Arvin Post Acute

During a review of Resident 34's Minimum Data Set (MDS - a comprehensive assessment tool), Section C, dated 6/2/25, the MDS indicated Resident 34's BIMS (Brief Interview for Mental Status) score was 14 (score of 13-15 means cognition is intact).

During an interview on 3/26/26 at 11:45 a.m. with Administrator, Administrator stated the facility leadership team did rounds in resident rooms and remove items not allowed such as extension cords with concern for fire hazard.

Administrator stated the expectation was that if an extension cord was removed, staff would replace it with a facility approved electrical outlet device.

During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Accommodation of Needs, (undated), the P&P indicated, 2.

The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis as needed.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

to participate in experimental research, and to formulate an advance directive.

(AD - written statement of person's wishes regarding medical treatment and end of life decisions,

wishes) options for three of 24 sampled residents (Resident 11, Resident 72, and Resident 6).

This failure had the potential for residents' end of life wishes to not be honored.Findings:During a review of Resident 11's Medical Record (MR), the MR contained no documentation the facility provided written information showing whether Resident 11 had formulated an advance directive, whether Resident 11 wished to do so, or if assistance was offered.During a review of Resident 72's MR, the MR contained no documentation the facility provided written information showing whether Resident 72 had formulated an AD, whether Resident 72 wished to do so, or if assistance was offered.During a review of Resident 6's MR, the MR contained no documentation the facility provided written information showing whether Resident 6 had formulated an AD, whether Resident 6 wished to do so, or if assistance was offered.

During an interview on 3/25/26 at 12:40 p.m. with Director of Regional Clinical Services (DRCS), DRCS stated there were no Advance Directive Acknowledgement forms completed for Resident 11, Resident 72, and Resident 6.During a review of facility's Policy and Procedure (P&P) titled, Advance Directives dated 9/2022, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment.

Advance directives are honored in accordance with state law and facility policy. 1.

Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2.

The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

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bed-hold policies.

assist residents in long-term care facilities with issues related to day-day care, health, safety, and

Resident 80) planned transfers and discharges.

This failure had the potential to result in Resident 11, Resident 12, Resident 6, and Resident 80 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.Findings:During a concurrent interview and record review on 3/25/26 at 9:47 a.m. with Assistant Regional Director Clinical Services (ARDCS), Resident 11's Medical Record (MR), [undated] was reviewed. ARDCS stated Resident 11 was transferred to hospital on 3/21/25, 8/26/25, and 3/15/26. ARDCS stated there was no ombudsman notification completed for 3/21/25, 8/26/25, and 3/15/26. ARDCS stated Ombudsman should have been notified after each transfer out to hospital.During a review of Resident 6's MR, [undated], the MR indicated Resident 6 was transferred to hospital on 9/10/25 and 10/3/25.

There was no indication in Resident 6's MR that Ombudsman was notified.During a review of Resident 80's MR, [undated], the MR indicated Resident 80 was transferred to hospital on 3/15/25 and 3/2/26.

There was no indication in Resident 80's MR that Ombudsman was notified.

During an interview on 3/25/26 at 11:19 a.m. with Director of Regional Clinical services (DRCS), DRCS stated Ombudsman notifications for Resident 80 and Resident 6 were not completed. DRCS stated Ombudsman should be notified when transfer to hospital. DRCS stated Ombudsman is only being notified when residents were being discharged to home.During a concurrent interview and record review on 3/25/26 at 1:47 p.m. with ARDCS, Resident 12's MR [undated] was reviewed. ARDCS stated Resident 12 was transferred to hospital 1/3/26 and 2/19/26. ARDCS stated there was no Ombudsman notification completed for 1/3/26 and 2/19/26.During a review of facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, dated 3/2021, the P&P indicated, Residents and/or representatives are notified in writing, and in language and format they understand, at least thirty (30) days prior to a transfer or discharge.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During a concurrent interview and record review on 3/25/26 at 9:47 a.m. with ARDCS, Resident 11's MR, [undated] was reviewed. Resident 11 was admitted on [DATE]. ARDSC stated she was unable to find documentation for BCP.During a review of facility's policy and procedure (P&P) titled, Care Plans - Baseline, dated 5/2024, the P&P indicated, A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During a concurrent interview and record review on 3/26/26 at 8:15 a.m. with Director of Staff Development (DSD), the clinical record of Resident 28 was reviewed. DSD stated Resident 28 was at risk for pressure injuries as indicated in the BSPS dated 12/26/25, 1/1/26, and 1/8/26. DSD stated Resident 28 had very limited mobility and needed frequent turning and repositioning. DSD stated the first care plan for prevention of pressure injuries including the intervention of turning and repositioning for Resident 28 was developed on 1/12/26.

During an interview on 3/26/26 at 11:28 a.m. with Regional Director of Clinical Services (RDCS), RDCS stated pressure injury prevention care plans should be created for all residents assessed to be at risk for pressure injuries and should contain interventions to address the risk factors identified in the BSPSs. RDCS stated pressure injury prevention care plans should be created as soon as residents are assessed to be at risk for pressure injuries.

