Health inspection·September 26, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow a system for controlling the spread of a communicable disease for one of four sampled residents (Resident 1) when Resident 1 was on transmission-based droplet precautions (a set of measures used to prevent the spread of organisms that cause disease through respiratory secretions) for a coronavirus disease (COVID-19-an infectious disease caused by a virus) exposure and was allowed to participate in activities with 11 other residents. This failure had the potential to cause the spread of COVID-19 to other residents in the facility. Residents Affected - Few Findings: A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of March 8, 2024. Resident 1 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of February 22, 2024. Resident 5 had diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to perform basic tasks). A review of Resident 5 ' s COVID-19 laboratory test dated September 18, 2024, indicated, Results: positive and symptomatic. A review of Resident 1 ' s care plan dated September 18, 2024, indicated, Focus: [Resident 1] with COVID-19 exposure. Date Initiated: [September 18, 2024] Revision on: [September 18, 2024]. Goal: Prevent the spread of COVID-19 in the facility Date Initiated: [September 18, 2024] Target Date: [October 2, 2024]. Interventions: Encourage/Remind Resident to wear mask and maintain social distancing. Date Initiated: [September 18, 2024] . Initiate transmission-based precaution (DROPLET). Staff to implement full PPE [Personal Protective Equipment] use (mask, face shield/goggles, gown, gloves) when providing direct care to the resident. Date Initiated: [September 18, 2024] Keep the number of staff assigned to enter the room at a minimum and staff to bundle resident care activity. Date Initiated: [September 18, 2024] Educate resident and provide information regarding COVID-19. Date Initiated: [September 18, 2024] Promote social distancing; and avoid communal dining/group activities. Provide means of communication/engagement with family members, resident representatives and/or friends while visitation is restricted. Provide individualized activities of choice. Date Initiated: [September 18, 2024] . During an observation on September 23, 2024, at 1:34 PM, arrived at Resident 1 and Resident 5's room. The room's door was closed, and an Isolation Precautions-Droplet sign was posted. PPE was (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 09/26/2024 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)