Other·August 14, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification visit conducted 7/1/2019. Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38552 Health Facilities Evaluator Nurse ID: 38601 Health Facilities Evaluator Nurse ID: 40081 Highest Severity and Scope: E Total Census: 48 Sample Size: 32

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 07/31/2019 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 1 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nursing staff failed to maintain resident's right to privacy for one of one sample resident (Resident 1) by failing to close the privacy curtain while providing care including eye drop administration during medication pass. This deficient practice violated Resident 1's right to privacy and can lead to feelings of loss of self-esteem and self-worth. Findings: A review of Resident 1's Admission Record, indicated the resident was originally admitted to the facility on June 2, 2015, and readmitted on April 26, 20176 with diagnosis including chronic obstructive pulmonary disease (COPDconstriction of the airways and difficulty in breathing), hypertension (abnormally high blood pressure), and osteoarthritis (damage of the joint that causes stiffness and pain). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 2 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's History and Physical (H&P), dated April 3, 2019, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - care screening tool), dated June 12, 2019, indicated the resident's cognition (ability to remember, understand, make decisions, and learn) was intact. The MDS indicated Resident 1 required physical supervision from staff with bed mobility, transfer, eating and toilet use, and limited assistance from staff for dressing and personal hygiene. During medication administration pass, on June 29, 2019, at 8:07 a.m., Licensed Vocational Nurse 4 (LVN 4) was observed administering eye drops to Resident 1's both eyes and did not pull the privacy curtain closed prior to administering eye drops to Resident 1's eyes. During an interview, on June 29, 2019, at 8:38 a.m., LVN 4 stated she was supposed to pull the privacy curtain closed prior to administering eye drops to Resident 1's eyes for privacy of the resident, however she forgot to close it. During an interview on June 29, 2019, at 8:57 a.m., Director of Nursing (DON) stated that all licensed nurses should pull the privacy curtains closed prior to administering eye drops to all residents for privacy. A review of the undated facility's Policy and Procedure (P&P), titled Privacy for Residents, indicated that each resident will be provided visual privacy during treatments and personal care. The P&P indicated that the facility will ensure the resident's rights to personal privacy and confidentiality of his/her personal and clinical records. The P&P also indicated treatments and personal care, whenever a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 3 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment or personal care is done: 1. The procedure will be explained to the resident. 2. Privacy will be provided by pulling the privacy curtain completely around the bed of the resident. 3. All staff shall knock at the bedroom, bathroom, or tub room door and ask for permission before entering.

F584 SS=E Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 07/31/2019 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 4 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe temperature levels, by failing to maintain a room temperature range of 71 to 81F for three of three sampled residents (Resident 29, 33, and 199). This deficient practice had the potential to adversely affect the health and safety of Residents 29, 33 and 199 while residing in the facility. Findings: On June 28, 2019, at 5:50 p.m., inside Residents 29, 33, and 129's room, with the Maintenance Supervisor (MS), one portable air conditioner was observed in between Resident 29 and 33's bed. During concurrent interview with MS, he stated that the air conditioner in the building was broken which is why there was a portable air conditioner in the rooms. On June 28, 2019, at 5:50 p.m., during an interview, Certified Nursing Aide 2 (CNA 2) assigned to Resident 33 was inside the room assisting the resident, CNA 1 confirmed that while she was assisting the resident she felt warm inside the room as she was pointing at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 5 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the hot air blowing inside the room coming out of the big long tubing attached to the back of the portable conditioner. A review of Resident 29's Admission Record, indicated the resident was originally admitted to the facility on October 20, 2009, and readmitted on June 14, 2019 with diagnosis including pneumonia (lung inflammation caused by bacterial or viral infection), bronchitis (infection resulting from the inflammation of the lining of the lungs), diabetes mellitus (abnormally high blood sugar). A review of Resident 29's History and Physical (H&P), dated April 24, 2019, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 29's Minimum Data Set (MDS - care screening tool), dated May 17, 2019, indicated the resident's cognition (ability to remember, understand, make decisions, and learn) was intact. The MDS indicated Resident 29 was able to make self-understood and was able to understand others. The MDS indicated Resident 29 required physical supervision from staff with bed mobility and eating, and required limited assistance from staff for transfer and toilet use, extensive assistance from staff with dressing and personal hygiene. A review of Resident 33's Admission Record, indicated the resident was originally admitted to the facility on December 4, 2005, and readmitted on November 11, 2016 with diagnosis including urinary tract infection (define), anemia (define), hypotension (abnormally low blood pressure). A review of Resident 33's History and Physical (H&P), dated November 14, 2018, indicated the resident did not have the capacity to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 6 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE understand and make decisions. A review of Resident 33's Minimum Data Set (MDS - care screening tool), dated May 28, 2019, indicated the resident's cognition (ability to remember, understand, make decisions, and learn) was intact. The MDS indicated Resident 33 was usually able to make self-understood and was able to understand others. The MDS indicated Resident 33 required extensive assistance from staff with bed mobility, transfer and personal hygiene, and was totally dependent from staff for dressing and toilet use. A review of Resident 199's Admission Record, indicated the resident was admitted to the facility on June 28, 2019 with diagnosis including tracheostomy (define), acute respiratory failure (define). A review of Resident 199's History and Physical (H&P), dated July 1, 2019, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 199's Care Plan(CP) #5, titled Activities of Daily Living (ADL) Maintenance/Pattern, dated July 5, 2019, indicated the resident required limited assistance from staff with bed mobility, transfer, and eating. The CP indicated Resident 199 required extensive supervision from staff with toilet use, bathing and personal hygiene. On June 28, 2019, at 5:55 p.m., during an interview, Director of Nursing (DON) stated that the portable air conditioners were provided in the rooms where it tends to get warm during the summer time. DON confirmed that the air conditioner in the building was old and not functioning the way it was supposed to be which is why the facility have provided portable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 7 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE air conditioners on some rooms. On June 28, at 7:14 p.m., during an observation with Maintenance Supervisor (MS), while checking the room temperature using his temperature gun (device used to measure air temperature) it indicated that the room temperature reading in Residents 29, 33, and 199 was 84F. On June 28, 2019, at 8:15 p.m., during an interview, Administrator (ADM) stated that there was no documentation that was provided by the maintenance supervisor for the daily room temperature log. ADM stated there should have been daily room temperature log to ensure that all the rooms were complying with acceptable temperature range. On July 1, 2019, at 5:50 p.m., during a telephone interview with the Air Conditioning Contractor (ACC), he stated that he had been servicing the facility's air conditioning units beginning June 28, 2019. A review of the Job Invoice (JI) from ACC, dated June 17, 2019, JI indicated that the seven package air conditioning units are very old and are not operating correctly, and only two out of seven units in the building are working, one was about to go out. A review of the undated facility's Policy and Procedure (P&P), titled Air Temperature Readings, indicated that air temperature readings are taken in response to air temperature complaints. P&P indicated that the acceptable range for air temperatures is 7181F.