Health inspection·February 23, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures for Fall Risk Assessment for one of three sampled residents (Resident 1) when Resident 1 was not accurately assessed for fall risk. Residents Affected - Few This failure resulted in Resident 1 to experience a fall. Findings: An unannounced visit was made to the facility on November 30, 2023, at 5:30 PM, to investigate a Facility Reported Incident (FRI) regarding quality of care/treatment. During an observation on November 30, 2023, at 5:35 PM, in Resident 1's room, Resident 1 was lying down on her bed on her back, with head of the bed elevated. Resident 1 had a bandage wrapped around her leg and heel protector on feet. During an interview on November 30, 2023, at 5:45 PM, in Resident 1's room, Resident 1 stated she did not remember when she had a fall. During a review of Resident 1's face sheet (a document which contain basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis which include cerebral infarction (stroke), Glaucoma (a disease of the eyes which causes blindness) and osteoporosis (a bone disease which causes brittle bones). During a review of Resident 1's History and physical (H&P) dated June 16, 2023, indicated Resident 1 has a history of falls, and history of compression fracture vertebra (a broken bone that cause the back to collapse, making them shorter). Further Review of Resident 1's H&P dated June 16, 2023, indictated Resident 1 can make decisions. During a review of Resident 1's Fall Risk Assessment dated October 18, 2023, indicated, Score 9, category: Low Risk . Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicated under section, 4. Vision, Resident 1's vision was adequate. Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicate under section, 7. Medications indicated Resident 1 was taking 1- 2 of these medications currently and /or within last 7 days. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056365 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 02/23/2024 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)