Other·July 3, 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 a recertification survey conducted April 30, 2018 through May 7, 2018. Representing the California Department of Public Health: 26825 34661 38215 38249 Census: 92 Sample: 27 An Immediate Jeopardy (IJ - a situation with the potential to harm the health and safety of 52 residents) was called under 483.12, Freedom from abuse, neglect, and exploitation (refer to F600 Free from Abuse and Neglect) on May 2, 2018 at 5:10 PM in the presence of the Administrator and Director of Nursing (DON). The Administrator and the DON were verbally notified of the IJ situation identified based on the facility's failure to ensure residents were free from verbal abuse. The corrective action plan was reviewed and accepted on May 2, 2018 at 8:53 PM, in the presence of the Administrator and DON. The IJ was lifted on May 2, 2018 at 9:10 PM in the presence of the Administrator and Director of Nurses in the Administrator office. The facility had four FRIs (Facility Reported Incident) that were investigated as follows: 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: LK4211 Facility ID: CA240000682 If continuation sheet 1 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 1. CA00582884 - Substantiated with no regulatory violations. 2. CA00585860 - Substantiated with no regulatory violations. 3. CA00585849 - Substantiated with no regulatory violations 4. CA00585857 - Unsubstantiated

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 05/22/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 2 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: 4. During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, "Every time FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 3 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated, "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 4 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with SWA 1, on May 4, 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 5 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled, "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 6 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 7 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs." Based on observation, interview, and record review, the facility failed to ensure for four of 27 sampled residents (Resident's 263, 265, 56 and 211) were treated with dignity and respect when the following occurred: 1. Resident 263 felt she was forced by staff to change her room after her roommate acted in an aggressive manner with her. 2. Resident 265 was placed in physical restraints when she could ambulate freely and without consent. 3. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 4. Resident 211 was subjected to verbal abuse by his physician. These failures had the potential to cause embarrassment, shame and affect the psychosocial wellbeing of the residents. Findings: 1. During an observation, and interview of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 8 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Resident 263 on April 30, 2018, at 8:30 AM, Resident 263 was in a bariatric bed (specialized size for obese patients) with a low air loss mattress (used in the prevention, treatment, and management of pressure ulcers that uses air bladders that use alternating pressure throughout the mattress), and overhead trapeze (a device that is located at the head of the bed, that assists resident reposition themselves in bed). Resident 263 was using a nasal cannula (a device used to deliver supplemental or increased airflow to a patient attached to an oxygen concentrator {device that concentrates oxygen from a gas supply to provide a supply of enriched oxygen.}) On either side of the bed was a wound vacuum system (used for wound therapy for pressure ulcers to promote healing), a suction machine (an instrument that uses suction to remove mucus from the airway) and nebulizer (a machine that produces a fine spray to inhale a medication). Resident 263 stated, "I have only been here for a couple of days and the staff is doing well, and she is happy with her care. Resident 263 further states that her roommate, who requires a sitter (someone assigned to sit with a resident one to one {1:1}, 24 hours a day." A clinical review of Resident 263's medical records, indicates Resident 263 was admitted to the facility on April 27, 2018, with diagnoses which included wound care for Stage 4 pressure ulcer (serious loss of skin, fat, muscle, and bone), wound sepsis (infection of a wound), urosepsis (infection being spread throughout the blood), congestive heart failure (CHF - the heart is unable to maintain an adequate circulation of the blood to the body), and paraplegia (paralysis of the legs and lower body). Resident 263 has capacity to make her own decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 9 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a review of Resident 263's "Resident Notification of Room Change", dated May 4, 2018, indicates "Reason for room change: Resident not getting along with roommate." The comments section of the document indicated "Urgent!' During a review of Resident's 263 "Nurses Notes" dated May 4, 2018, do not indicate that any altercations occurred between Resident's 263 and 264. "Nurses Notes" in the clinical record for Resident 264 dated May 4, 2018, at 2:30 AM, indicated "Aide brought to nurses attention that Resident 264 got out of bed acting aggressive with Resident 263 demanding that Resident 263 turn off the TV because it was too loud. Upon assessment the TV was at a low volume. Resident 264 currently has a sitter at the bedside and being monitored. Social Services (SS) will be notified early morning to consider a room change. There is no indication that the other Residents safety is an issue at this hour." During a review of "Nurses Notes" for May 4, 2018, at 2:30 PM, indicated, "Was reported to SS that Resident 263 would like to speak with us about her roommate. Resident reported to me that she was scared for her safety. Resident 263 said she wanted the resident in bed B to be moved out. I spoke to the resident in bed B about the issue and she absolutely refused to be moved. Resident 263 reported to me that the resident in bed B comes at her in the night with her hands up as if she is going to choke her, she calls her a pig and uses other profanities with her. When the resident in bed B refused, I spoke some more to Resident 263 to see if she wanted to move and she refused as well. I reported this to the Administrator (ADM) and Charge Nurse (CN), the CN spoke with bed A, who agreed to move. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 10 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a review of Resident 263's "Nurses Notes" dated May 4, 2018 at 2:40 PM, indicates, the certified nursing assistant (CNA) reported to nurse that patient and her roommate were arguing. SS notified, ADM notified, SS offered room change immediately. Patient declined. While SS was interviewing patient she voiced concerns that she felt unsafe with neighbor, that her neighbor was going to physically hurt her. SS continued to offer room change, monitor resident's behaviors." A nurses note written at 3:00 PM, indicates that patient to have room change at this time, husband notified. A review of Resident 264's medical record, indicated that Resident 264 was admitted to the facility on April 24, 2018, with diagnoses that included dementia (a group of thinking and social symptoms that affect memory, interferes with memory, judgement and impaired reasoning), violent anti-social behavior (disruptive acts characterized by covert and overt hostility and intentional aggression toward others). During a review of "Nurses Notes", dated May 4, 2018, at 2:30 PM, indicated, "CNA reported to nurse that patient was not getting along with roommate, SS notified, ADM notified, SS offered Resident 263 a room change immediately. Pt denied room change, states I am not moving all my stuff is here. I refuse to move all my stuff, she can move. Staff will continue to monitor." During a review of "Nurses Notes", dated May 4, 2018, at 7:00 PM, indicated "Resident roommate 263 changed rooms will continue to monitor resident behavior." During an interview and concurrent record review on May 7, 2018, at 12:00 PM with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 11 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Director of Nurses (DON), the DON reviewed the nursing notes, and stated "Why would the staff continue to go to Resident 263 regarding the room change when it clearly was the roommate who was the issue." Resident 263 had complained and was fearful, that her roommate got up at night, and made gestures towards her, called her names. I would also look at the medical conditions of both residents before making a room change, clearly Resident 263 had the largest amounts of items and medical equipment to move. The DON states "It appears that after so many times of the staff asking her to change rooms, she just gave into them. If she didn't want to move, she should not have been moved. The Interdisciplinary Team (IDT) should have gotten together and discussed the situation and called the Responsible Party (RP- make medical decisions for those who are deemed not to have capacity, regarding changing rooms for bed B." During an interview with Resident 263 on May 7, 2018, at 2:00 PM, Resident 263 states, "Her roommate pulled back the privacy curtain early in the morning a couple of days ago and frightened me, she was yelling and had her hands up like she was going to come and choke me. This was not the first time that she had done something like this. She was always yelling through the curtain calling me names since she became my roommate." Resident 263 further states that the placement of B bed was not a good fit, she has dementia, and she has to have a 1:1 sitter. The sitter did nothing when Resident 264 yelled at me or pulled the curtains and made aggressive movements towards me. She was very angry, seems as though she thought I was interrupting her routine and was a bother. Interview with Resident 263 continued, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 12 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 said "I told all the different staff members who came to me over and over, that I did not want to move. After a while of them just coming back at me, I didn't want to move, but they were not doing anything else to assist me with the situation. I was frustrated and crying and they made me feel as if I was the one who had done something wrong. So I finally gave into them, I don't know why they would have wanted to move me, just look around at all the medical equipment that comes with me, and she had nothing. Now I am in this room and my roommates stuff is all over the place, it's messy and there are dead plants and jars of water. I don't know what's in here, but I have had a runny nose and have been sneezing since I have been in here." During an interview and concurrent record review on May 7, 2018, at 4:00 PM, with the ADM, he stated that they were not getting along so we offered a room change and Resident 263 agreed to move.The ADM stated that he had not read the residents chart notes or interviewed the residents prior to Resident 263 being moved. He stated he was not aware that Resident 263 was in fear, her roommate had been the aggressor, and called her names. The ADM confirmed that the policy and procedure for room changes and the patients' bill of rights was not followed for Resident 263 given this information. The owner of the facility was present during the interview and stated, " No matter what the issue, the best answer is that Bed A should not have been moved." The facility policy and procedure entitled, "Change in Room or Roommate", dated November 2013, "Policy indicated, ... Reasonable accommodations of individual needs and preferences, and in a manner that avoids a decline in physical, mental, or psychosocial well-being." Procedure "1. When FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 13 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 making a change of a room or roommate, the resident and his/her needs and preferences will be considered and, insofar as practical, will be the determining factor when such changes are made ...." 