Findings: A review of Resident 12's Admission Record, indicated the resident was admitted to the facility on 12/18/14 and was re-admitted on 3/24/17, with diagnoses that included dementia (is the name for a group of symptoms caused FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 6 of 37 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 12/21/2018 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 by disorders that affect the brain, it is not a specific disease) and was under hospice care. A review of Resident 12's MDS dated 9/19/18, indicated the resident usually made selfunderstood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff for transferring, dressing, eating, and personal hygiene. Under Section O, the resident was marked for dialysis (a process in which a machine helps filter your blood to rid your body of harmful wastes, extra salt, and water) and not hospice. During an interview and concurrent record review, on 12/19/18, at 2:31 p.m., the MDS Nurse (MDSN) stated, Resident 12's MDS was incorrectly coded and should have indicated hospice instead of dialysis. The Director of Nursing (DON) stated that the resident was never on dialysis. A review of the facility undated policy and procedure titled, "Policy/Procedure-Nursing Administration," indicated that the licensed nurse was responsible for compiling all resident information ensuring all information was entered accurately into each resident's database.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 01/17/2019 §483.21 Comprehensive Person-Centered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 7 of 37 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 12/21/2018 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 Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 8 of 37 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 12/21/2018 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 necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a plan of care was developed for one (Resident 105) of six residents reviewed for falls/accidents out of 30 sampled residents. For Resident 105, there was no plan of care developed for the use of 1/4 bilateral bed rails. This had the potential risk for injury from inadequate care for the use of the bed rails. Findings: A review of the Admission Record for Resident 105, indicated the resident was originally admitted to the facility on 10/8/13, and readmitted on 3/21/18, with diagnoses which included generalized muscle weakness and dementia (a decline in mental ability severe enough to interfere with daily life). A review of the latest Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/19/18, indicated Resident 105 usually had the ability to make self understood and understand others. The MDS also indicated resident required extensive assistance from staff for most of his activities for daily living (ADL). A review of Resident 105's clinical record indicated a physician's order, dated 11/13/18, for the use of 1/4 bed rails in bed as an enabler to assist the resident in turning and repositioning. Further review of the clinical record for Resident 105, indicated there was no care plan developed for the use of the 1/4 bed rails to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 9 of 37 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 12/21/2018 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 identify and prevent potential injury for its use. During an observation, on 12/18/18, at 10:05 a.m., Resident 105 was observed laying asleep in bed. The bed was in its lowest position with bilateral 1/4 bed rails up and floor mats on both beds. During another observation, on 12/19/18, at 9:34 a.m., Resident 105 was again observed in bed asleep with bilateral 1/4 bed rails up. During an interview, with Medical Records on 12/19/18, at 1:05 p.m., she stated, after she reviewed Resident 105's clinical record, that there was no care plan developed for the use of the bed rails. During an interview and concurrent record review, with the Director of Nursing (DON) on 12/19/18, at 3 p.m., after reviewing Resident 105's clinical record, the DON stated, that there was no care plan developed for the use of the bed rails. The DON stated, that the bed rails was being used as an enabler for turning and repositioning and not as a restraint.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 01/17/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 10 of 37 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 12/21/2018 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) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the care plan was revised to reflect changes made for one of 30 sampled residents (Residents 58). Resident 58, who was currently ordered for Temazepam (a medication used to help fall asleep) 7.5 milligram (mg), had a care plan indicating that the resident was receiving Temazepam 30 mg. This deficient practice had the potential for the resident to receive inaccurate care and/or treatment services. Findings: A review of Resident 58's Admission Record, indicated the resident was admitted to the facility on 9/1/15 and was re-admitted on 10/7/15, with diagnoses that included history of fall and major depressive disorder. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 11 of 37 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 12/21/2018 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 58's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 10/21/18, indicated that the resident was able to make self-understood or understood others and had moderate impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff for transferring and personal hygiene. A review of Resident 58's monthly physician's orders for 12/2018, indicated the resident was ordered on 10/12/18, Temazepam 7.5 mg by mouth (PO) at bedtime (QHS) for insomnia manifested by (m/b) persistent poor sleep. A review of Resident 58's care plan titled, "Is on Hypnotic Therapy related to insomnia ...," dated 10/23/17, indicated under interventions for Temazepam capsule 30 mg. During an interview and concurrent record review, on 12/19/18, at 2:46 p.m., the Director of Nursing (DON) stated, Resident 58 was ordered for Temazepam 7.5 mg PO QHS for insomnia m/b persistent poor sleep on 10/12/18 . The DON stated, that prior to 7.5 mg, the resident was on 15 mg on 3/28/17, and prior to that the resident was on 30 mg of Temazepam. The DON stated, that the resident's care plan regarding Temazepam was not revised to reflect the current dose and/or any changes made in the gradual dose reduction of the medication. A review of the facility policy and procedure titled, "Policy/Procedure - Nursing Administration," dated 6/2012, indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 12 of 37 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 12/21/2018 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 new physician's orders for psychotherapeutic medications would be communicated to the social services department for referral to Psychotropic Drug Review Committee and appropriate care planning to ensure accurate information was in the resident the resident's psychosocial care plan.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/17/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers 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 services to one of four sampled residents (Resident 99) with risk of developing a pressure ulcer (or injury [PI]/areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 13 of 37 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 12/21/2018 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 develop a sore) in a total resident sample of 30 by failing to: 1. Offload (elevate to relieve direct pressure) the feet while in bed. 2. Provide the treatment to the coccyx (bone located at the bottom of the spine/tail bone) region in accordance with the physician's order on 12/11/18, 12/12/18, 12/15/18, and 12/18/18. 3. Ensure Resident 99's PI care plan was specific for the location and staging (description of the pressure injury) of the PI. These deficient practices placed Resident 99's at risk of developing additional PIs, delay healing and worsening of the PI. Findings: A review of Resident 99's Admission Record dated 12/21/18, indicated the resident was admitted to the facility on 6/4/18 and readmitted on 11/5/18, with diagnoses that included dementia (decline of memory and other mental abilities) and cachexia (loss of weight with weakness). A review of Resident 99's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 11/12/18, indicated the resident had cognitive (the mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 99 required extensive assistance (staff provided support with bearing weight, at times full staff performance of activity) from staff with activities of daily living ([ADLs] such as dressing, toileting, personal hygiene, and bed mobility) and had application of medication for a skin condition. A review of Resident 99's Order Summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 14 of 37 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 12/21/2018 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 Report dated 11/30/18, indicated the following physician orders for the PI care: 1. On 11/12/18, to offload heels while in bed. 2. On 11/27/18, for the coccyx PI to cleanse with wound cleanser, pat dry, cover with hydrocolloid patch (gel packed bandages and dressings help to induce healing by trapping moisture under the bandage). A review of the skin pressure ulcer weekly assessment dated 12/4/18, indicated on 11/27/18, Resident 99 developed a Stage II, PI (loss of the skin with exposure to underlying tissue) to the coccyx area. A review of Resident 99's care plan for potential of pressure ulcer development dated 11/14/18 and 12/20/18, both care plans failed to indicate the location and staging for the PI. Both care plans included the interventions to off load heels while in bed and to provide/monitor the treatment for the wound. During an observation on 12/21/18, at 9:07 a.m., Licensed Vocational Nurse 1 (LVN 1) verified Resident 99 had pillows to the right side of the body and was facing the window. Upon removal of the blankets, Resident 99's feet were observed directly on the air mattress and the left heel had a healed dark discoloration. During a skin check on 12/21/18, at 9:13 a.m., LVN 2, verified Resident 99 had an open wound to the coccyx area. During an interview and concurrent record review on 12/21/18, at 9:56 a.m., Registered Nurse 1 (RN 1) verified Resident 99's order for off-loading while in bed and was not implemented. RN 1 further stated, the feet are usually off loaded by putting a pillow to elevate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 15 of 37 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 12/21/2018 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 heels to prevent sore (wound). RN 1 also verified on 12/10/18, Resident 99's Stage II, PI had healed. RN 1 verified on 12/10/18, the physician ordered: Wash coccyx area with soap and water, pat dry, and apply zinc oxide (prevents skin irritation by forming a barrier to protect it from irritants and moisture) for skin maintenance. RN 1 further verified on the Treatment Administration Record for 12/2018, there was no documentation that Resident 99's treatments had been done 12/11/18, 12/12/18, 12/15/18, and 12/18/18 during the evening shift. The boxes were blank with no initials or codes to indicate the treatments had been done. During an interview and concurrent record review on 12/21/18, at 10:10 a.m., the Treatment Nurse (TN) stated, Resident 99 has an on and off coccyx PI due to limited mobility. The TN verified the only place nurses document when treatment orders are done was on the Point Click Care (PCC/electronic medical record) TAR (Treatment Administration Record). The TN verified the treatments for Resident 99's evening shift were not done on 12/11/18, 12/12/18, 12/15/18, and 12/18/18. The TN further stated the risk when treatments are not done was for the wound to worsen. During an interview on 12/21/18, at 11:56 a.m., the Director of Nursing (DON) verified she was aware of Resident 99's open wound during the skin check and concerned that the treatments were not done for four days. A review of the facility policy and procedures titled, "Skin Management System," dated 6/2013, indicated it was the facility policy that a resident who enters the facility without PI does not develop a wound by providing the appropriate preventive measures: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 16 of 37 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 12/21/2018 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 1. A plan of care to address the actual skin breakdown. 