Health inspection·January 2, 2025

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 enforce its own policy related to a safe, sanitary environment and infection control when a shared bathroom was noted with overflowing toilet paper in the trash, stool and urine noted inside the toilet bowl for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: A record review of Resident 1's admission Record indicated the resident was admitted on [DATE] with medical history including Parkinson's disease (a disorder of the central nervous system that affects movement), metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), acute pancreatitis (inflammation of the pancreas), urinary tract infection (bladder infection), dementia (memory loss), hypertension (elevated blood pressure), asthma (inflammation of airways), and Alzheimer's disease (a progressive disease that destroys memory). A record review of Resident 1's Minimum Data Set (resident assessment tool), dated 4/13/2024, indicated Resident 1 was severely cognitively (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impaired and required moderate assistance with activities of daily living. During an observation and interview with Resident 1 on 1/2/2024 at 8:00 a.m., Resident 1 stated, she gets up the bathroom and the bathroom needed no be cleaned. Bathroom noted with toilet paper overflowing from the trash can and noted toilet bowl with urine and feces inside. During an interview with Certified Nurse Assistant (CNA 1) on 1/2/2024 at 8:10 a.m., CNA 1 stated, the bathroom needs to be cleaned and sanitized right away. CNA 1 stated the bathroom is shared between two rooms and other residents use the bathroom. CNA 1 stated, not sanitizing the bathroom poses the residents at risk for infections. During an interview with the Infection Preventionist (IP) on 1/2/2025 at 9:20 am, the IP nurse stated, the trash was overflowing, and toilet was not flushed. IP stated, this had the potential risk for the spread of infections to all the residents using the shared bathroom. IP stated, she does not know the exact times when house keeping is supposed to clean the bathrooms. During an interview with Director of Nurses (DON) on 1/2/25 at 9:25 am, DON stated, the room needs (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: 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 01/02/2025 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)