2. During an observation of Resident 265 on April 30, 2018, at 9:00 AM, the resident was located in her room asleep on top of a mattress on the floor. During an interview with Certified Nurse's Assistant 5 (CNA 5) on April 30, 2018, at 9:02 AM, CNA 5 stated that she heard Resident 265 say that she did not feel that she deserved a bed and preferred to lay on the ground. During an observation of Resident 265 on April 30, 2018 at 1:20 PM, Resident 265 was seen walking, she was up and dressed in a robe with a CNA 5 following closely behind her. CNA 5 assisted Resident 265 to her room, where she jumped onto the floor and stated that she was going to take a nap. Once the resident lay on the mattress, the CNA left the room. During a review of Resident 265's medical record, face sheet indicated, Resident 265 was admitted to the facility on April 25, 2018, with diagnoses that included, anxiety (feeling of worry, nervousness, or unease) and dementia (loss of memory and impaired judgement). During a review of the admission "Physician's Orders" dated April 25, 2018, did not indicate Resident 265 had an order for the mattress to be on the floor. Resident 265 had an order to provide a 1:1 sitter, and to monitor the resident for agitation. During an observation of Resident 265 on April 30, 2018, at 4:30 PM, she was dressed laying on top of her mattress on the floor. No sitter FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 14 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 was present. During a review of the facility's "Admission Assessments", dated, April 26, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", the facility identified Resident 265 to be a safety risk for combativeness. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. Adequate monitoring based on the residents condition; 4. Meds as ordered. A further review of the "Admission Assessment", dated, April 27, 2018, section entitled "Actual / Potential Concern" Elopement was identified as a potential concern. The goal indicated that "Resident will remain safely within the facility." The following interventions were listed "Shadow Checks (staff monitoring resident) every 30 minutes, and monitor all exits." During an observation on May 1, 2018, at 7:50 AM, Resident 265 was not located in the room, and no personal items were present. During an observation on May 1, 2018, at 11:30 AM, Resident 265 was in a high bed, with a full bolster mattress (A mattress with firm arms and legs side which inhibits a resident's freedom of movement.) The resident had been moved to another room, right next to an exit door. No,1:1 sitter was present. During an interview, and concurrent record review of the physician's orders with the Registered Nurse Supervisor 3 (RNS) on May 2, 2018, at 12:10 PM, RNS 3 confirmed that there was no physician order for the use of the bolster mattress restraint. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 15 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 RNS 3 on May 2, 2018, at 12:15 PM, a review of all "Nursing Notes" dated April 25, 2018 through May 2, 2018, did not indicate that Resident 265's physician was notified regarding behaviors other than refusal of medication and taking vital signs. The remaining portions of the clinical record was reviewed with RNS 3. RNS 3 confirmed there was no assessment completed to determine if the resident required physical restraints, no interdisciplinary team meeting was held, no consent was obtained from Resident 265's family. RNS 3 also confirmed there was no physicians order for the use of physical restraints with the resident. During the review of the clinical record, RNS 3 states she could not locate any documentation to indicate that the facility policy and procedures were followed prior to Resident 265 being placed into physical restraints. During the interview and concurrent record review with RNS 3 on May 2, 2018, at 12:25 PM, RNS 3 stated Resident 265 on initial assessment was classified as a wanderer. RNS 3 confirmed Resident 265 was walking without any assistive devices (example cane, walker). During an observation on May 1, 2018 at 6:20 PM, Resident 265 was observed in the hallway walking toward the nursing station. Resident 265 was heard saying "I'm hungry can I get a cup of coffee". A CNA approached her and assisted her towards the cart that contained coffee and then back to her room. No sitter present. During an observation on May 2, 2018, at 10:45 AM, Resident 265 was seen naked and attempting to go out of the exit door located right next to her room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 16 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a review of Resident 265's care plans, no care plans were created for the identified concern of elopement, or for the use of restraints. During an interview and concurrent record review with the Director of Nurses (DON), on May 3, 2018, at 1:30 PM. The DON explained the facility's policy on the use of restraints in the facility. The DON stated the interdisciplinary group should have been held to assess the risks and benefits of the restraints. She further stated that a physician's order and consent should have been obtained prior to the use and a care plan should have been developed. The DON confirmed that Resident 265 was ambulatory and with the use of the physical restraint, the resident could be put in harm's way if she attempted to get out of bed. The DON confirmed that all the facility procedures were not followed prior to the use of physical restraints. The use of a Bolster mattress would be considered a physical restraint. She also confirmed that the use of this type of restraint without any documentation for use, and the issue of having her bed on the floor would diminish Resident 265 dignity. The facility policy and procedure entitled, "Restraints", dated October 2017, indicates, "It is the policy of this facility to not use physical restrain for convenience or discipline and not required to treat a resident's medical condition." Procedure indicates, "1. Assess resident's need for restrain use and document the assessment; 2. Obtain physician's order for restraint and verify informed consent. Restraints may not be applied until the physician has obtained informed consent and the facility has verified such consent (absent emergencies as to the immediate health and safety danger to a resident or other residents but this must be clearly documented); 3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 17 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Develop a plan of care for type of restraint, reason for use, and method of application." During a review of the facility's "Resident Bill of Rights" undated, indicates, "6. To be encouraged and assisted throughout the period of stay to exercise his or her rights as a resident and as a citizen. The resident may voice grievances and recommend changes in policy and services to the facility staff and/or outside representative of the resident's choice, free from restraints, interference, coercion, discrimination or reprisal" "8. To be free from mental abuse and from chemical and physical restraints, except in the following circumstance: a. When authorized in writing by a physician for a specific period of time." " 10. To be treated with consideration, respect, dignity and individuality ..." 