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 07/31/2019 §483.20(g) Accuracy of Assessments. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 8 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a standardized assessment and screening tool) of one (1) out of five (5) residents investigated addressing the care area of positioning and mobility (Resident 26). This deficient practice had the potential to negatively affect Resident 26's plan of care and delivery of necessary care and services. Findings: A review of Resident 26's Admission Record indicated the resident was admitted to the facility on February 7, 2019 with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), generalized muscle weakness, lack of coordination, and left hand contracture (abnormal shortening of muscle tissue). A review of Resident 26's Medication Review Report indicated the following physician's orders dated April 5, 2019 for Restorative Nursing Assistant (RNA) treatment (nursing intervention program that assists or promotes a resident's ability to maintain or attain his maximum potential) to: 1. Ambulate the resident with wide base quad cane with supervision as tolerated 5x/week every Monday, Tuesday, Wednesday, Thursday, and Friday. 2. Assist the resident with active range of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 9 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE motion (AROM - amount of motion at a given joint when the person moves voluntarily) to both upper and lower extremities as tolerated 5x/week every Monday, Tuesday, Wednesday, Thursday, and Friday. A review of Resident 26's May 2019 Restorative Orders Record (document containing the resident's participation with the prescribed RNA program) indicated the resident received the prescribed RNA treatments during the look-back period (time frame for observation) of May 10, 2016 to May 16, 2019. A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and screening tool) dated May 16, 2019 did not indicate that resident received the prescribed RNA programs. On June 29, 2019 at 3:34 p.m., during an interview, the Director of Nursing (DON) stated the MDS dated May 16, 2019 did not reflect that the resident received the prescribed RNA treatments during the look-back period of May 10, 2016 to May 16, 2019. A review of the facility's undated policies and procedures titled "Minimum Data Set" indicated the policy to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity using Resident Assessment Instrument (RAI). A review of the facility-provided Centers for Medicare and Medicaid Services (CMS) LongTerm Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, dated October 2017, indicated to record the number of days during the 7-day look-back period on which the restorative nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 10 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE program was performed for a total of at least 15 minutes during the 24-hour period.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 07/31/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 11 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: b. A review of Resident 18's Admission Record indicated the resident was originally admitted to the facility on January 24, 2014 and was readmitted on March 29, 2015 with diagnoses of, but not limited to, dysphagia (difficulty swallowing), diabetes mellitus (DM - high blood sugar), dementia (decline in mental ability severe enough to interfere with daily functioning/life), and gastrostomy (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration). A review of Resident 18's comprehensive Minimum Data Set (MDS - a standardized assessment and screening tool) dated May 5, 2019 indicated the resident's latest admission was dated April 23, 2019. The MDS indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS also indicated the resident was totally dependent with bed mobility, transfer, locomotion, dressing, tube feeding, toilet use, personal hygiene, and bathing. A review of Resident 18's Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) Conference Record dated April 25, 2019 indicated the discharge plan was for the resident to be transferred to another facility when bed is available. On June 29, 2019 at 2:35 p.m., during an interview, the Director of Nursing (DON) stated Resident 18 was discharged to another facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 12 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on June 13, 2019. The DON stated there was no comprehensive care plan developed addressing discharge planning. The DON stated the care plan should have been developed by the Social Services Department staff upon the resident's admission. A review of the facility's policies and procedures titled "Care Planning," dated April 19, 2017 indicated the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Planning of resident care will identify care needs based on initial written and continuing assessment of the resident needs with input, as necessary, from the health professionals involved in the care of the resident. Based on observation, interview, and record review, the facility failed develop and/or implement an individualized personcentered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of five sampled residents (Residents 7 and 18). For Resident 7, failed to address the resident's antidepressant medication (a psychotropic medication) Wellbutrin. This deficient practice had the potential to negatively affect the delivery of necessary care and services. For Resident 18, failed to address discharge planning that reflects the resident's discharge needs, goals, and treatment preferences and involvement of responsible party/family and interdisciplinary (IDT - a group of experts from several different fields) team. This deficient practice had the potential to result in incomplete or ineffective discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 13 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE planning and can lead to lack of necessary care for Resident 18 after discharge. Findings: a. A review of Resident 7's admission clinical record indicated resident was readmitted to the facility on May 1, 2015 with diagnoses that included major depressive disorder and chronic pain syndrome. A review of Resident 7's History and Physical dated November 24, 2018, indicated resident has the capacity to understand and make decisions. A review of Resident 7's Physician's Orders indicated Wellbutrin XL tablet extended release 24 hours 150 milligrams (mg), give one tablet by mouth two times a day for manifestation of verbalization of low energy related to major depressive disorder, ordered on 3/7/19. A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated April 2, 2019, indicated resident's decision-making skills is cognitively intact. A review of Resident 7's Psychotherapeutic Drug Summary Sheet, indicated for 3/7/19 to 3/31/19 resident exhibited behavior one time for verbalization of low energy and from 4/1/19 to 6/30/19, no behaviors were exhibited for the use of Wellbutrin XL. During a concurrent interview and record review of Resident 7's care plans on 7/1/19 at 7:25 p.m., the MDS Assistant (MDSA) confirmed there was no care plan for Wellbutrin. MDSA stated the purpose of the care plan to monitor behavior and interventions and the goal is to lessen the behavior the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 14 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents. MDSA stated the behavior of verbalization of low energy, monitoring of his weakness, hours of sleep, verbalization of tiredness, feeling tired, check triggers that causing him to feel weak. MDSA stated before starting another psychotropic medication there is an Interdisciplinary Team Meeting and attempt nonpharmacological interventions prior to starting a psychotropic medication. During an interview on 7/1/19 at 7:43 p.m., the Assistant Director of Nursing (ADON) stated there should be nonpharmacological interventions attempted and there should be a care plan for medication use of Wellbutrin in the resident's clinical record and interventions in place whenever the resident manifests those behaviors. A review of the facility's policy and procedure titled "Care Planning" effective date April 19, 2017, indicated that resident care plans will be reviewed, evaluated, and updated as necessary by the nursing staff and oter professional personnel involved in the care of the resident at least quarterly, and more often if there is a change in the resident's condition.