Other·September 21, 2018

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 investigate a complaint. Complaint Number: CA00585851 Representing the California Department of Public Health: Surveyor: 35183 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued as a result of the investigation for complaint number CA00585851

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/05/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent multiple falls with progressive injuries for one of three sampled residents (Resident A), when the facility did not 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: T7X111 Facility ID: CA240000252 If continuation sheet 1 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 adequately assess the reasons for the falls and revise the care plan based on the identified reasons for the falls. These failures caused Resident A to suffer life threatening injuries as evidenced by: bleeding in the brain, the need for a ventilator (a machine that breathes for the resident) and placement in the general acute care hospital's intensive care unit (ICU). Findings: An unannounced visit was made to the facility on May 4, 2018 at 9:56 AM, to investigate a complaint in regards to a resident fall with injuries. Resident A's clinical record was reviewed on May 4, 2018. Resident A's face sheet (a document that gives a resident's information at a quick glance and includes a resident's contact details, a brief medical history and the resident's level of functioning, along with resident preferences and wishes), undated, set forth that Resident A was admitted to the facility on February 6, 2018, with diagnoses that included dementia (a disorder of the brain which causes memory loss, personality changes, and impaired reasoning). Resident A's fall assessment, dated February 18, 2018, set forth Resident A's history of falls due to balance problems during transition (moving from one position to another) and as a result of side effects of medications. During an initial tour of the facility on May 4, 2018 at 11:23 AM, with the Director of Nursing (DON), the DON stated that Resident A was in the intensive care unit at the hospital and had not regained her base line status (normal level of functioning) at that time. Resident A's nursing notes from February 6, 2018 to May 5, 2018, were reviewed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 2 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 nursing notes set forth Resident A had sustained five falls as follows: a. [Fall 1] On February 22, 2018, Resident A fell from a wheelchair when trying to stand unassisted and the wheelchair rolled out from under her. Resident A complained of 6 out of 10 pain (a zero to 10 pain scale where zero equals no pain and 10 equals the worst pain) to her left lower leg. (16 days after admission). b. [Fall 2] On March 17, 2018, Resident A fell from a bed and was found on the floor. (23 days after Fall 1). c. [Fall 3] On March 25, 2018, Resident A fell while ambulating (walking) with a walker, striking her head on the walker (a frame used by disabled or infirm people for support while walking, typically made of metal tubing with small wheels or rubber-tipped feet). Resident A sustained a gash to her left eyebrow and a reddened area to her neck where she had been hit by the walker. (8 days after Fall 2). d. [Fall 4] On May 1, 2018 at 6 AM, Resident A fell from a bed after a bed alarm did not alert staff. Resident A sustained a 5 cm (centimeter) x 4 cm bump to the back of the head. (37 days after Fall 3). e. [Fall 5] On May 1, 2018 at 5:45 PM, while ambulating with a walker (11 hours and fortyfive minutes after Fall 4), Resident A suddenly stiffened and fell directly backwards hitting the back of her head on the floor resulting in a brain injury and the need for a ventilator. During an interview with a Physical Therapist (PT 1) on June 27, 2018 at 10 AM, PT 1 stated he was responsible for evaluating residents after a fall. PT 1 stated he had a post-fall procedure he followed to determine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 3 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 interventions to reduce the risk of future falls. PT 1 stated he had not been informed about any of Resident A's five falls at the facility (Fall 1, 2, 3, 4 and 5). PT 1 stated he had not been invited to, nor attended, any of Resident A's Interdisciplinary Team Meetings [IDT- a group of health care professionals who work in a coordinated fashion toward a common goal for the resident) regarding Resident A's five falls (Falls 1, 2, 3, 4, and 5). PT 1 stated, "I should have been notified a long time ago in regards to these falls. This is clearly a pattern and we should have been consulted to keep this resident safe." During an interview with a Certified Nursing Assistant (CNA 2) on June 27, 2018 at 11:24 AM, CNA 2 stated she had witnessed Resident A's first fall. CNA 2 stated Resident A was in the dining room in her wheel chair and attempted to stand up on her own. CNA 2 stated Resident A changed her mind and tried to sit back down in the wheel chair when the wheel chair wheeled backwards and Resident A fell to the floor. CNA 2 stated that the wheelchair wheels should have been locked by staff but they were not. CNA 2 stated she was unable to reinforce teaching for Resident A to ask for assistance with standing because Resident A communicated in a language different from the language spoken by CNA 2. During an interview with a Licensed Vocational Nurse (LVN 