3. During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated, "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was being disruptive to the rest of the staff and the other Residents and I needed to leave." Resident 56 further stated that "there were two other staff who saw what happened." As the interview continued, Resident 56 continued to say over and over, "Why can't I eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..." Resident 56 stated, "I said something to CNA 2 who was sitting next to me that was nice that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 18 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 [Name] got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job." Resident 56 stated, "The RNA walked out of the dining room and everything was quiet for a while. Then the RNA returned and started yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, "What did I do wrong? What did I do wrong? " Resident 56 further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated, " I felt as if I was being treated like a child who was being scolded and disrespected." A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 19 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (paralysis of the legs and lower body, typically caused by spinal injury or disease), diabetes mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated Resident 56 "was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. " The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart). The RNA stated, "He got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD." I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Resident 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, "The resident came in to talk with me and we talked about the dining room rules and that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 20 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 at me not to talk to Resident 56 about personnel issues. She further stated, "The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on." I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on May 3, 2018, at 11:30 AM with the Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in and separated them and told the RNA to go talk to her supervisor." I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, "From what I saw the resident was not being disruptive." When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident to anyone. During an interview on May 3, 2018, at 11:45 AM with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM with Resident 56, the Resident stated "What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident was observed to be anxious and fidgeting in his bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 21 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with the privacy curtain pulled, and sitting in the dark. Resident 56 continues, "I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded." He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me. During an interview on May 3, 2018, 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated, I'm glad you came to me when you did, Resident 56 is "very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further stated, Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit in. A review of the PhD note dated May 3, 2018, indicted "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personnel business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the incident. During a review of "Care Plans" Resident 56 is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 22 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 care planned for anxiety and depression. The last review of the care plan was March 3, 2018, with no changes noted. During an interview on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, "he is easy to get along with, is very independent in his care." CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write "the resident was counseled on appropriate behavior". The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated "The incident yesterday (May 3, 2018) was not reported to me. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 23 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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

F578 Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/22/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 24 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 60) desire for physician orders for life sustaining treatment (POLST) were reviewed, signed and dated by a physician. This failure has the potential for the resident's wishes not to be honored during a medical emergency. Findings: During an observation on April 30, 2018, at 1:57 PM, Resident 60 walked around the hallways in the facility. A review of the clinical record for Resident 60, the history and physical dated September 7, 2017 indicated diagnoses of: traumatic brain injury (an injury to the brain), epilepsy (a medical condition causing seizures), and dementia (impairment of memory and judgement). During a review of the clinical record for Resident 60, medical records dated May 19, 2016, indicated Resident 60 was admitted to the facility on May 19, 2016. Resident 60 was his own responsible representative and had the capacity to make decisions. A review of the clinical record for Resident 60, the physician orders dated May 1, 2018 indicated "full code, full treatment." During a review of the clinical record on May 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 25 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 2018, the Physician Orders for Life-Sustaining Treatment (POLST) form was not dated when the form was prepared. The physician did not complete his portion which requires his name, his phone number, his license number, his