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 07/31/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: d. A review of Resident 197's Admission Record, indicated the resident was initially admitted to the facility on October 31, 2013 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 15 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE readmitted on April 24, 2018 with diagnoses including cellulitis of left upper limb (potentially serious bacterial skin infection that appears red and swelling), contracture of muscle (stiffness that restricts normal movement), and dementia (decline in mental ability severe enough to interfere with daily life). A review of Resident 197's History and Physical, dated April 10, 2019, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 197's Minimum Data Set (MDS- a care screening tool), dated February 25, 2019, indicated the resident was usually able to make self-understood and was usually able to understand others. The MDS indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, and totally dependent from staff for transfers, toilet use, and personal hygiene. A review of Resident 197's Medication Review Report, dated May 8, 2018, indicated that the order summary: RNA orders - RNA will apply inflatable hand splints to left hand 4-6 hours 5X/week as tolerated. A review of Resident 197's Restorative Orders, dated January 2019, indicated that RNA's assigned to resident would initial the administration daily, with no narrative documentation in the front or at the back for specific hours and how much tolerated. During an interview on July 1, 2019, at 5:10 p.m., Restorative Nursing Aide 2 (RNA 2) stated that she has been working in the facility full time as activity assistant for two days and the rest of the days as RNA. RNA 2 stated she was responsible to provide RNA exercises to Resident 197 and to report to the Occupational FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 16 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Therapist (OT) any difficulty of the resident with the RNA program. RNA 2 also stated she was able to describe how many hours did Resident 197 tolerated the hand splint on his left hand but only signed and initialed the RNA book, and there were no documented specific hours applied and tolerated on the daily RNA exercises. During an interview on July 1, 2019, at 5:38 p.m., Director of Nursing (DON) stated that the physician's RNA orders for Resident 197's left hand splint was to apply for four to six hours as tolerated, and there was no validated narrative documentation at the back of the RNA's daily administration as to how many hours the hand splint was applied and how much it was tolerated. During a concurrent record review of the policy for contracture management, if the resident had difficulty with the RNA then the Occupational Therapist (OT) would evaluate the resident. DON validated there was no documented difficulty or intolerance of the RNA exercises since the program started. A review of the undated facility's Policy and Procedures (P&P), titled Contracture Management of the Wrist and Hand, indicated that to prevent further contractures of the resident's wrist and hand while maintaining functional mobility through appropriate positioning. The P&P indicated Range of Motion Program: The Occupational Therapist will assess and recommend an appropriate ROM Program to meet eh specific needs of the residents. The therapist will train any of the following staff to carry out the program: RNA, CNA, and/or licensed Nurse. Any difficulty/intolerance of the resident to participate in the established program will be reported to the Occupational Therapist for further evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 17 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to observe professional standards by failing to: 1. Ensure the insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) injection sites were rotated when administered for three (3) out of 3 sample residents (Residents 6, 22 and 41) investigated addressing the rotation (a method to ensure repeated injections of medications are not administered in the same area) of injection site. 2. Ensure Range of Motion (ROM- the full movement potential of a joint), exercises to left hand were specific, per physician's order for one of one sampled residents (Resident 197). These deficient practices had the potential for injection site reactions such as pain, redness, itching, hives (red and itchy bumps on the skin), swelling, inflammation, and lipodystrophy (a defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot) that may result in ineffective management of the residents' diabetes mellitus (DM - high blood sugar) and result in further decline of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity) of joints to Resident 197's left hand. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 18 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: a. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on December 13, 2016 and was readmitted on January 11, 2019 with diagnosis that included diabetes mellitus (DM - high blood sugar). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and screening tool) dated March 29, 2019 indicated the resident had intact cognition. The MDS indicated the resident needed supervision with transfer, walking in corridor, eating, and toilet use; and needed limited assistance with dressing and personal hygiene. The MDS also indicated the resident received insulin injections. A review of Resident 6's Medication Review Report indicated a physician's order dated May 22, 2019 to administer Tresiba FlexTouch Solution (long-acting hormone used to lower blood glucose [sugar] levels) 25 units before breakfast and 15 units before dinner subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) for DM. A review of Resident 6's June 2019 Medication Administration Record (MAR) indicated Tresiba insulin doses for the morning and evening were administered to the resident's left deltoid (muscle on the uppermost part of the arm and the top of the shoulder) on: 1. June 11, 2019 2. June 13, 2019 3. June 15, 2019 4. June 17, 2019 5. June 19, 2019 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 19 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 6's June 2019 MAR indicated Tresiba insulin doses for the morning and evening were administered to the resident's right deltoid on: 1. June 12, 2019 2. June 14, 2019 3. June 16, 2019 4. June 18, 2019 5. June 20, 2019 On July 1, 2019 at 6:22 p.m., during an interview, the Director of Nursing (DON) stated the insulin injection sites should have been rotated (a method to ensure repeated injections of medications are not administered in the same area) to avoid potential tissue damage. A review of the facility's undated policies and procedures titled "Medication and Treatment Administration" indicated the purpose was to ensure safe administration of medications to the residents. Medications and treatments will be administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. A review of the facility-provided Tresiba manufacturer's literature, revised in November 2018, indicated to inject Tresiba subcutaneously into the thigh, upper arm, or abdomen, and to rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy (a defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot). b. A review of Resident 22's Admission Record indicated the resident was admitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 20 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility on July 24, 2018 with diagnosis that included diabetes mellitus (DM - high blood sugar). A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and screening tool) dated May 2, 2019 indicated the resident had intact cognition. The MDS indicated the resident needed supervision with transfer, walking, locomotion, eating, and toilet use; and needed limited assistance with dressing and personal hygiene. The MDS also indicated the resident received insulin injections. A review of Resident 22's Medication Review Report indicated a physician's order dated March 7, 2019 to administer Levemir (longacting hormone used to lower blood glucose [sugar] levels) 15 units in the morning subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) for DM. Another physician's order dated July 24, 2018 