Health inspection·October 1, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary shower area was provided for the residents. This failure had the potential for injury and spread of infectious disease to facility residents. Findings: During a concurrent observation and interview on 10/1/24 at 2:10 p.m. with Certified Nursing Assistant (CNA) 1, in the south shower room stall one. CNA 1 stated, There was a plastic piece (vinyl cover) that fell off over the weekend on Saturday (9/28/24). CNA 1 stated she put the vinyl cover to the side (space just outside of shower room stall one). During a concurrent observation and interview on 10/1/24 at 2:15 p.m. with Housekeeping Manager (HM), in the south shower room stall one. There was a broken and missing tiles and a tan substance noted on the pony wall (half wall) of shower stall one. HM stated the housekeeping staff could not properly clean the area with the missing tiles. There was a black substance noted on the bottom of the shower grout line. HM stated, I do not know what that is but it looks like it will come back if you clean it, probably has mold (a superficial often woolly growth produced especially on damp or decaying organic matter or on living organisms by a fungus) under there. During an interview on 10/3/24 at 10:57 a.m. Maintenance Personnel (MP), MP stated he was made aware of the vinyl cover falling off on the south shower room stall one on 10/1/24. MP stated it was not reported to him nor was the repair request listed in the maintenance log. MP stated the tiles fell off about a year ago and they placed the vinyl cover over it. During a review of the facility ' s policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, revised July 2017, the P&P indicated, ll hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: . c. Sharp objects that are accessible to vulnerable residents; . 2. Any element of the resident environment that has potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. 13. As part of an overall culture of safety, staff, residents, and family will be encouraged to report anything that appears to be an environmental hazard or safety concern. During a review of the facility ' s P&P titled, Bathrooms, revised February 2020, the P&P indicated, 1. Residents . are ensured timely access to a safe, clean, sanitary, and accessible toileting (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: 555170 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 555170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arvin Post Acute 323 Campus Drive Arvin, CA 93203 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)