Health inspection·July 24, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were implemented to help prevent development and transmission of diseases and infections for two of four sampled residents (Residents 3 and 4) and six of six nonsampled residents (Residents 5, 6, 7, 8, 9, and 10). Residents Affected - Some * The facility failed to properly store and label two bedpans and a basin observed on a handrail in Room A's restroom occupied by Residents 5 and 6. * The facility failed to properly store and label a basin found in Room B's restroom occupied by Residents 3, 7, 8 and 9. * The facility failed to properly store and label a urinal found on top of a toilet tank in Room C occupied by Residents 4 and 10. These failures had the potential for cross contamination and spread of infections. Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 9/18/24, showed an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's P&P titledResident's Personal Property revised 8/25/21, showed the facility should protect the resident's rights to retain his/her personal belongings and preserve the resident's individuality and dignity. 1. During an initial tour on 7/24/24 at 0829 hours, there were two unlabeled bedpans and one unlabeled basin in Room A's restroom. Room A was occupied by Residents 5 and 6. 2. On 7/24/24 at 0905 hours, an observation was conducted in Room B. Resident 3 was in Room B with Residents 7, 8 and 9. There was an unlabeled basin touching the clean toilet paper seat dispenser. 3. On 7/24/24 at 1050 hours, an observation was conducted in Room C. Room C wasoccupied by Residents 4 and 10. There was anunlabeled urinal placed on top of the toilet tank. On 7/24/24 at 1130 hours, an observation and concurrent interview was conducted with the DON. The DON verified all the findings and stated all bedpans, basins, and urinals should be properly stored (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055653 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Post Acute 1030 W Warner Ave Santa Ana, CA 92707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)