Other·June 26, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to in investigate a complaint. Complaint Number: CA00536615 Representing the California Department of Public Health: Surveyor, 36985 Census: 57 An immediate jeopardy situation (IJ - a crisis situation which has threatened or is likely to threaten the health and safety of the residents) was called for the following: An IJ was called under Resident Rights 483.10(i)(6) Comfortable and safe temperature (refer to F 257 - Comfortable and Safe Temperatures) on May 23, 2017, at 8:25 PM, and were verbally notified in the presence of the facility's regional nurse (RN) and the Director of Staff Development (DSD). The facility failed to ensure comfortable and safe temperatures for 13 residents who resided on the 200 hallway (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13), and nine residents (Residents 14, 15, 16, 17, 18, 19, 20, 21 and 22) who resided on the 300 hallway, when the air conditioning unit failed. This failure resulted in the residents complaining of extreme heat, (the facility's temperatures ranged from 87 degrees to 92 degrees Fahrenheit (F) which had the potential LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 1 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to adversely affect the health and safety of the residents by placing them at risk for heat exhaustion (condition of physical weakness accompanied by nausea, muscle cramps, and dizziness, due to exposure to intense heat) and heat stroke (condition with fever and often unconsciousness, when exposed to excessively high temperatures). A corrective action plan was received and accepted on May 24, 2017 at 11:42 AM, with the following information: a. Fans were placed in residents rooms and in common corridors, with ice buckets in front of fan to cool the air. b. Air conditioning unit was repaired. c. Staff were in-serviced on interventions for high temperatures, and reporting any change of conditions to the facility's supervisors. d. Staff to provide rounds with hydration every hour to residents unable to get to hydration cart in the dining room. e. Temperature logs implemented and will continue until room temperatures are 72-81 degrees Fahrenheit (F). f. Staff will have in-service training regarding reporting "life safety" issues to the administrative staff, and [for]the administrative staff, on unusual occurrence reporting to the California Department of Public Health (CDPH) as required by regulation. The IJ was lifted on May 24, 2017 at 11:42 AM in the presence of the Registered Nurse (RN) and the Director of Maintenance, after the corrective action plan was verified to have been implemented through observation, temperature FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 2 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE checks in residents rooms and common areas, interviews with residents and staff and review of in-services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 3 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F252 SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/13/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents (Resident 16 and 17) in a universe of 57, when their bedroom toilet remained out of order for one week, requiring Resident 16 and Resident 17 to use an alternate restroom FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 4 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE across the hall, located in the conference room. This deficient practice resulted in Resident 16 and Resident 17 being subjected to unsanitary conditions, and created a hardship getting to the restroom, which had the potential to negatively affect their health and well-being. Findings: During a facility tour of the dining room on May 24, 2017 at 10:19 AM, the surveyor was approached by a family member of Resident 16, who stated that Resident 16's toilet was clogged and would not flush after Resident 16 used the toilet. The Restroom toilet was out of order for over a week before maintenance unclogged the toilet. During an interview with Resident 16 on May 24, 2017 at 10:25 AM, she stated, "It [the toilet] was broken, they didn't [did not] fix it [the toilet]." Resident 16 stated "yes" it was hard on me to use the conference room's restroom, that was located across the hall. During an interview with Resident 17 on May 24, 2017 at 10:36 AM, she stated the bathroom was broken for over a week. Resident 17 stated she used the bathroom across the hall. Resident 17 also stated her roommate [Resident 16] reported the clogged toilet to the facility staff. During an interview with the Director of Maintenance (DM) on May 24, 2017 at 10:38 AM, he confirmed the toilet had been clogged and unable to flush, but thought he fixed it the same day. The DM stated he had to borrow a snake to unclog the toilet. When asked if there was any documentation to support his statement that the toilet was unclogged on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 5 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE same day, he stated that using the maintenance log was something he was working to get completed. During a review of the maintenance log book (book where repairs and updates are kept), it indicated no documentation of the "broken" toilet, and no documentation that the toilet was corrected on the same day. During an interview with the Regional Registered Nurse (RN) on May 24, 2017 at 11:45 AM, she stated she did remember the toilet being out of order for a least a few days, and stated, "I made the out of order sign for the restroom." A review of the facility's policy and procedure titled, "Maintenance Service," (undated), indicated, "1. The Maintenance Department is responsible for...f. Establishing priorities in providing repair service...i. Providing routinely scheduled maintenance service to all areas." A review of the facility's policy and procedure titled, "Supervision, Maintenance Services," dated August, 2008, indicated, "1. The day-today maintenance operation is under the supervision of the Maintenance Director." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 6 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F257 COMFORTABLE & SAFE TEMPERATURE LEVELS CFR(s): 483.10(i)(6)