indicated to administer Levemir 10 units SQ at bedtime for DM. A review of Resident 22's June 2019 Medication Administration Record (MAR) indicated Levemir insulin doses for the morning and bedtime were administered to the resident's left deltoid (muscle on the uppermost part of the arm and the top of the shoulder) on: 1. June 12, 2019 2. June 14, 2019 3. June 16, 2019 4. June 18, 2019 5. June 20, 2019 A review of Resident 22's June 2019 MAR indicated Levemir insulin doses for the morning and bedtime were administered to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 21 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's right deltoid on: 1. June 11, 2019 2. June 13, 2019 3. June 15, 2019 4. June 17, 2019 5. June 19, 2019 On July 1, 2019 at 6:25 p.m., during an interview, the Director of Nursing (DON) stated the insulin injection sites should have been rotated (a method to ensure repeated injections of medications are not administered in the same area) to avoid potential tissue damage. A review of the facility's undated policies and procedures titled "Medication and Treatment Administration" indicated the purpose was to ensure safe administration of medications to the residents. Medications and treatments will be administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. A review of the facility-provided Levemir manufacturer's literature, revised in January 2019, indicated to inject Levemir subcutaneously into the thigh, abdominal area, or upper arm. Injection sites should be rotated within the same region from one injection to the next to reduce the risk of lipodystrophy (a defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot). c. A review of Resident 41's Admission Record indicated the resident was admitted to the facility on September 18, 2005 and was readmitted on May 5, 2019 with diagnosis that included diabetes mellitus (DM - high blood sugar). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 22 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 41's Minimum Data Set (MDS - a standardized assessment and screening tool) dated April 17, 2019 indicated the resident had intact cognition. The MDS indicated the resident needed supervision with walking in corridor, locomotion, eating, and toilet use; and needed limited assistance with dressing and personal hygiene. The MDS also indicated the resident received insulin injections. A review of Resident 41's Medication Review Report indicated a physician's order dated June 19, 2019 to administer Levemir (long-acting hormone used to lower blood glucose [sugar] levels) 75 units two times a day subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) for DM. A review of Resident 41's June 2019 Medication Administration Record (MAR) indicated both Levemir insulin doses were administered to the resident's left deltoid (muscle on the uppermost part of the arm and the top of the shoulder) on: 1. June 21, 2019 2. June 24, 2019 3. June 26, 2019 A review of Resident 41's June 2019 MAR indicated both Levemir insulin doses were administered to the resident's right deltoid on: 1. June 20, 2019 2. June 22, 2019 3. June 25, 2019 4. June 27, 2019 5. June 30, 2019 On July 1, 2019 at 6:24 p.m., during an interview, the Director of Nursing (DON) stated the insulin injection sites should have been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 23 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rotated (a method to ensure repeated injections of medications are not administered in the same area) to avoid potential tissue damage. A review of the facility's undated policies and procedures titled "Medication and Treatment Administration" indicated the purpose was to ensure safe administration of medications to the residents. Medications and treatments will be administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. A review of the facility-provided Levemir manufacturer's literature, revised in January 2019, indicated to inject Levemir subcutaneously into the thigh, abdominal area, or upper arm. Injection sites should be rotated within the same region from one injection to the next to reduce the risk of lipodystrophy (a defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot).

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 07/31/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 24 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcer (any lesion caused by unrelieved pressure that results in damage to underlying skin tissues) from redness to Stage III pressure ulcer (full thickness tissue loss), for one of one sample resident (Resident 197) by failing to: 1. Ensure Resident 197 who was assessed at risk to develop pressure ulcers was provided with care and services that included keep clean and dry at all times as indicated in the plan of care. 2. Monitor and document every shift for 72 hours when redness on the left thumb of Resident 197 was identified on March 21, 2019 as indicated on the facility policy for Change of Condition. 3. Implement plan of care for left thumb redness identified on March 21, 2019 by monitoring wound for signs and symptoms of infection, drainage, and increase in size. These deficient practices resulted in Resident 197 to develop Stage 1 pressure ulcer on the left thumb on March 21, 2019, and further worsened to Stage III pressure ulcer on March 27, 2019. Findings: A review of Resident 197's Admission Record, indicated the resident was initially admitted to the facility on October 31, 2013 and readmitted on April 24, 2018 with diagnoses including cellulitis of left upper limb (potentially serious bacterial skin infection that appears red and swelling), contracture of muscle (stiffness that restricts normal movement), and dementia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 25 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (decline in mental ability severe enough to interfere with daily life). A review of Resident 197's History and Physical, dated April 10, 2019, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 197's Minimum Data Set (MDS- a care screening tool), dated February 25, 2019, indicated the resident was usually able to make self-understood and was usually able to understand others. The MDS indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, and totally dependent from staff for transfers, toilet use, and personal hygiene. A review of Resident 197's Care Plan (CP) #16, titled pressure Ulcer/Skin Integrity, dated April 26, 2019, indicated the resident was at risk to develop pressure ulcers and skin breakdown, goals included resident will have no skin breakdown/pressure ulcer, and no further skin breakdown daily times three months. The CP's interventions included keep clean and dry at all times, and monitor for pressure ulcers, tears, and bruises. A review of Resident 197's Care Plan (CP) #5, titled Activities of Daily Living (ADL) Maintenance/Pattern dated April 26, 2019, indicated the resident required extensive assistance for bed mobility, dressing, eating, and total assistance for transfers, ambulation, locomotion, toilet use, personal hygiene and bathing. The CP indicated goals including: be kept clean and dry and odor free daily times three months. The CP's interventions included monitor for any changes in condition. On June 29, 2019, at 10:31 a.m., during an on observation of Resident 197's wound treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 26 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administration, and concurrent interview, Licensed Vocational Nurse 3 (LVN 3) observed asking the resident for pain on his left thumb, Resident 197 stated no pain. LVN 3 stated that the resident was given pain medication thirty minutes prior to the treatment procedure. LVN 3 proceeded and performed: 1)Hand hygiene and donned gloves 2)Removed the old Kerlix (woven cotton gauze bandage rolls) from the resident's left hand 3)Removed gloves, performed hand hygiene, donned gloves 4)Cleansed with Normal Saline (solution to clean wound) 5)Removed gloves, performed hand hygiene, donned gloves. Asked Resident 197 to take a photo of his wound on the left thumb and resident gave permission. LVN 3 continued with the procedure; 6)Applied Calcium Alginate with Silver (medication to treat wound) on resident's left inner most left thumb 7)Covered wound with triangular foam on the left thumb and wrapped with Kerlix gauze dressing 7)Removed gloves, and performed hand hygiene LVN 3 confirmed that the treatment administration procedure on Resident 197's left thumb was completed at 11:30 a.m. LVN 3 stated the CNAs assigned to the resident cleans and keep Resident 197's hands every shift during Activities of Daily Living (ADL) care. On June 29, 