Health inspection·December 2, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another that results in bodily injury) and verbal abuse (harsh and insulting language directed at a person) when on 11/17/2024 at 7 a.m. Resident 2 struck Resident 1, pushed the bedside table towards Resident 1 causing him (Resident 1) to fall on the floor as he attempted to get up from the bed to move out of his (Resident 2) way, and yelling profanities (a type of language that includes dirty words and ideas) at Resident 1. This deficient practice resulted in Resident 1 sustaining injuries including abrasion (a minor injury where the top layer of your skin is scraped off, usually caused by rubbing against a rough surface) to Resident 1's left forearm (the part of the human arm between the elbow and the wrist), abrasion to Resident 1's lower back, bruise to Resident 1's right thigh, abrasions to Resident 1's left posterior (the back side of things) leg, and scattered discoloration on Resident 1's right thigh. On 11/18/2024, the facility sent Resident 2 to the General Acute Care Hospital (GACH) for psychiatric evaluation (a mental health assessment that helps diagnose and treat mental health issues). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/7/2014 with diagnoses that included metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood, which affects brain function), bipolar disorder (a mental health condition that causes extreme mood swings, or episodes, that can affect a person's energy, mood, and ability to function), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2024, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, showering, lower body dressing and putting on and taking off footwear and required partial assistance (helper does less than half the effort) with oral (mouth) hygiene, upper body dressing, and personal hygiene. During a review of Resident 1's Change in Condition (COC - a significant change in resident's health status) Evaluation, dated 11/17/2024 at 7 a.m., the COC indicated Licensed Vocational Nurse 1 (LVN 1) heard Resident 1 yelling for help and, upon entering the room, LVN 1 observed Resident 1 lying on the floor his right side. LVN 1 saw Resident 2 standing in front of Resident 1 yelling and attempting to strike Resident 1. The COC indicated Resident 1 said that Resident 2 physically assaulted him (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 4 Event ID: 555011 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 555011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineland Post Acute 10830 Oxnard Street North Hollywood, CA 91606 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)