Health inspection·April 18, 2024

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 ensure a safe environment for two of three sampled residents (Residents 1 and 3) when: Residents Affected - Few 1. Resident 1 ' s call light was found hanging from a light fixture on a wall. 2. Resident 3 ' s call light was found behind a nightstand on the floor. These failures had the potential to result in resident harm and unmet needs for Residents 1 and 3. Findings: 1. During a review of Resident 1 ' s admission Record (contains demographic and medical information), the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a condition where a person experiences a decline in their memory, thinking and reasoning skills), unsteadiness on feet, and repeated falls. During a concurrent observation and interview, on March 12, 2024, at 10:19 AM, with Resident 1, in her room, Resident 1 ' s call light was hanging from the light fixture on the wall, inaccessible. Resident 1 stated she did not know where the call light was. Resident 1 further stated she needed to use the restroom. During a concurrent observation and interview, on March 12, 2024, at 10:20 AM, with the Director of Staff Development (DSD) and a Certified Nurse Assistance (CNA 1), in Resident 1 ' s room, the DSD and CNA 1 acknowledge Resident 1 ' s call light was not within reach and should have been. 2. During a review of Resident ' s 3 admission Record indicated Resident 3 was admitting on December 6, 2020, with diagnoses of dementia (condition where a person experiences a decline in their memory, thinking and reasoning skills), peripheral vascular disease (condition that affects the blood circulation in their body), and respiratory failure (when the lungs can ' t provide enough oxygen to the body.). During an observation, on March 12, 2024, at 10:19 AM, at Resident 3's room, Resident 3 was lying down in bed with her eyes closed. Residents 3 ' s call light was found on the floor, inaccessible. During a concurrent observation and phone interview, on March 12, 2024, at 10:24 AM, with the DSD and CNA 1, in Resident 3 ' s room, the DSD and CNA 1 acknowledge that Resident 3 ' s call light was behind the nightstand on the floor, and stated the call light should be within the resident ' s reach. (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 04/18/2024 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)