2019, at 3:13 p.m., during a review of Resident 197's clinical record, titled "Nurses Progress Notes," and concurrent interview, LVN 3 stated that resident had a Restorative Nursing Aide (RNA) order for inflatable hand splint (device used for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 27 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contracture management) to apply inside the resident's left hand. LVN 3 stated he documented on the "Nurses Progress Notes" (NPN) on March 21, 2019 that the RNA identified the redness on the resident's left thumb while applying the inflatable hand splint, measured 1.5 centimeters (cm) X 2 cm length and width. LVN 3's NPN documentation included both hands kept clean and dry, physician was notified and treatment orders were carried out. LVN 3 confirmed that his next NPN documentation was dated March 27, 2019, indicated resident's left thumb measured 1.5cm X 1cm X 0.3cm serosanguineous drainage (bloody red fluid). LVN 3 also stated that the wound doctor examined the left thumb wound as Stage III (full thickness tissue loss). On June 29, 2019, at 6:46 p.m., during a review of Resident 197's clinical record and concurrent interview, Assistant Director of Nursing (ADON) stated the resident's identification of redness on the left thumb should have initiated a Change of Condition (COC). A review of Resident 197's Care Plan (CP) titled "Skin Integrity," dated March 21, 2019, indicated that resident had redness on his left thumb. CP's interventions included monitor wound for signs and symptoms of infection, drainage and increase in size. ADON stated there was no documented evidence of a COC, no 72-hour monitoring, and no Interdisciplinary Team Meeting (IDT) pertaining to the resident's identified redness on the left thumb on March 21, 2019. On June 29, 2019, at 7:00 p.m., during an interview, Director of Nursing (DON) stated that there should have been an Interdisciplinary Team (IDT) Meeting pertaining to Resident 197's redness on the left thumb and a 72-hr monitoring of the redness which was identified on March 21, 2019. DON stated that it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 28 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE missed as there was no documented evidence in the resident's clinical record. On July 1, 2019, at 6:29 p.m., during an interview, Certified Nursing Aide 5 (CNA 5) stated he has been working in the facility full time every 3-11 shift and was assigned to take care of Resident 197 since resident's admission to the facility. CNA 5 confirmed he did not clean the resident's contracted left hand. CNA 5 validated he was not trained to clean the resident's hands because of the contracture, and only the available treatment nurses are allowed to clean the resident's contracted hands. On July 1, 2019, at 6:49 p.m., during an interview, Director of Staff Development (DSD) stated that he did not provide training service to Certified Nursing Aides (CNAs) on how to clean the resident's contracted hands. DSD confirmed that if the CNAs do not provide cleaning of Resident 197's contracted hands therefore CNAs will not be able to identify any skin break down. DSD validated CNAs will only to report to the charge nurses if they identify a skin break down. On July 1, 2019, at 8:11 p.m., during an interview, Director of Nursing (DON) stated the CNAs should clean contracted hands of Resident 197 whenever they are providing morning care, evening care and as needed. A review of the undated facility's Policy and Procedures (P&P), titled Pressure Sore Preventions and Treatment, indicated that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates they were unavoidable. The P&P indicated a resident having pressure sores receive necessary treatment and services to promote FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 29 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE healing, prevent infection and prevent new sores from developing. The P&P also indicated prevention: CNAs will inspect resident's skin at least once a day while doing personal care paying particular attention to bony prominences. Any redness will be reported to the charge nurse for further assessment. A review of the undated facility's Policy and Procedures (P&P), titled Change of Condition (COC), indicated the licensed nurse will: communicate any changes in intervention to Certified Nursing Assistants (CNA). The P&P indicated document each shift for at least 72 hours after resident returns from acute care, if resident is started on antibiotic for any specific infection, any incident or accident, or any change in resident's condition. A review of the undated facility's Policy and Procedures (P&P), titled Care Planning, indicated resident care plans will be reviewed, evaluated and updated as necessary by the nursing staff and other professional personnel involved in the care of the resident at least quarterly, and more often if there is a change in the resident's condition.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 07/31/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 30 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility: 1. Failed to conduct a medication regimen review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage) for one (1) out of five (5) sample residents investigated under the care area of unnecessary medications (Resident 27). 2. Failed to indicate the specific time frames in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 31 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order to readily and timely act upon the pharmacist's recommendations in the Medication Regimen Review policies and procedures. These deficient practices had the potential to place the residents at risk of receiving unnecessary medications. Findings: a. A review of Resident 27's Admission Record indicated the resident was admitted to the facility on March 31, 2016 and was readmitted on March 18, 2019 with diagnoses of, but not limited to, hypertension (HTN - elevated blood pressure), dementia (decline in mental ability severe enough to interfere with daily functioning/life), schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension). A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and screening tool) dated April 20, 2019 indicated the resident had intact cognition. The MDS indicated the resident needed limited assistance with bed mobility, transfer, locomotion, dressing, eating, and personal hygiene; and needed extensive assistance with walking and toilet use. The MDS also indicated the resident received antipsychotic, antianxiety, and antidepressant. On June 29, 2019 at 10:41 a.m., during an interview and a concurrent review of Resident 27's clinical records, Director of Nursing (DON) stated the pharmacist will sign the monthly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 32 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pharmacy observation notes if the resident's clinical records have been reviewed. The DON stated the resident's medication regimen was not reviewed by the pharmacist last March 2019; the monthly pharmacy observation notes was not signed by the pharmacist for that month. The DON stated the pharmacist comes every month but does not see all the residents. A review of the facility's policies and procedures titled "Medication Regimen Review," dated December 2016 indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. b. On July 1, 2019 at 6:31 p.m., during an interview and a concurrent review of the facility's policies and procedures titled "Medication Regimen Review," dated December 2016, the DON stated there are no time frames for notifying the physician of the pharmacist's recommendations and for carrying out physician's orders if any. A review of the facility's policies and procedures titled "Medication Regimen Review," dated December 2016, indicated recommendations are acted upon and documented by the facility staff and or the prescriber. The facility policies and procedures did not indicate the specific time frames when the facility will address the pharmacist's recommendations in order to timely act upon on the pharmacist's Medication Regimen Review. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 33 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F758 Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/31/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 34 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 7) who received psychotropic (any drug that affects brain activities associated with mental processes and behavior), medications were adequately monitored, by: 1. Failing to ensure non-pharmacological (nondrug) interventions were attempted prior to starting a new psychotropic medication, Wellbutrin (antidepressant). This deficient practice placed the resident to receive unncessary psychotropic medications. Findings: A review of Resident 7's admission clinical record indicated resident was readmitted on May 1, 2015 with diagnosis of major depressive disorder (define) and chronic pain syndrome (define). A review of Resident 7's History and Physical dated November 24, 2018, indicated resident has the capacity to understand and make FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 35 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE decisions. A review of Resident 7's Physician's Orders indicated Wellbutrin XL tablet extended release 24 hours 150 milligrams (mg), give one tablet by mouth two times a day for manifestation of verbalization of low energy related to major depressive disorder, ordered on 3/7/19. A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated April 2, 2019, indicated resident's decision-making skills is cognitively intact. A review of Resident 7's Psychotherapeutic Drug Summary Sheet, indicated for 3/7/19 to 3/31/19 resident exhibited behavior one time for verbalization of low energy and from 4/1/19 to 6/30/19, no behaviors were exhibited for the use of Wellbutrin XL. During a concurrent interview and record review of Resident 7's care plans on 7/1/19 at 7:25 p.m., the MDS Assistant (MDSA) confirmed there was no care plan for Wellbutrin. MDSA stated the purpose of the care plan to monitor behavior and interventions and the goal is to lessen the behavior the residents. MDSA stated the behavior of verbalization of low energy, monitoring of his weakness, hours of sleep, verbalization of tiredness, feeling tired, check triggers that causing him to feel weak. MDSA stated before starting another psychotropic medication there is an Interdisciplinary Team Meeting and attempt nonpharmacological interventions prior to starting a psychotropic medication. During an interview on 7//19 at 8:04 p.m., the Director of Nursing (DON) stated before starting new psychotropic medications or increasing dosages of psychotropic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 36 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications non-pharmacological interventions should be done for three (3) days then call MD how the resident is responding to the interventions and depends on resident's response. DON stated the physician may order new medications and/or increased dosage if the interventions were ineffective. A review of the facility's policy and procedure titled "Psychotherapeutic Drug Treatment" undated, indicated nursing services, social servcies, and other members of the interdisciplinary team (IDT, when different disciplines meet to address resident's problem) will address te behaviors in progress notes and on the resident centered care plan. Medication use is not the sole approach for behavioral intervention. Other non-phamacological interventions will be identified and implemented on the plan of care.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 07/31/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 37 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain a safe and secure storage of all medications, by: 1. For one of one medication storage room in Nursing Station 1, failed to monitor medications at appropriate temperatures by not having thermometer inside for 12 of 12 months. This deficient practices had the potential to result in ineffective medications and exposure to out of range temperature conditions that can lead to medication errors. Findings: During a concurrent observation and interview on 6/28/19 at 5:58 p.m., the Licensed Vocational Nurse (LVN 3) confirmed there was no thermometer in the medication room and stored house supply medications, PO (by mouth) emergency kits (e-kits, define), Intramuscular (IM, through the muscles) e-kits, and Intravenous (IV, through the veins) e-kits. During an interview on 7/01/19 at 8:12 p.m., the Director of Nursing (DON) confirmed they have not had thermometer in the medication since the last survey. The DON stated the purpose of the thermometer is to monitor the temperature of the medication room for the room temperature medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 38 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy and procedure titled "Storage of Medications" effective date April 2008, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The policy indicated medications requiring storage at "room temperature" are kept at temperatures ranging from 15 degrees celsius (C) (59 degrees fahrenheit [F]) to 30C (86F).Based on observation, interview and record review, the facility failed to keep 1 (one) out of two (2) medication carts (Medication Cart 1) locked and secured when unattended during the checking of blood sugars as part of the medication administration observations for Residents 11 and 14. This deficient practice had the potential for unsafe access by residents, staff, and visitors and potential for drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes). Findings: a. A review of Resident 11's Admission Record indicated the resident was admitted to the facility on April 3, 2018 with diagnosis of, but not limited, diabetes mellitus (a condition that affects how the body uses blood sugar [glucose]). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and screening tool) dated April 10, 2019 indicated the resident had intact cognition. The MDS indicated the resident needed supervision with transfer, walking, locomotion, eating, and toilet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 39 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE use; and needed limited assistance with dressing and personal hygiene. A review of Resident 11's Medication Review Report indicated a physician's order dated September 12, 2018 to monitor the resident's blood sugar before breakfast and before dinner and to call the doctor if the result is above 200 milligrams per deciliter (mg/dl) for insulin order. On June 29, 2019 at 4:07 p.m., during the checking of the blood sugar as part of the medication administration observation of Resident 11, observed Licensed Vocational Nurse 2 (LVN 2) leave the medication cart unlocked and unattended while checking Resident 11's blood sugar behind the curtain. On June 29, 2019 at 6:16 p.m., during an interview, Assistant Director of Nursing (ADON) stated the medication cart should have been locked when unattended and out of sight. A review of the facility's policies and procedures titled "Storage of Medications," dated April 2008 indicated medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. b. A review of Resident 14's Admission Record indicated the resident was admitted to the facility on April 3, 2018 and was readmitted on June 11, 2019 with diagnosis of, but not limited, diabetes mellitus (a condition that affects how the body uses blood sugar [glucose]). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 40 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 14's Minimum Data Set (MDS - a standardized assessment and screening tool) dated April 10, 2019 indicated the resident had moderately impaired cognition. The MDS indicated the resident needed limited assistance with bed mobility, transfer, walking in room, locomotion, and eating; and needed extensive assistance with walking in corridor, dressing, toilet use, and personal hygiene. A review of Resident 14's Medication Review Report indicated a physician's order dated June 11, 2019 to administer Novolog FlexPen Solution Pen-injector (rapid-acting medication used in the control of elevated blood sugar) as per sliding scale coverage (progressive increase in the insulin dose based on predefined blood glucose ranges) subcutaneously (a method of administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) before breakfast and before dinner. On June 29, 2019 at 4:19 p.m., during the checking of the blood sugar as part of the medication administration observation of Resident 14, observed Licensed Vocational Nurse 2 (LVN 2) leave the medication cart unlocked and unattended while checking Resident 14's blood sugar behind the door and curtain. On June 29, 2019 at 6:16 p.m., during an interview, Assistant Director of Nursing (ADON) stated the medication cart should have been locked when unattended and out of sight. A review of the facility's policies and procedures titled "Storage of Medications," dated April 2008 indicated medications and biologicals are stored safely, securely, and properly following manufacturer's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 41 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access.