2. Ensure administration of treatment are conducted as prescribed. According to National Pressure Ulcer Advisory Panel (NPUAP) handbook on Prevention and Treatment of Pressure Ulcer: A Quick Reference Guide, for PI prevention staff should ensure that the heels are free from the bed and the plan for dressing changes should be followed. http://www.npuap.org/wpcontent/uploads/2014/08/Quick-ReferenceGuide-DIGITAL-NPUAP-EPUAP-PPPIAJan2016.pdf

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 01/17/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that one of 30 sampled residents (Resident 99) was receiving oxygen (O2) at the ordered rate. Resident 99 was observed with O2 at three liters per minute (LPM) via nasal cannula (N/C, a tubing used to deliver O2 via the nares). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 17 of 37 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 12/21/2018 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 deficient practice had the potential for the resident to receive too much O2 and have complications. Findings: A review of Resident 99's Admission Record, indicated the resident was admitted to the facility on 6/4/18 and was re-admitted on 11/5/18, with diagnoses that included pneumonitis (general term that refers to inflammation of lung tissue) and dementia (is the name for a group of symptoms caused by disorders that affect the brain, it is not a specific disease). A review of Resident 99's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 9/19/18, indicated that the resident rarely/never made self-understood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 99 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 99's monthly physician's order for 12/2018, indicated the resident was ordered for O2 at two LPM via N/C as needed (PRN) to keep O2 saturation greater than 90% on 11/5/18. During an observation and concurrent interview, on 12/18/18, at 1:41 p.m., Licensed Vocational Nurse 4 (LVN 4) stated, that Resident 99 was receiving O2 at three LPM via N/C. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 18 of 37 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 12/21/2018 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, on 12/19/18, at 3:42 p.m., the Director of Nursing (DON) stated, that the resident should receive O2 at the ordered rate. The DON stated, if the resident needed more O2, then the resident's physician should be notified and a new order written. A review of the facility undated policy and procedure titled, "Policy/Procedure - Nursing Clinical," indicated to obtain appropriate physician's order and turn the unit to the desired flow rate.

F700 SS=D Bedrails CFR(s): 483.25(n)(1)-(4)

F700 01/17/2019 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 19 of 37 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 12/21/2018 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 one (Resident 105) of six residents reviewed for falls/accidents, out of 30 sampled residents, was assessed for the risk of entrapment before using bilateral bed rails. Resident 105, who was observed with bilateral 1/4 bed rails up while in bed, was not assessed for the risk of entrapment from the bed rails. This had the potential risk for injury from using these bed rails. Findings: A review of the Admission Record for Resident 105, indicated resident was originally admitted to the facility on 10/8/13, and readmitted on 3/21/18, with diagnoses which included generalized muscle weakness and dementia (a decline in mental ability severe enough to interfere with daily life). A review of the latest Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/19/18, indicated Resident 105 usually had the ability to make self understood and understand others. The MDS also indicated resident required extensive assistance from staff for most of his activities for daily living (ADL). A review of Resident 105's clinical record indicated a physician's order, dated 11/13/18, for the use of 1/4 bed rails in bed as an enabler to assist resident in turning and repositioning. Further review of the clinical record for Resident 105, indicated there was no assessment for the risk of entrapment done prior to the use of the 1/4 bed rails to identify potential injury for its use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 20 of 37 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 12/21/2018 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 observation, on 12/18/18, at 10:05 a.m., Resident 105 was observed laying asleep in bed. The bed was in its lowest position with bilateral 1/4 bed rails up and floor mats on both sides. During another observation, on 12/19/18, at 9:34 a.m., Resident 105 was again observed in bed asleep with bilateral 1/4 bed rails up. During an interview and concurrent record review, with the Director of Nursing (DON) on 12/19/18, at 3 p.m., after reviewing Resident 105's clinical record, the DON stated, that there was no assessment for the risk of entrapment from the use of the bed rails. The DON stated, they have assessment for restraint and said that the bed rails were being used as an enabler for turning and repositioning and not as a restraint. However, after reviewing Resident 105's restraint assessment, the DON, verified that the assessment for the risk for entrapment was not part of the restraint assessment.