1) on June 27, 2018 at 2 PM, LVN 1 stated she had assisted Resident A after Fall 1 and had documented Fall 1 in the nursing notes. LVN 1 stated that Resident A would spontaneously stand up and then sit right back down again. LVN 1 stated, "You just didn't know what would happen." LVN 1 stated that the staff should have locked Resident A's wheelchair wheels so it would not go out from underneath her. LVN 1 stated she had difficulty FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 4 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 communicating with Resident A because Resident A would transition between speaking a language LVN 1 did not speak and the English language. LVN 1 stated the communication difficulties made it impossible for her to reinforce teaching with Resident A to stay in her wheel chair. A review of Resident A's "Event Investigation Record," dated February 23, 2018, for Fall 1 indicated, "Conduct a ROOT CAUSE ANALYSIS [a systematic process for identifying "root causes" of problems or events and an approach for responding to them]. What factor (s) caused or contributed to this incident/accident? Chooses independence over safety." A review of Resident A's "Interdisciplinary Team Conference Record-Falls," dated February 23, 2018, indicated, "Other factors considered by team: Enc. [encourage] pt. [patient] to comply with plan of care, re-direct and assist as needed." A review of a nursing note dated March 17, 2018 at 6:45 AM, by a Licensed Vocational Nurse (LVN 2), indicated, "Res [resident] was found sitting directly next to her bed on her buttocks...When asked what occurred res stated, 'I don't know.'" A review of Resident A's "Event Investigation Record," dated March 19, 2018, indicated, "Date of the event: 3/17/18 [March 17, 2018] Type of Event: unwitnessed fall." A review of Resident A's "Event Investigation Record," dated March 19, 2018, for Fall 2 indicated, "Conduct a ROOT CAUSE ANALYSIS [a systematic process for identifying "root causes" of problems or events and an approach for responding to them]. What factor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 5 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 (s) caused or contributed to this incident/accident? Poor safety awareness, dx [diagnosis] dementia, depression, Chooses independence over ad lib [ ad libitumspontaneously without restraint]- amb. [ambulation-walking] Ad lib c [with] walker." A review of Resident A's "Interdisciplinary Team Conference Record-Falls," dated March 19, 2018, indicated, "Other factors considered by team: Encourage res. [resident] to use call light." During an interview with a Certified Nursing Assistant (CNA 1) on June 27, 2018 at 1:04 PM, CNA 1 stated she had witnessed Resident A's third fall (Fall 3). CNA 1 stated Resident A was standing at the nursing station and when she turned to the left with her walker to start down the hallway she fell over to her left. CNA 1 stated she had been behind the nursing station and could only see from the middle of Resident A's chest and up to her head. CNA 1 stated, "I couldn't see what happened below that; she just fell over." CNA 1 stated Resident A would have benefitted from assistance by staff while she ambulated with her walker. CNA 1 stated, "I never discussed with anyone that I thought the resident could use more assistance." During an interview with a Licensed Vocational Nurse (LVN 3) on June 28, 2018 at 7:12 AM, LVN 3 stated she had witnessed Resident A's Fall 3 and had documented Fall 3 in the nursing notes. LVN 3 stated Resident A had come up to the counter to ask where to go for lunch and LVN 3 had pointed and instructed to her that it was upfront. LVN 3 stated Resident A had her walker in front of her and she misstepped, caught the walker with her foot and fell to the left onto the floor. LVN 3 stated Resident A's neck was hit by the walker and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 6 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 she had a gash to her left eyebrow. LVN 3 stated Resident A was transported to the hospital. LVN 3 stated Resident A would not use the walker consistently and the staff would have to remind her constantly to use the walker. LVN 3 stated Resident A would attempt to ambulate independently then grab for something nearby when she lost her balance. LVN 3 stated that Resident A did not have a tab alarm (an alarm clipped onto the resident's clothing with a string that was attached to a magnet on a device on the wheelchair. When a resident tried to stand the string would pull and set off an alarm) to alert staff that she was ambulating independently. A review of the hospital's CT (computed tomography) scan (an x-ray of the head and brain) report, dated March 25, 2018, indicated, "Acute [immediate] subdural [under a brain membrane] hemorrhage [bleeding] seen over the left frontal lobe [front, left side of the brain] measuring up to 4 mm [millimeters-a unit of measurement] ...slight 2-3 mm left-to-right midline shift [the brain is pushed to the right due to the pressure from the bleeding] noted." Resident A returned to the facility on March 26, 2018, with physician's instructions to monitor bruising to upper arms and left eyebrow, every shift for 14 days, then re-evaluate. A review of Resident A's physician's order dated March 26, 2018 indicated, "RNA [restorative nurse assistant- a certified nursing assistant with special training by the rehabilitation staff] ambulation 3x [times] wk [week] x 7 d [days]." A review of Resident A's