F257 SS=K PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/13/2017 (i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 degrees F. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level of 71-81 degrees Fahrenheit (F) in the common area by the nurses station, where residents had congregated, five rooms on the 200 hallway (Rooms 200, 201, 202, 203 and 205) and four rooms (Rooms 300, 301, 303 and 304) on the 300 hallway. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 7 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This failure had the potential to adversely affect the health and safety of residents by placing them at risk for heat exhaustion (condition of physical weakness accompanied by nausea, muscle cramps, and dizziness, due to exposure to intense heat) and heat stroke (condition with fever and often unconsciousness, when exposed to excessively high temperatures), when the air conditioning unit failed. An immediate jeopardy (IJ) was called on May 23, 2017 at 8:25 PM, in the presence of the facility's Regional Nurse (RN) and the Director of Staff Development (DSD), due to excessive heat, (Facility temperatures ranged from 87 to 92 degrees F), and the facility's inoperable air conditioning unit. Findings: During the initial tour on May 23, 2017 between 6:00 PM and 6:14 PM, the nurses' station, where residents (Resident 14, 22 and 23) congregated, felt hot and uncomfortable. The temperature was taken with the surveyor's laser thermometer gun and determined to be 87 degrees Fahrenheit (F) and verified with the Licensed Vocational Nurse (LVN 1 and 2). During the initial tour, observation revealed no facility staff had been observed to be passing hydration to clients affected by the elevated temperatures in the building. The facility's maintenance personnel were not on site, and no work was being completed on the air conditioning unit. During an observation while conducting the initial tour on May 23, 2017 at 6:06 PM, two residents (Resident 1 and 2) were observed in their room (Room 202). They were visibly sweating, and complained of the excessive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 8 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE heat in their room. Their room temperature was 91 degrees F, using the surveyor's laser thermometer gun and verified with Resident 1 and Resident 2, who complained of the elevated temperature. The Director of Staff Development (DSD) was also present to verify the elevated temperature of 91 degrees F. During an observation on May 23, 2017 at 6:19 PM, the hydration cart (cart with fluids available to independently serve individuals in the facility) had been observed in the dining room, unavailable to any residents who were unable to get out of bed independently, or to self-propel in their wheelchair. During additional observations, on May 23, 2017, between 6:00 PM and 7:04 PM, the following area's temperatures were taken with the surveyor's laser thermometer gun, and verified with the DSD. a. Nurses' Station: 87 degrees F. During an interview with Resident 14 on May 23, 2017 at 6:20 PM, she stated, "I'm [I am] hot," indicating she had been uncomfortable in the common area located by the nurses' station. The temperature in the common area where Resident 14 was sitting was taken with the surveyor's laser thermometer gun and was 87 degrees F, verified with LVN 1 and 2. b. Room 201: 92 degrees F. During an interview with Resident 3, on May 23, 2017 at 6:19 PM, she stated, "I'm [I am] hot; it's [it is] always hot [in my bedroom]." The temperature in Room 201 was taken with the surveyor's laser thermometer gun and was 90 degrees F, verified with Resident 3, and the DSD. Resident 3 stated the facility had not provided any means of comfort since the air FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 9 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conditioning unit failed to operate. c. Room 202: 91 degrees F. During an interview with Resident 1 on May 23, 2017 at 6:14 PM, he stated, "It's [it is] hot, and has been since yesterday [in our room]." Resident 1 stated the air conditioning does not work and the fan is "Blowing hot air." The temperature was 91 degrees F, taken with the surveyor's laser thermometer gun, verified with Resident 1 and the DSD. During an interview with Resident 2 on May 23, 2017 at 6:16 PM, he stated, "I'm [I am] hot [in our room], and the [facility's] air conditioning never works." Resident 2 stated, "The heat works just fine, but it is always hot [in our room]." The temperature was 91 degrees F, taken with the surveyor's laser thermometer gun, verified with Resident 2 and the DSD. d. Room 303: 90 degrees F. During