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 01/17/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 21 of 37 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 12/21/2018 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 (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure unnecessary medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 22 of 37 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 12/21/2018 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 was not ordered for one of 30 sampled residents (Resident 12). Resident 12, who was ordered Ativan (a medication used to treat anxiety) 0.5 milligram (mg) sublingual (SL, under the tongue) every 6 hours (Q 6 hrs) as needed (PRN) for anxiety/shortness of breath (SOB), did not have a stop day and/or was reviewed by the resident's physician to ensure it was still needed. This deficient practice had the potential for the resident to be medicated unnecessarily with psychotropic drugs and be at risk for adverse side effects. Findings: A review of Resident 12's Admission Record, indicated the resident was admitted to the facility on 12/18/14 and was re-admitted on 3/24/17, with diagnoses that included dementia (is the name for a group of symptoms caused by disorders that affect the brain, it is not a specific disease) and was under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 9/19/18, indicated that the resident usually made self-understood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 12 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff for transferring, dressing, eating, and personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 23 of 37 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 12/21/2018 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 12's monthly physician's orders for 12/2018 indicated on 11/26/18, the resident was ordered Ativan 0.5 mg SL Q 6 hrs PRN anxiety/SOB, hold if respirations less than 12. Not to exceed two mg/24 hrs. During an interview and concurrent record review, on 12/19/18, at 2:38 p.m., the Director of Nursing (DON) stated, that Resident 12's physician ordered on 11/26/18 for Ativan 0.5 mg SL Q 6 hrs PRN anxiety/SOB, did not have a stop date. The DON stated, that it should have a stop date of 14 days and then be reevaluated if the medication needed to be continued by the resident's physician. The DON stated, that Resident 12's medication administration record (MAR) for 12/2018 indicated that the resident did not receive any Ativan. The DON also stated, that the licensed nurses should have called the resident's physician for clarification of the order. A review of the facility policy and procedure titled, "Psychotropic Drug Use," dated 8/2017, indicated that PRN orders for psychotropic drugs were limited to 14 days.

F837 SS=D Governing Body CFR(s): 483.70(d)(1)(2)

F837 01/17/2019 §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 24 of 37 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 12/21/2018 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 operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provide adequate administrative management to 149 residents in the facility. This deficient practice could result in facility's policy and procedures not being carried out. Findings: On December 17, 2018 at 11:35 am, during an unannounced recertification survey, the current administrator's license was observed not posted in the facility lobby. On December 26, 2018 at 11:20 am, during an interview, the Director of Nursing (DON) was not aware that the current administrator's license was not displayed in the facility per State regulation. The DON stated the administrator will not be in the facility for interview because he travels to other locations, as part of his administrator's duties. The DON could not recall when the administrator was last present at the facility. On December 26, 2018 at 2:46 pm, during a telephone interview, the Market Leader (ML) stated the current administrator's license was made available to the facility sometime in September 2018. The ML was not aware that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 25 of 37 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 12/21/2018 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 administrator's license was not displayed in the facility. The ML stated the current administrator functions as consultant for a total of 42 facilities throughout the United States and was not available immediately due to travel to another state.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 01/17/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 26 of 37 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 12/21/2018 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 oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the clinical record indicated an accurate representation of the actual treatment provided for one of 30 sampled residents (Resident 99). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 27 of 37 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 12/21/2018 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 Quality Assurance Nurse (QAN), who was not the treatment nurse, placed her initials on Resident 99's Treatment Administration Record (TAR) on 12/11/18, 12/12/18, 12/15/18 and 12/18/18, to indicate that Resident 99 received wound treatments as ordered by the physician. This deficient practice would not promote highest well-being of Resident 99 and was not consistent with the professional standards of practice. Findings: A review of Resident 99's Face Sheet (admission record), dated 12/21/18, indicated the resident was admitted to the facility on 6/4/18, and readmitted on 11/5/18, with diagnoses that included dementia (decline of memory and other mental abilities) and cachexia (loss of weight with weakness). A review of Resident 99's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 11/12/18, indicated the resident had cognitive (the mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 99 required extensive assistance (staff provided support with bearing weight, at times full staff performance of activity) from staff with activities of daily living ([ADLs] such as dressing, toileting, personal hygiene, and bed mobility) and requiring an application of medication for a skin condition. A review of Resident 99's Order Summary Report, dated 11/30/18, indicated a physician's order on 11/27/18, for treatment of the coccyx (tail bone) pressure injury (PI) to cleanse with wound cleanser, pat dry, cover with hydrocolloid patch (gel packed bandages and dressings that help to induce healing by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 28 of 37 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 12/21/2018 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 trapping moisture under the bandage). During a skin check on 12/21/18 at 9:13 a.m., Licensed Vocational Nurse 2 (LVN 2) verified Resident 99 had an open wound to the coccyx area. During an interview with Registered Nurse 1 (RN 1) on 12/21/18 at 9:56 a.m., and concurrent review of Resident 99's Treatment Administration Record, dated 12/1/18-12/31/18, there was no documentation that the physician's treatment order was provided on 12/11/18, 12/12/18, 12/15/18 and 12/18/18 on the evening shift. The boxes were blank with no initials or codes. During an interview with the Treatment Nurse (TN) on 12/21/18 at 10:10 a.m., stated Resident 99 has an on and off coccyx PI due to limited mobility. During a concurrent record review, the TN verified that the only place nurses document when treatment orders were provided was on the Point Click Care (PCC/electronic medical record) TAR. The TN verified that the TAR, dated 12/1/18-12/31/18, indicated the wound treatments for Resident 99 were not provided on the evening shift on 12/11/18, 12/12/18, 12/15/18 and 12/18/18. The TN stated the boxes were blank. The TN stated when treatments were not provided, the higher the risk for the wound to worsen. During an interview on 12/21/18 at 11:56 a.m., the Director of Nursing (DON) stated she was aware of Resident 99's open wound during the skin check and concern with treatments not done for four days. The DON was notified about the copies provided on 12/21/18, that included initials for 12/11/18, 12/12/18, 12/15/18 and 12/18/18, which did not have initials and were blank when verified with RN 1 and TN. The DON stated she will investigate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 29 of 37 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 12/21/2018 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 whose initials were on the TAR. During an interview on 12/21/18 at 12:01 p.m., the Director of Staff Development (DSD) provided the name of LVN 3, who was in charge to do the treatment for Resident 99 on 12/11/18, 12/12/18, 12/15/18 and 12/18/18. During a subsequent interview on 12/21/18 at 12:16 p.m., the DON stated the QAN signed the treatments for 12/11/18, 12/12/18, 12/15/18 and 12/18/18, as late entry when she was doing her audit. The documentation on the TAR were documented as initials and did not indicate a late entry. During an interview on 12/21/18 at 12:19 p.m., the QAN stated her role was to identify "gaps" in the documentation when she does the audits. QAN stated if the nurses miss something such as checking for low air loss mattress, pad alarms or giving medications, she verifies with the nurse that was assigned to follow the order. The QAN provided the example of medication administration by stating that she checks with the assigned nurse the bubble pack of the medication to verify if the medication was given. When asked if she checked with the nurse that was assigned to do the treatment on 12/11/18, 12/12/18, 12/15/18 and 12/18/18, she stated no. The QAN read the physician's treatment order and verified that her initials on the TAR for the four days meant the physician's treatment order was provided. The QAN stated she was in her office and did not know what was going on, all she knows was that, "it was her job to fill in the gaps." QAN verified she failed to follow her knowledge that she was required to verify with the charge nurse if the treatment was provided prior to initialing. QAN stated the treatments for 12/11/18, 12/12/18, 12/15/18 and 12/18/18 were not verified because the treatment nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 30 of 37 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 12/21/2018 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 was not in the facility. The QAN stated she was scared there were lots of gaps and needed to fill them in. A review of the facility's Job Duties and Responsibilities titled, "Licensed Vocational Nurse" signed by QAN on 7/6/18, indicated it was the facility's policy that the nurse would provide treatments as agreed upon by the physician. According to the Principles for Nursing Documentation by the American Nurses Association, page 12, indicated that high quality documentation is "accurate, relevant, consistent ... [is] clear, concise, and complete ... thoughtful ... [and] timely, contemporaneous (current), and sequential."