Health inspection·January 13, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1) when Resident 1, a resident who was at high risk for falls and fully dependent upon staff for mobility while in bed, fell from his bed while being changed by Certified Nursing Assistant 1 (CNA 1). This failure resulted in Resident 1 to sustain a head injury which included a bleeding laceration to his right eyebrow and a subarachnoid hemorrhage (bleeding in the area between your brain and the thin tissues that cover and protect it). Findings: During a review of Resident 1's admission Record (contains medical and demographic information), the record indicated Resident 1 was admitted on [DATE], with diagnoses which included cerebral palsy (neurological disorder that causes permanent problems with movement, balance, and posture), parkinson's disease (a disorder of the central nervous system that affects movement), disorders of bone density and structure (medical conditions that affect the strength and composition of bones which can significantly impact bone structure and increase fracture risk), and epilepsy (a brain disorder that causes recurring, unprovoked seizures). During an interview on November 4, 2024, at 3:25 PM, with the Director of Nursing (DON), the DON stated on October 18, 2024, Resident 1 fell off his bed when CNA 1, who was a contracted registry staff member (an employee provided by a contracted staffing agency), turned the resident away from her (rolled the resident towards the opposite side of the bed from which the CNA was standing) when cleaning up the resident's bowel movement. During a continued interview on November 4, 2024, at 3:35 PM, with the DON, the DON stated CNA 1 should have had another staff member assist with turning the resident in bed since the resident had contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The DON further stated as a result of the fall, Resident 1 sustained an abrasion to his right eyebrow and was subsequently sent to the hospital where it was identified that the resident also had a subarachnoid hematoma. During a review of Resident 1's Minimum Data Set assessment (MDS - a computerized resident assessment tool), dated October 18, 2024, the MDS assessment indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 1 (score of 0-7 is severe cognitive impairment). (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 01/13/2025 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)