During a review of facility policy and procedure (P&P) titled Care Plans, Comprehensive Person Centered, dated March 2022, the P&P indicated, A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

During a review of facility's P&P titled Prevention of Pressure Injuries, dated 4/2020, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During a review of facility P&P titled, Falls Risk Assessment dated [DATE], the P&P indicated, The nursing staff, in conjunction with the attending physician, consulting pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During an interview on 3/23/26 at 3:32 p.m. with Resident 105, Resident 105 stated she was not receiving enough showers. Resident 105 stated she wanted more showers. Resident 105 stated she requested a shower yesterday but was denied.

During a concurrent interview and record review on 3/25/26 at 10:05 a.m. with the Director of Staff Development (DSD), Resident 105's shower flowsheets were reviewed. DSD opened Resident 105's Bathing log in the computer which indicated Resident 105 had a total of four showers since admission, on 3/17/26, 3/19/26, 3/20/26 and 3/24/26. DSD stated there were no shower refusals documented in Resident 105's Bathing log. DSD stated the facility's policy was for residents to be offered showers twice a week but residents could have showers as frequently as they wanted.

DSD stated Resident 105's shower days were Tuesday and Thursdays.

During an interview on 3/25/26 at 10:20 a.m. with Resident 105, Resident 105 stated she wanted showers every other day not only twice a week.

During a review of facility policy and procedure (P&P) titled Shower/Tub Bath, dated October 2010, the P&P indicated showers/tub baths promote cleanliness, provided comfort to the resident and to observe the condition of the resident's skin.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During a concurrent observation and interview on 3/25/26 at 3:35 p.m. with the Director of Nursing (DON) in Resident 43's room, Resident 43 was receiving tube feedings while lying flat in his bed. DON stated Resident 43's head of bed should be elevated 30 degrees when receiving tube feedings.

During a review of Resident 43's care plan (CP) titled Resident requires tube feeding ., dated 3/20/26 with the objective, Resident will remain free of side effects or complications related to tube feeding . the CP indicated, Resident's HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed.

During an interview on 3/26/26 at 11:28 a.m. with Regional Director of Clinical Services (RDCS), RDCS stated residents receiving tube feeding should be kept with their heads elevated at 45 degrees to prevent aspiration.

During a review of facility policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions dated 2001, the P&P indicated, Elevate the head of bed (HOB) at least 30 degrees during tube feeding .

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

nurses on a full time basis.

duty eight hours a day, seven days a week.

This failure had the potential for resident care to be

with Director of Staff Development (DSD), the Detail Time and Job (clock in log) dated 1/10/26, 2/22/26, 3/14/26, and 3/15/26 was reviewed. DSD stated there was no RN present in the building for 8 hours a day during those days.During a review of facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent nursing, dated 8/2022, the P&P indicated, 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

(Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3, CNA 4, CNA 5) were completed.

This failure had

affect resident care.Findings:During a concurrent interview and record review on 3/25/26 at 8:13 a.m. with Director of Staff Development (DSD), CNA 1's Personnel File (PF) was reviewed.

The PF indicated CNA 1 was hired on 2/1/18 and last PE was done on 7/5/24 and there was no PE found after 7/5/24. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:27 a.m. with DSD, CNA 2's PF was reviewed.

The PF indicated CNA 2 was hired on 5/7/24 and there was no PE found in their PF. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:29 a.m. with DSD, CNA 3's PF was reviewed.

The PF indicated CNA 3 was hired on 5/22/24 and there was no PE found in their employee file. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:33 a.m. with DSD, CNA 4's PF was reviewed.

The PF indicated CNA 4 was hired on 4/28/22 and there was no PE found in their employee file. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:37 a.m. with DSD, CNA 5's PF was reviewed.

The PF indicated CNA 5 was hired on 4/12/22 and annual PE was completed on 6/25/24 and there was no PE found in their employee file. DSD stated PE should be completed annually.During a review of facility's policy and procedure (P&P) titled, Performance Evaluations, dated 9/2020, the P&P indicated, The job performance of each employee shall be reviewed and evaluated at least annually.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

Based on observation, interview, and record review, the facility failed to ensure the safe

medication self- administration assessment or a physician order for one of 24 sampled resident (Resident 33).

This failure had the potential for medications to be administered incorrectly and unsafely.Findings:During a concurrent observation and interview on 3/23/26 at 9:20 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 33's room, Resident 33 had a medication cup on the bedside table with five pills and three capsules in the medication cup and no nurse was present in the room. LVN 2 stated in the medication cup there were pantoprazole (medication used for stomach acid), aspirin (to prevent blood clots), cresemba (medication to treat fungal infections), metformin (medication used to treat high blood sugar), multi-vitamin, vitamin C, Vitamin B12 (used for vitamin deficiency) and senna (stool softener). LVN 2 stated nurses should wait and watch until residents swallow all the medications.During a concurrent interview and record review on 3/26/26 at 1:49 p.m. with Assistant Regional Director Clinical Services (ARDCS), Resident 33's Medical Record (MR), [undated] was reviewed. ARDCS stated there was no physician order to keep medications at bedside.