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/17/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 31 of 37 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 12/21/2018 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 upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which 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; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 32 of 37 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 12/21/2018 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 §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a bedside commode was labeled appropriately to ensure infection control practices were maintained for one of 30 sampled residents (Resident 141). Resident 141's bedside commode was stored in a shared restroom without a label to indicate to whom it belonged to. This deficient practice had the potential for the spread of infection and cross contamination. Findings: A review of Resident 141's Admission Record, indicated the resident was admitted to the facility on 9/4/18, with diagnoses that included history of falling and dementia (is the name for a group of symptoms caused by disorders that affect the brain, it is not a specific disease). A review of Resident 141's Minimum Data Set (MDS, a standardized assessment and carescreening tool) dated 12/3/18, indicated the resident usually made self-understood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 141 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, toileting, and personal hygiene. During an observation and concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 33 of 37 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 12/21/2018 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, on 12/18/18, at 1:50 p.m., Resident 141's Family Member 1 (FM 1) stated that the resident did not have enough space in the room so the facility had to keep the resident's bedside commode in the restroom. Resident 141 had three other resident's sharing the room and the resident's bedside commode was observed in the restroom. During an observation and concurrent interview, on 12/20/18, at 2 p.m., the Director of Nursing (DON) stated, the resident's bedside commode should not be stored in the restroom. The DON stated, the bedside commode should also be labeled indicating it was for Resident 141, for infection control. A review of the facility undated policy and procedure titled, "Bedpan, Urinals and Bed Side Commode, Cleaning of," dated 5/2007, indicated that the bed side commode would be labeled accordingly.

F912 SS=E Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 01/17/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 34 of 37 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 12/21/2018 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 two of 50 resident rooms (Rooms 419 and 425) met the minimum requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice did not allow for adequate room for the proper placement of resident care equipment and a potential fall risk. Findings: A review of Resident 141's Admission Record, indicated the resident was admitted to the facility on 9/4/18, with diagnoses that included history of falling and dementia (is the name for a group of symptoms caused by disorders that affect the brain, it is not a specific disease). A review of Resident 141's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 12/3/18, indicated that the resident usually made self-understood or understood others and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance (resident involved in activity, staff provided weightbearing support) from staff for transferring, dressing, toileting, and personal hygiene. During an observation and concurrent interview, on 12/18/18, at 1:50 p.m., Resident 141 was observed in Room 425. Resident 141's Family Member 1 (FM 1) stated, the resident did not have enough space in the room so the facility had to keep the resident's bedside commode in the restroom. Resident 141 had three other resident's sharing the room and the resident's bedside commode was stored in the restroom. During an observation and concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 35 of 37 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 12/21/2018 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, on 12/20/18, at 2 p.m., the Director of Nursing (DON) stated, the resident's bedside commode should not be stored in the restroom. The DON stated, it should be kept at the bedside so that the resident would not have to walk to the restroom. The DON stated, that it put the resident at risk for falls. A review of the facility undated policy and procedure titled, "Bedpan, Urinals and Bed Side Commode, Cleaning of," dated 5/2007, indicated that after cleaning item, return to the resident's bedside. On 12/20/18, at 2:50 p.m., during an inspection of Rooms 419 and 425, with the Maintenance Supervisor and a Registered Environmental Health Specialist Surveyor, the rooms were measured to be 317.20 sq. ft. (79.3 sq. ft. per resident) and 317.46 sq. ft. (79.37 sq. ft. per resident). On 12/20/18, at 2:55 p.m., during an interview, the Administrator stated, according to the licensed contractor (builders of the facility) all the rooms in the facility met the 80 sq. ft. per residents in multiple residents room. The Administrator stated, they were not cited for this deficiency before and would not submit a room waiver request. A review of the facility Client Accommodation Analysis, dated 12/19/18, indicated that all twobed rooms measured between 207.48 sq. ft. and 287.71 sq. ft., providing at least 103.7 sq. ft. per resident. Four-bed resident rooms measured between 323.5 sq. ft. and 325.74 sq. ft., providing at least 80.9 sq. ft. per resident. The minimum square footage for a two-bed room is 160 sq. ft. and for a four-bed room is 320 sq. ft. These two resident rooms were below the minimum requirements and could FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 36 of 37 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 12/21/2018 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 lead to possible inadequate nursing care to the resident in those rooms. There were total of six unoccupied beds during the survey (Room 301D, 311-D, 408-D, 413-B, and 427 A&D had unoccupied beds). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 90EO11 Facility ID: CA940000015 If continuation sheet 37 of 37