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 07/31/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to serve food that accomodates residnet's food preferences for one of two sampled residents (Resident 16). For Resident 16, the responsible who preferred resident to be served with more vegetables and offered salads during meals and less carbohydrates and starchy foods, the facility did not serve those items during lunch and dinner meals. This deficient practice had the potential to result in weight gain because resident is not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 42 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE getting the balanced meal as preferred by Resident 16's responsible party. Findings: A review of Resident 16's admission record indicated resident was readmitted on January 30, 2017 with diagnosis of degenerative disease of the nervous system and generalized muscle weakness. A review of Resident 16's history and physical dated February 13, 2019, indicated resident does not have the capacity to understand and make decisions. A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated April 23, 2019, indicated residnet with adequate hearing, clear speech, and rarely or never understood and sometimes understood others. The MDS indicated resident required one person physical assistance with eating and on a therapeutic diet. A review of Resident 16's Weights and Vitals (W&V) Summary sheet indicated the resident's ideal body weight range (IBWR) is between 117 - 143 pounds (lbs). The W&V Summary indicated the resident's weights as follows: - July 2018, 131 lbs. - September 2018, 145 lbs. - October 2018, 147 lbs. - December 2018, 152, lbs. Resident gained 21 lbs in the last six months since July 2018. - January 2019, 152 lbs. - February 2019, 161 lbs. - March 2019, 162 lbs. - May 2019, 163 lbs. - June 2019, 163 lbs. Resident gained another 11 lbs in the last six months since January 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 43 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 6/29/19 at 9:01 a.m., the responsible party (RP 1) stated she has issues with Resident 16's diet in the facility. RP 1 stated she has attended quarterly meetings and spoken to the dietitian but wishes facility could serve her sister more vegetables with less carbohydrates and currently on a low fat consistent carbohydrate diet, however, when she comes an visits Resident 16's meal plate is all carbohydrates and in the past 6 months had gained 20 pounds. RP 1 stated the weight gain is too much. RP 1 stated Resident 16's preferences could include more fresh fruits and vegetables and not canned. Duringa an observation in the dining room on 6/29/19 at 12:09 p.m., Resident 16 with regular consistent carbohydrate, low fat meal card, no preferences indicated on the meal card. On the meal plate observed, broccoli, rice, bread, turkey, fat free milk x1 box, and apple dessert. During a concurrent observation and interview on 6/29/19 at 12:24 p.m., the Certified Nursing Aide (CNA 1) confirmed Resident 16 ate 90% for lunch. CNA 1 stated Resident 16 did eat the stem of the vegetables because they were hard for her. CNA 1 stated the resident did not like the stem's firmness. During an observation on 6/29/19 at 5:10 p.m., Resident 16 was observed dinner meal tray with cheeseburger on a bun, creamy cucumber onion salad, tater tots, one chocolate chip cookie, and fat free milk. During an interview on 7/1/19 at 5:40 p.m., the Assistant Director of Nursing (ADON) stated the dietary supervisor completes the food preferences section and updates quarterly and as needed. During a concurrent interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 44 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review of Resident 16's food preferences on 7/01/19 at 6:07 p.m., the Dietary Supervisor (DS) stated she has spoken to RP 1 for Resident 16's food preferences and sometimes serve resident banana for snacks. DS stated the dietitian recommended to give more salads with lettuce and tomato during lunch only. DS stated on saturdays they do not offer salad because they do not offer salad every day. DS confirmed the Nutritional Screening and Assessment dated 4/10/19 inficated Resident 16's food preferences reviewed with all food likes and no food dislikes and no complaints of taste of food and did not indicate specific request and preferences provided by the RP. DS stated the RP provides Resident 16's preferences. A review of the facility's policy and procedure titled "Interdisciplinary Team Conference (IDT)" undated, indicated that is the facility's policy to develop a plan of care for each resident on the basis of an interdisciplinary assessment and addressed at the IDT conference. The policy indicated each team member willdocument onthe IDT conference form the pertinent information changes in treatment plan, followup, strengths, and recommendations.

F814 SS=D Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 07/31/2019 §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure garbage and refuse was properly collected and disposed in a safe and efficient manner. This deficient practice had the potential to result in harboring, feeding, and attracting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 45 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pests and vermin. Findings: On June 28, 2019 at 4:45 p.m., during the initial kitchen tour, with the Dietary Supervisor (DM), three boxes of empty cartons and one empty white round container of sanitizing solution were observed on the ground outside of the kitchen back door. During a concurrent interview with the DM, she stated the garbage should be disposed immediately to the dumpster and not outside the kitchen door as it is potential for harboring pests. DM confirmed that it was her responsibility to oversee that garbage are being disposed of properly. A review of the undated facility policy and procedure (P&P), titled Dispose of Garbage and Refuse, indicated that all garbage and refuse will be collected and disposed of in a safe and efficient manner. The P&P also indicated that the Dining Services Director (DSD) will ensure that: garbage and refuse is removed from the kitchen area routinely during the day and at the end of the work day.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 07/31/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 46 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 47 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to prevent the transmission of communicable diseases and infections by failing to: 1. Ensure nursing staff to perform hand washing after providing peri-care for one of three sampled resident (Resident 16). 2. Ensure nursing staff to perform hand washing before and after medication administration (Resident 1). Thisdeficient practice had the potential for the development and spread of communicable diseases and infections to other residents for two of three Sample Resident Resident 16 and 1). Findings: During a peri-care observation on 6/29/19 at 9:38 a.m., the Certified Nursing Aide (CNA 3) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 48 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assisted by Restorative Nursing Aide (RNA 1) for Resident 16 for toileting in the bathroom. CNA removed resident's soiled briefs and disposed in the trash and provided peri-care using wash cloths wiped from front to back and used different corners of the cloth then applied clean briefs. CNA 3 removed her gloves and placed Resident 16 back to geri-chair and handed resident her toys, however, CNA 3 did not perform hand washing or hand hygiene after providing peri-care. During an interview on 6/29/19 at 2:44 p.m., CNA 3 stated she was trained to wash her hands with soap and water before and after briefs/diaper change. CNA 3 stated the purpose of hand washing is to observe infection control and protect other residents from getting an infection. CNA 3 stated she did not wash her hands after exiting te bathroom and after placing resident back to geri-chair. During an interivew on 7/01/19 at 8:06 p.m., the Director of Nursing (DON) stated that before and after every procedure all staff must wash their hands and follow infection control procedures. A review of the facility's policy and procedure titled "Handwashing" undated, indicated the purpose of handwashing is to prevent the spread of infeciton. Infection can be spread from resident to employee, employee to resident, employee to employee and resident to resident. In order to protect residents from inhospital infections called nossocomial infection, handwashing must be performed routinely between every resident contact and after handling contaminated articles. b. A review of Resident 1's Admission Record, indicated the resident was originally admitted to the facility on June 2, 2015, and readmitted on April 26, 20176 with diagnosis including