ARDCS stated there was no self-administer assessment in Resident 33's MR. ARDCS stated there was no care plan to keep medications at bedside. ARDCS stated nurses should ensure Resident 33 swallowed the medication before leaving the room.During a review of facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.

Only authorized personnel have access to keys.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During an interview on 3/24/26 at 10:02 a.m. with the Director of Maintenance (DM) in the kitchen, DM stated he was responsible for cleaning the ice machine. DM stated he cleaned the ice machine using a cleaner which he poured into the machine's water reservoir and let the cleaner to run through the machine's ice-making cycle. DM provided the cleaner he used which read Nickel-Safe Ice Machine Cleaner. DM stated this was the only product he used to clean the ice machine.

During a concurrent interview and record review on 3/24/26 at 11:35 a.m. with DM, the ice machine's Installation, Use & Care Manual (Ice Machine Manual), dated 10/13 was reviewed.

The Ice Machine Manual, under Section 4 Maintenance, indicated the cleaning of the ice machine should be followed by sanitizing it, which comprised running a sanitizer solution through the ice machine in the same way as the cleaner.

The Ice Machine Manual indicated, Ice machine cleaner is used to remove lime scale and mineral deposits.

Ice machine sanitizer disinfects and removes algae and slime. DM stated he did not know he was supposed to sanitize the ice machine. DM stated he did not sanitize the ice machine.

During an interview on 3/24/26 at 11:47 a.m. with the Dietary Director (DD), DD stated ice from the ice machine was placed in residents' water bottles, drinks, and used for food preparation for residents.

During a review of facility policy and procedure (P&P) titled Ice Machines and Ice Storage Chests dated January 2012, the P&P indicated, Ice-making machines, ice storage chests/containers, and ice can all become contaminated by . colonization by microorganisms .

Our facility has established procedures for cleaning and disinfecting ice machines . which adhere to manufacturer's instructions. 2.

During observations on 3/24/26 at 10:33 a.m., 10:43 a.m., 10:46 a.m. and at 10:47 a.m., a haired food delivery worker entered the kitchen without a hair net and placed food boxes in front on the refrigerators. In each instance the food delivery worker passed a few feet away from trays of bread rolls and from a food preparation table where [NAME] 1 was preparing lunch for residents.

During an interview on 3/24/26 at 4:20 p.m. with the Registered Dietician (RD), RD stated everyone entering the kitchen should wear a hair net, including non-staff and delivery people.

During a review of facility policy and procedure (P&P) titled, Food Preparation and Service, dated November 2022, the P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices .

Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

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Arvin Post Acute 323 Campus Drive Arvin, CA 93203

During a concurrent observation and interview on 3/23/26 at 9:03 a.m. in the doorway of Resident 56's room, CNA 6 was at Resident 56's bedside wearing gloves (no gown) tying a trash bag then exited the room.

CNA 6 stated Resident 56 had a wound on his groin but was not sure what EBP means. CNA 6 stated she was only wearing gloves while providing care to Resident 56.

During a review of Resident 56's Order Summary (OS) dated 2/24/26, the OS indicated, Resident [56] requires Enhanced Barrier Precautions (EBP) during high contact care activities r/t [related/to]: Surgical Wound RT [right] groin.

During an observation on 3/25/26 at 9:16 a.m. with Licensed Vocational Nurse (LVN) 1 at Resident 43's bedside, LVN 1 donned gloves (no gown) and checked Resident 43's gastrostomy tube (g-tube - a tube inserted into the stomach through the abdominal wall used to administer medications and nutrition) placement and residual (how much liquid was in the stomach). LVN 1 attached a syringe to the g-tube and flushed with 30 milliliters of water.

During a concurrent observation and interview on 3/25/26 at 10:03 a.m. with LVN 1 outside of Resident 43's room, a sign on the nameplate indicated Resident 43 was on EBP. LVN 1 was unable to verbalize what EBP meant and why Resident 43 was on EBP. LVN 1 stated she only wore gloves while caring for Resident 43's g-tube but because Resident 43 was on EBP she also needed to wear a gown when providing care.

During a review of Resident 43's OS, dated 12/4/25, the OS indicated, Resident [43] requires Enhanced Barrier Precautions (EBP) during high contact care activities r/t: G-Tube.

During an interview on 3/26/26 at 2:13 p.m. with Infection Preventionist (IP), IP stated residents who have been colonized (presence of germs without causing disease symptoms) with MDRO (Multi Drug Resistant Organisms - germs immune to antibiotic drugs), have an indwelling device (medical instruments inserted into the body including g-tube), or have an open wound will be placed on EBP. IP stated staff have to wear a gown and gloves when providing care and touching the environment of residents on EBP to help prevent infections.

During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 2/2025, the P&P indicated, 1.

Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. a.

Gloves and gown are applied prior to performing the high contact resident care activity.