Health inspection·September 13, 2023

F 0689 fallen three times in the month of April 2023 (April 7, 2023, April 9, 2023, and April 13, 2023). Level of Harm - Actual harm During a review of Resident 1 ' s physician ' s orders, an order dated April 10, 2023, indicated, 1:1 [one on one] monitoring by CNA [Certified Nursing Assistant]. Residents Affected - Few During a telephone interview on August 8, 2023, at 4:48 PM with Certified Nursing Assistant 1, CNA 1 stated he worked at the facility [name of facility] on April 13, 2023, when Resident 1 fell and sustained a head injury and had to be sent to the hospital. CNA 1 stated Resident 1 was one of the residents assigned to him during his shift. CNA 1 stated he could not remember which Licensed Vocational Nurse (LVN) but stated an LVN told him that he was on a 1:1 (one to one) assignment with Resident 1 and that he needed to keep checking in on Resident 1 throughout his shift. CNA 1 stated he was also responsible to help other residents throughout his shift even though he was assigned 1:1 with Resident 1. CNA 1 stated when Resident 1 fell on April 13, 2023, the resident was in his room with the door closed and was not accompanied by any staff members inside the room. CNA 1 stated at the time Resident 1 fell, he (CNA 1) was outside the Resident 1 ' s room and was attempting to redirect another resident who was trying to open Resident 1 ' s door. CNA 1 stated he did not want Resident 1 to be woken up and that ' s when he heard Resident 1 yell and as he opened the door and entered the room, he found Resident 1 had fallen and hit the back of his head on the floor and was bleeding. CNA 1 further stated he was the first to respond to the fall. During an interview on August 16, 2023, at 12:15 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was working at the facility [name of facility] on April 13, 2023, when Resident 1 fell during her shift. LVN 1 stated CNA 1 was assigned to do 1:1 monitoring with Resident 1 that day and when Resident 1 fell, CNA 1 was outside the door of Resident 1 ' s room. LVN 1 further stated Resident 1 required 1:1 monitoring due to his history of falls and stated Resident 1 was unsteady on his feet. During an interview on August 16, 2023, at 4:15 PM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated he was working at the facility on April 13, 2023, when Resident 1 fell. CNA 2 stated CNA 1 was assigned to do 1:1 with Resident 1 because Resident 1 kept getting up all the time and had a history of falls. CNA 2 stated throughout his shift, he saw CNA 1 outside Resident 1 ' s room with the door closed on multiple occasions (could not quantify how many times). CNA 2 further stated when he saw CNA 1 outside Resident 1 ' s room, he (CNA 1) was just standing there and sometimes talking to staff but was not performing any particular tasks. CNA 2 further stated on other occasions when he saw other staff members assigned to 1:1 monitoring, they were in the room with Resident 1 and not outside the room with the door closed, but stated this time was different. During an interview on August 23, 2023, at 9:20 AM, with the Director of Nursing (DON), the DON stated Resident 1 had behaviors and would at times be unsteady on his feet and had physician orders for 1:1 (one on one) supervision. The DON stated her expectation was that if a staff member was assigned to do 1:1 (one on one) with a resident, they should always be in the room with the resident. The DON further stated any staff assigned to do 1:1 monitoring of a resident should be next to the resident or near them and in the line of sight of the resident at all times. The DON stated it would be unacceptable for a staff member to be outside a room of a resident on 1:1 monitoring with the door closed. The DON stated 1:1 monitoring is important for the safety of the resident and other residents within the facility. During a concurrent interview and record review, on August 23, 2023, at 9:46 AM, with the DON, the written statement from CNA 1, dated April 13, 2023, was reviewed. The statement indicated, I, [name (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056365 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yucaipa Hills Post Acute 13542 2nd St. Yucaipa, CA 92399 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few of CNA 1] making a statement about [name of Resident 1] ' s fall incident. I was assigned to do one on one with [name of Resident 1]. Around 7:20 PM I was redirecting another patient not to get in into [sic] [name of Resident 1] ' s room because I don ' t [sic] want the patient to be disturbed onto [sic] his sleep. I heard [name of Resident 1] yelled and I immediately came up to him and I found him laying [sic] on the floor . The DON stated, Reading the statement from the CNA, it sounds as though it was an unwitnessed fall. The DON further stated it would have been unacceptable if the staff member was outside of the room of a resident with the door closed while on 1:1 monitoring. The DON further stated if the door is closed, the staff should be inside the room with the resident. During an interview on August 23, 2023, at 4:00 PM, with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she worked on April 13, 2023, when Resident 1 fell. CNA 3 stated she recalled seeing CNA 1 assigned to do 1:1 supervision for Resident 1 and stated she saw CNA 1 sitting in a chair outside Resident 1 ' s room on multiple occasions while the resident was in the room with the door closed. During a review of Resident 1 ' s document titled, [name of hospital] .ED [emergency department] Provider Report . dated 4/13/23, the document indicated, [name of Resident 1] .History of Present Illness .Fall Injury .62 y/o [year old] male .BIBA [brought in by ambulance] from [name of facility] after sustaining an unwitnessed fall today. Per EMS [emergency medical services] pt was noted to have a hematoma [a collection or pooling of blood outside a blood vessel] to the back of his head .he's had a total of 3 falls this week .CT [computated tomography- an imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body] scanning .Impression: Small posterior right parafalcine and tentorial subdural hemorrhage [bleeding in the posterior (rear) aspect of the brain], 3 mm [Millimeters - a unit of measure] in thickness .Posterior scalp 3 cm [centimeters - a unit of measure] partial-thickness laceration .3 staples placed without incident .Diagnosis: Altered mental status fall, close head injury, scalp laceration, subdural hemorrhage .Condition: Critical . During a review of the facility ' s policy and procedure titled, Falls and Fall Risk, Managing, revised March 2018, the policy indicated, .Resident conditions that may contribute to the risk of falls include: .c. Delirium [a mental state in which you are confused, disoriented, and not able to think or remember clearly] and other cognitive impairment; .i. functional impairments . 3. Medical factors that contribute to the risk of falls include: .e. balance and gait [manner of walking] disorders .Resident-Centered Approaches to Managing Falls and Fall risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. During a concurrent interview and record review on August 23, 2023, at 10:18 AM, with the DON, the facility ' s policy and procedure titled, Safety and Supervision of Residents, (undated), the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .4. Implementing interventions to reduce accident risks and hazards shall include the following routine checks of resident or 1:1 supervisions to ensure safety .d. ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; . The DON stated the policy was not followed. During an interview on August 14, 14, 2023, at 4:05 PM, with the DON, the DON stated the facility did not have a policy and procedure regarding 1:1 supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056365 If continuation sheet Page 3 of 3