chronic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 49 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE obstructive pulmonary disease (COPDconstriction of the airways and difficulty in breathing), hypertension (abnormally high blood pressure), osteoarthritis (damage of the joint that causes stiffness and pain). A review of Resident 1's History and Physical (H&P), dated April 3, 2019, indicated the resident had the capacity to understand and make decisions. A review of Resident1's Minimum Data Set (MDS - care screening tool), dated June 12, 2019, indicated the resident's cognition (ability to remember, understand, make decisions, and learn) was intact. The MDS indicated Resident 1 required physical supervision from staff with bed mobility, transfer, eating and toilet use, and limited assistance from staff for dressing and personal hygiene. During medication administration pass, on June 29, 2019, at 8:07 a.m., Licensed Vocational Nurse 4 (LVN 4) was observed administering eye drops to Resident 1's both eyes and did not wash hands before and after eye drop administration. During an interview on June 29, 2019 at 8:38 a.m., LVN 4 stated that she was supposed to wash her hands before and after eye drop administration, but did not remember to wash her hands. During an interview on June 29, 2019, at 8:57 a.m., Director of Nursing (DON) stated that all licensed nurses should wash hands prior to and after administering eye drops to the residents for infection control purposes. A review of the facility's Policy and Procedure (P&P), titled Medication Administration General Guidelines, dated October 2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 50 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated that: B. Administration 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. 2. Medication are administered in accordance with written orders of the attending physician. 3. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 4. Medications are administered at the time they are prepared. Medications are not prepoured. 5. Medications are administered without unnecessary interruptions. 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record c. If necessary, verifying resident identification with other facility personnel 8. Hands are washed before and after administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 51 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F881 Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/31/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics), for antibiotic use protocol (official procedure or system of rules) for two of three sample residents (Resident 41 and 49) by failing to ensure residents met the urinary tract infection criteria (a standard by which something may be decided) prior to starting an antibiotic. This deficient practices resulted in inappropriately prescribed antibiotics and placed Resident 41 and 49 at higher risk of antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections). Findings: a. A review of Resident 41's admission clinical record indicated resident was readmitted on May 5, 2019, with diagnoses including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 52 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Alzheimer's disease (define) and Parkinson's disease (define). A review of Resident 41's history and physical dated May 6, 2019, indicated resident has the capacity to understand and make decisions. A review of Resident 41's Physician's Orders indicated the order of Hiprex (antibiotic) 1 gram one tablet by mouth twice a day for 10 days for asymptomatic bacteriuria (bacteria in the urine). b. A review of Resident 49's admission clinical record indicated resident was readmitted on October 31, 2018, with diagnoses including dementia (define) and hypertension (high blood pressure). A review of Resident 49's history and physical dated November 1, 2018, indicated resident does not have the capacity to understand and make decisions. A review of Resident 49's MDS dated November 6, 2018, indicated resident's decision-making skills is cognitively intact. The MDS indicated an order for Hiprex 1 gram twice a day for 10 days for asymptomatic bacteriuria. During a concurrent interview and record review of the May 2019 Antibiotic Surveillance Log on 6/29/19 at 10:47 a.m., the Director of Staff Development (DSD) confirmed Resident 41 and 49 did not meet urinary tract infection criteria. DSD stated for Resident 41 adn 49 did not have signs and symptoms of infection. During a concurrent interview and record review of the May 2019 Antibiotic Surveillance Log on 6/29/19 at 2:13 p.m., the Licensed Vocational Nurse (LVN 3) confirmed Resident 41 and 49 were asymptomatic. LVN 3 stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 53 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE is also the infection prevention assistant and fills out the antibiotic surveillance log. LVN 3 stated the Antibiotic Stewardship Programs purpose is for the facility to track its usage of antibiotics in the facility and ensure if residents need the antibiotic to minimize its usage. LVN 3 stated this is implemented when licensed nurses receive antibiotic orders from the doctor and the resident does not meet the criteria to notify the doctor that the resident does not meet the criteria. LVN 3 stated then the licensed nurses should document the doctor's statement and notification. LVN 3 stated when residents do not meet the criteria for antibiotic use it could potentially result in resident's developing antibiotic resistance and not meet the purpose of implementing the Antibiotic Stewardship Program to lessen the unnecessary use of antibiotics. A review of the facility's policy and procedure titled "Antibiotic Stewardship Program" dated April 19, 2017, indicated that it is the facility's policy to develop and maintain an Antibiotic Stewardship Program (ASP) to promote appropriate use if antibiotic while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 07/22/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.) per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 54 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident in a multiple resident bedrooms. Five resident rooms (16, 17, 18, 19, 20) contained 4 residents in each room, and 13 resident rooms (1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, and 14) contained 2 residents in each room. These rooms measured less than 80 sq. ft. per resident. This deficient practice had the potential to not afford the residents enough space for nursing care and limit the resident's ability to maneuver personal care devices. Findings: On 6/28/19 at 4:50 p.m., during the Entrance Conference with the Director of Nursing (DON), and according to the facility's variance request, dated 6/28/19, 18 residents' bedrooms did not measure 80 sq. ft. per resident. On 6/29/19 at 10:00 a.m., during a Group Interview, the residents when asked did not voice concerns about the space in their room. A review of the facility's waiver request letter dated 6/28/19, indicated that the rooms were in accordance with the special needs of the residents, and will not have an adverse effect on the residents' health and safety or impedes the ability of any resident in the rooms to attain his or her highest practicable well-being. According to the facility's Client Accommodation Analysis provided on 6/28/19, the following rooms were less than 80 square feet per resident: Rooms: No. of Beds: Square Feet: Required Square Footage: Feet per Resident: 1 2 148.5 160 74.25 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 55 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 2 160 3 160 4 160 5 160 6 160 7 160 8 160 9 160 11 160 12 160 13 160 14 160 16 320 17 320 18 320 19 320 20 320 2 148.5 2 148.5 2 148.5 2 148.5 2 143.5 2 148.5 2 148.5 2 148.5 2 148.5 2 148.5 2 148.5 2 148.5 4 300 4 300 4 300 4 300 4 300 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 74.25 74.25 74.25 74.25 74.25 74.25 74.25 74.25 74.25 74.25 74.25 74.25 75.00 75.00 75.00 75.00 75.00 During the course of the re-certification survey between 6/28/19 and 7/1/19, the evaluator observed that the above listed rooms had sufficient space for the residents' freedom of movement. The evaluator also noted that the nursing staff had enough space to provide nursing care, privacy during care, and ability to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 56 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555011 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINELAND POST ACUTE 10830 Oxnard St North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maneuver resident care equipment within the room. The room size did not present any adverse effect on the residents' personal space, nursing care, and comfort. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8LHB11 Facility ID: CA920000073 If continuation sheet 57 of 57