care plan, that was completed and in effect for Resident A beginning February 6, 2018, did not demonstrate that facility staff made revisions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 7 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 nor added any preventative interventions for Resident A after Resident A sustained her second and third falls (Fall 2 and 3). A review of Resident A's "Event Investigation Record," dated March 26, 2018, for Fall 3 indicated, "Conduct a ROOT CAUSE ANALYSIS [a systematic process for identifying "root causes" of problems or events and an approach for responding to them]. What factor (s) caused or contributed to this incident/accident? Chooses independence over safety, thin fragile skin." A review of Resident A's "Interdisciplinary Team Conference Record-Falls," dated March 26, 2018, indicated, "Reinforce importance of seeking assistance, incl. [include] activities, monitor closely." During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on June 27, 2018 at 3:06 PM, the RNS stated that a root cause analysis was a process to understand why the resident fell so the IDT could review the reasons and come up with interventions to prevent future falls. The RNS stated the root-cause analysis did not document that Resident A's wheelchair wheels had not been locked nor the difficulties with communication. The RNS stated the root cause analysis was not conducted in a way to be effective. The RNS stated that the IDT did not address the unlocked wheelchair wheels or the communication difficulties. The RNS stated, "PT should have been invited to the 'Fall' IDT." During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on June 27, 2018 at 3:23 PM, the RNS stated she did not speak Resident A's language, so she did not talk to Resident A about the fall. RNS stated her root cause FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 8 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 analysis investigation did not identify why Resident A fell from her bed. The RNS stated the root cause analysis was not conducted in a way to be effective. The RNS stated the IDT meeting determined one intervention which was to "encourage use of call light." The RNS stated that the IDT did not take into consideration the communication problems. The RNS stated that there was no documentation to show the physical therapist had attended the IDT meetings. The RNS stated: "The care plan should have been updated with teach and reinforce, teaching of call light use - which would have been difficult to do because of the language barrier and dementia." During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on June 27, 2018 at 3:38 PM, the RNS stated the root-cause analysis conducted after the fall did not adequately identify reasons why Resident A fell as Resident A had been ambulating with her walker and was using her walker appropriately. The RNS stated the root cause analysis was not conducted in a way to be effective. The RNS stated it did not make sense to reinforce importance for seeking assistance, as recommended by the IDT, when Resident A used her walker and used it appropriately. The RNS stated that there was no documented evidence to show the physical therapist had attended the meeting and the care plan had not been updated with interventions to prevent future falls after Fall 3. The RNS stated that the order for RNA ambulation should have been discussed in the IDT meeting and included on Resident A's care plan and it was not. During an interview with a Certified Nursing Assistant (CNA 3) on June 28, 2018 at 6:50 AM, CNA 3 stated he, a Licensed Vocational FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 9 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 Nurse (LVN 4) and another CNA (CNA 3 did not remember the name) were walking in the hallway and saw Resident A on her back on the floor of her room. CNA 3 stated that they all assessed Resident A at the same time and found the "bump" on the back of her head. CNA 3 stated, "I saw the bump on her head, it was pretty visible." CNA 3 stated it was apparent to him that Resident A had fallen and the resident was incoherent and not speaking much. CNA 3 stated, "I don't remember her saying anything that made sense." CNA 3 stated that he had been very concerned that the facility decided not to send her to the hospital. During an interview with a Licensed Vocational Nurse (LVN 4) on June 27, 2018 at 2 PM, LVN 4 stated she had assisted Resident A after Fall 4 and had documented Fall 4 in the nursing notes. LVN 4 stated she did not remember where she had assessed Resident A after the fall but there had been a very large "bump" to the back of Resident A's head. LVN 4 stated Resident A had told her she hit her head on her bed. LVN 4 stated she had been very concerned that the facility had decided not to send Resident A to the hospital when she had such a large bump on her head. LVN 4 stated she obtained a verbal order from the physician on May 1, 2018 at 6:30 AM to monitor bruising every shift for 14 days. LVN 4 stated that she had not completed an incident report or updated the care plan for Fall 4 because it had happened at the change of shift. A review of Resident A's clinical record from May 1, 2018 to June 27, 2018 was conducted. There was no documentation by facility staff to show an incident report, a root cause analysis, an IDT meeting or an update to the plan of care was completed for Fall 4. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 10 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 an interview and concurrent record review with the Registered Nurse Supervisor (RNS) on June 27, 2018 at 3:57 PM, the RNS stated that there was no incident report, root cause analysis, IDT meeting or update to the plan of care for Fall 4. The RNS stated, "We should have done this and we did not." During an interview with a Licensed Vocational Nurse (LVN 1) on June 27, 2018 at 2:21 PM, LVN 1 stated she had witnessed Resident A's Fall 5. LVN 1 stated she was down by the nurse's station and Resident A was down the hall by room 19 or 20. Resident A was walking away from LVN 1 with her walker and Resident A was using her walker appropriately. LVN 1 stated Resident A stopped walking suddenly and then went straight backwards still holding onto her walker. LVN 1 stated that there was no crumble to the floor it was just stiff and flat backwards. LVN 1 stated there was no attempt by Resident A to brace or catch her fall. LVN 1 stated she ran down to Resident A and took her walker off of her and waved her hand over Resident A's face. LVN 1 stated, "Her eyes were open and there was no response, no blinking, she was breathing." LVN 1 stated she called 911 and then sat with Resident A until they arrived. LVN 1 stated she did not document any interventions to Resident A's care plan other than to send her to the hospital. A review of the general acute care hospital's, "History and Physical," dated May 1, 2018, indicated the following interventions were taken for Resident A: a. Intubation and mechanical ventilation (breathing tube in place and hooked up to a breathing machine), not following commands b. CT (computed tomography) scan (an x-ray of the head and brain), indicated the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 11 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 "Acute [immediate] left subdural [under a brain membrane, left side] hemorrhage [bleeding] measuring 17 mm [millimeters-size of area filled with blood] thick. Acute parenchymal [functional brain tissue] hemorrhage bordering along the right aspect [side] corpus callosum [nerves joining the two sides of the brain] measuring 8.5 x 3.6 x 2.0 cm [centimeters-size or area filled with blood]. Mild intraventricular [within the ventricles of the brain] hemorrhage. A 17 mm rightward midline shift. [the brain is pushed to the right due to the pressure from the bleeding]." A review of Resident A's "Event Investigation Record," dated May 2, 2018, for Fall 5 indicated, "Conduct a ROOT CAUSE ANALYSIS [a systematic process for identifying "root causes" of problems or events and an approach for responding to them]. What factor (s) caused or contributed to this incident/accident? "History of multiple falls, chronic microvascular ischemic disease (damage to the small blood vessels of the brain), cataracts (clouding of the lenses of the eye), glaucoma (increased pressure within the eyeball), dementia, anterograde amnesia (inability to recall the recent past), chooses independence over safety, web toes bilateral feet." During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on June 27, 2018 at 4:03 PM, the RNS stated that the root cause analysis was a process to understand why the resident fell so the IDT could review the reasons and come up with interventions to prevent future falls. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 12 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 RNS stated the root cause analysis conducted after the fall did not adequately identify reasons why Resident A fell, as it did not take into account the fall the same day at 6:00 AM with a head injury or that the resident did not appear to trip or crumble to the ground. Resident A instead went stiff and fell straight backwards still clutching her walker. The RNS stated that "choosing independence over safety" does not fit this picture so, the root-cause analysis was not conducted in a way to be effective. A review of the facility's policy and procedure titled, "Fall Management Program," dated 2013, indicated the following: "Purpose: This policy is intended to: (1) Explain how the facility will assess residents for fall risk and intervene to reduce falls; and (2) Describe procedures in the event of a resident fall. Policy: ...A proactive interdisciplinary team approach will be maintained in an effort to reduce the number and severity of falls...Residents will be assessed for fall risk factors after a fall occurs and at least quarterly. Individualized care plans will be developed and updated as needed to address risk factors for falls. The interdisciplinary team will review all fall reports and will recommend interventions to help reduce future falls. Procedure: The plan of care should provide individualized interventions specific to the resident's fall risk factors. Post-Fall Documentation: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 13 of 14 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: _______________ 555772 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JOSHUA TREE POST ACUTE 8515 Cholla Ave Yucca Valley, CA 92284 (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 Update the care plan after each fall as needed. Interdisciplinary Fall Review: Members of the IDT will review fall reports, review contributing risk factors, and investigate as needed to assist in revising the plan of care to reduce the risk of future falls." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T7X111 Facility ID: CA240000252 If continuation sheet 14 of 14