an interview with Resident 15 on May 23, 2017 at 6:23 PM, he stated, "90 degrees [Fahrenheit] is too warm [in Room 303]." The temperature in Room 303 was 90 degrees F and was taken with the surveyor's laser thermometer gun, verified with Resident 15, and the DSD. During an interview with the Director of Staff Development (DSD) on May 23, 2017 at 6:42 PM, she stated the air conditioning was not working and had not worked since yesterday (May 22, 2017). The DSD stated, "The air conditioner repair person will not repair the air conditioner until tomorrow (May 24, 2017)." The DSD stated, "I don't [do not] know, why the repairs are not being done." The DSD confirmed the maintenance personnel and the air conditioning unit repair person were not at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 10 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility. During an interview with the Director of Maintenance (DM) on May 23, 2017 at 7:22 PM, he stated the air conditioning was not working when he had left the facility today (May 23, 2017). The DM stated the air conditioner repair person was not scheduled to come back here until tomorrow (May 24, 2017). The DM confirmed that he called the air conditioning unit repair person to come to the facility, after the surveyor arrived on site. A review of the facility's policy and procedure titled, "Policy," (undated), indicated, "It is our policy to keep the room temperatures between 72 and 81 degrees [Fahrenheit]... If the situation cannot be addressed in a timely manner, more aggressive steps must be taken..." A review of the facility's policy and procedure titled, "Maintenance Service," (undated), indicated, "2. Functions of maintenance personnel include...d. Maintaining the heat/cooling system...f. Establishing priorities in providing repair service..." The IJ was lifted on May 24, 2017 at 11:42 AM, in the presence of the RN and the Director of Maintenance, after the corrective action plan was verified to have been implemented through observation, temperature checks in residents rooms and common areas, interviews with residents and staff and review of in-services with the following: a. Fans were placed in residents rooms and in common corridors, with ice buckets in front of fan to cool the air. b. Air conditioning was repaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 11 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE c. Staff were in-serviced on interventions for high temperatures, and reporting any change of conditions to the facility's supervisors. d. Staff to provide rounds with hydration every hour to residents unable to get to hydration cart in the dining room. e. Temperature logs implemented and will continue until room temperatures are 72-81 degrees Fahrenheit (F). f. Staff will have in-service training regarding reporting "life safety" issues to administrative staff and administrative staff reporting to California Department of Public Health (CDPH). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 12 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F463 RESIDENT CALL SYSTEM ROOMS/TOILET/BATH CFR(s): 483.90(g)(2)

F463 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/13/2017 (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area (2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure one of 57 residents (Resident 17) had a working call light (button to summon assistance from facility staff) for 19 days, forcing Resident 17 to have to wait until facility staff walked by her room so she could call out for assistance. This failure had the potential for Resident 17 being unable to summon assistance when needed. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 13 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the clinical record for Resident 17, titled, "Admission Record," (undated), indicated Resident 17 was admitted to the facility on April 12, 2017 with diagnoses of heart failure, muscle weakness, and blindness in the left eye. During an interview with Resident 17 on May 24, 2017 at 12:05 PM, she confirmed the call light in her room was non functional, "They would fix it is what they [DM] said." Resident 17 stated, "It took a long time to fix it [call light], they [DM] said they had to wait for a part." Resident 17 further stated, "I had to yell out for somebody." During an interview with the Director of Maintenance (DM) on May 24, 2017 at 10:38 AM, he confirmed Resident 17's call light was not working for 19 days. The DM stated he needed to order a part. The DM also stated, "I'm [I am] doing my best, that's something I need to get used to [repairs in a timely matter]. During a record review of the "Maintenance Log," indicated on May 5, 2017 at 9:05 AM, "Call light does not work..." The "Maintenance Log" also indicated, "Date Completed May 23, 2017, 19 days after being reported. During an interview with the facility's Regional Registered Nurse (RN) on May 24, 2017 at 11:45 AM, she stated that there was no documentation of any interventions to keep Resident 17 safe and her needs met while Resident 17's call light was not functioning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSB611 Facility ID: CA240000031 If continuation sheet 14 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055557 (X3) DATE SURVEY COMPLETED 06/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: NSB611 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000031 (X5) COMPLETE DATE If continuation sheet 15 of 15