Health inspection·November 12, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement infection control practices by failing to ensure a resident's urinal bottle (also known as urine bottle, a container used to collect urine) was labeled with the resident name and room number for one of six sampled residents (Resident 6). Residents Affected - Few This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), and hypertension (high blood pressure). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 10/15/2024, the MDS indicated that Resident 6's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 6 required moderate assistance from staff with personal hygiene and dependent with toileting hygiene and bathing. During a concurrent observation and interview on 11/12/2024 at 9:45 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 6 with two unlabeled urinal bottles, one urinal bottle was hanging on the right upper side of Resident 6's bed rail (also known as side rails, metal or plastic bars positioned along the side of a bed) and the other urinal bottle on Resident 6's left side on top of Resident 6's drawer. LVN 3 confirmed the finding and stated that facility staff should have labeled the urinal bottle with the name and room number of the resident because it is an infection control issue and to prevent switching of urinals with other residents that can lead to spread of infection. During a review of the facility's policy and procedure titled, Resident Dignity/Resident Rights, last reviewed in 2/29/2024, indicated it is the policy of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Label personal items for everyday use such as urinals, emesis basins, lotions, toothpaste, and toothbrushes for their own personal use and promote good infection control practice and procedures. During a review of the facility's policy and procedure, titled Infection Control Guidelines, last (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: 056031 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. Sunland, CA 91040 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)