signature and the date. During an interview on May 1, 2018, at 8:17 AM, the Medical Records staff stated the POLST found in the clinical record was not valid and should have been completed by the nurse at admission. During an interview on May 2, 2018 at 11:27 AM, Resident 60 stated he wanted cardiopulmonary resuscitation (CPR) to be done. During an interview on May 3, 2018, at 10:28 AM, the DON acknowledged the POLST was missing the date, the physician never signed or filled out the form, and that a date should be near Resident 60's signature. The DON stated the form should have indicated self - under relationship to the resident and the blank areas were not filled out. The DON stated this was not a valid POLST and should not have been put in chart. It is incomplete. The facility policy and procedure titled, "Advance Directives," dated November 2016 indicated, "A physician, NP [nurse practitioner] or PA [physician assistant] signature is required on the POLST form."

F600 SS=L Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 05/10/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 26 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow their policy on investigating and reporting to the California Department of Public Health (CDPH) an unusual occurrence when: 1. The facility failed to ensure Resident 211 to be safe and free from verbal abuse when the physician yelled at Resident 211, "You are acting like an idiot". 2. Resident 2 was witnessed by the facility staff to be physically hit multiple times by a family member. These failures had the potential for these two residents to be subjected to further types of abuse in a universe of 92 residents. Findings: During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 27 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 28 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 29 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 30 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 31 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs." The facility failed to ensure Resident 211 to be free from verbal abuse that resulted in feelings of fear, shame, degradation, and helplessness. The facility failed to identify verbal abuse, monitor and evaluate Resident 211. The facility failed to report verbal abuse. The facility failed to follow the facility policy and procedure 2. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. A review of the clinical record of Resident 2 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 32 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. In an interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM, she stated that Resident 2 had a prearranged doctor's appointment that day. Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. In an interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. The DSS stated that Adult Protective Services (APS) and police were not notified of the incident. In an interview with the Administrator on May 2, 2018 at 3:00 PM, he stated, "He was not able to report the unusual occurrence to California Department of Public Health." The facility failed to report, investigate and protect Resident 2 from further abuse. The Facility's policy and procedures titled "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 33 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 reports of resident abuse, mistreatment, neglect, or injuries of an unknown source ... I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..." An Immediate Jeopardy (I J) - [A situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment or death to a resident] was called on May 2, 2018 at 5:30 PM, in the presence of the Administrator and the Director of Nursing. The facility's corrective plan of action stated as follows: " Administrator, or designee, will ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state regulations. Resident accepted different following physician and physician involved will be in-serviced on abuse intervention and prevention. Resident 2 will only have supervised visits with her Mother Administrator, or designee, will interview all current Residents to rule out suspected abuse. The same tool used to interview all residents will be integrated into facilities daily (Mon.-Fri.) room rounds and reported during the daily (Mon.-Fri.) stand up meetings. Director of staff development (DSD) will inservice all staff and contracted staff, upon hire FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 34 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 and annually/as needed on abuse intervention and prevention. Information for reporting will be made more readily available throughout the facility. All new hired employees will continue to be background checked per policy and procedure (P&P). Administrator, or designee, will meet with residents Bi-monthly to ensure that the interview tool being used by management staff during morning rounds is effective. The IJ was lifted on May 2, 2018 at 9:15 PM, in the presence of the Administrator and the Director of NursingBased on observation, interviews, and record review, the facility failed to ensure that one of 92 residents (Resident 56) was free from mental abuse and retaliation. These failures had the potential to further jeopardize the health, safety and welfare of Resident 56. Findings: During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was being disruptive to the rest of the staff and the other Residents and I needed to leave." Resident 56 further stated that there were two other staff who saw what happened." As the interview continued, Resident 56 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 35 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 continued to say over and over, "Why can't I eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..." Resident 56 stated, I said something to CNA 2 who was sitting next to me that was nice that [Name] got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, "That the RNA walked out of the dining room and everything was quiet for a while. Then the RNA returned and started yelling even more, she told me to quit talking to the staff." Resident 56 stated over and over, "What did I do wrong? What did I do wrong? " Resident 56 further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated, " I felt as if I was being treated like a child who was being scolded and disrespected." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 36 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), diabetes mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated Resident 56 was "gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. " The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart). The RNA stated, "He got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD." I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Resident 56 was "being disruptive in the dining room and talking to staff and gossiping." She stated, "The resident came in to talk with me and we talked about the dining room rules and that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, I was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 37 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, "The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on." I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on May 3, 2018, at 11:30 AM with the Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in and separated them and told the RNA to go talk to her supervisor." I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, "From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling" and the pitch of her voice was rising, then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident to anyone. During an interview on May 3, 2018, at 11:45 AM with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM with Resident 56, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 38 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Resident stated "What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident was observed to be anxious and fidgeting in his bed with the privacy curtain pulled, and sitting in the dark. Resident 56 continues, "I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded." He further went on to say that he "overheard staff members talking saying that I'm nothing but a trouble maker" after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me. During an interview on May 3, 2018, 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is" very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further stated, Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit in. A review of the PhD note dated May 3, 2018, indicted "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personnel business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 39 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the incident. During a review of "Care Plans" Resident 56 is care planned for anxiety and depression. The last review of the care plan was March 3, 2018, with no changes noted. During an interview on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write "the resident was counseled on appropriate behavior". The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated." The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated "The incident yesterday (May 3, 2018) was not reported to me." The DON confirmed that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 40 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. A review of the facility policy and procedure entitled, "Abuse Prevention and Prohibition Program", undated, indicates "Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements." "Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. An immediate Jeopardy (IJ, a situation that has threatened or is likely to threaten the health and safety of clients) was called for the following: An IJ was called under 483.12 (a) (1) Free from Abuse and Neglect, on May 3, 2018, at 5:30 PM in the presence of the Administrator and the Director of Nurses. The facility failed to ensure that one resident (Resident 56) was not subjected to ongoing verbal, and mental abuse and retaliation. (Refer to F 600) The facility submitted an acceptable corrective action plan on May 3, 2018, 9:30 PM in the presence of the Administrator and the Director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 41 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 of Nursing, with the IJ to remain in place. The corrective action plan included: 1. Staff member involved with psychosocial abuse on 05.03.18 at approximately 8:30 AM was suspended immediately upon management's awareness, pending investigation. 2. LVN Charge Nurse that incident was witnessed by and not reported properly per facilities Abuse P & P, was also suspended pending investigation. 3. Director of Nurses, or designee, (Social Services) to monitor (per shift) resident involved in incident for any negative impact to psychosocial well-being for 72 hrs. 4. Director of Staff Development (DSD) to inservice all available staff immediately on mandated reporting, respect & dignity, proper communication with residents, resident's rights and self-determination and all other areas of abuse. Staff not following proper reporting protocols per facilities Abuse Prevention P&P, will be reported to the appropriate CNA, LVN, and RN boards. The NOC shift will be inserviced by DSD, or designee, on 05.03.18 before starting their shift. The day shift on 05.04.18 will be in-serviced by the DSD, or designee, before starting their shift. This process will be repeated per shift until 100% compliance is achieved. 5. Social Services Department will lead out with monitoring resident's psychosocial needs through routine interaction with residents weekly. 6. DSD will in-service and role play with all available staff regarding "Understanding Challenging Behaviors" to properly address FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 42 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 resident causes of behavior, procedures for responding to the behavior, and tips how to respond to challenging behaviors. In addition, all staff will be reminded of the Professional Culture of Nursing Services that we all have the privilege to work in. The NOC shift will be inserviced by DSD, or designee, on 05.05.18 before starting their shift. The day shift and PM shift were in-serviced on 05.05.18. This process will be repeated per shift until 100% compliance is achieved. During an observation and interview on May 5, 2018 at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating "There was another incident last night" (May 4, 2018) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated, "I feel that my previous complaint to the state had backfired on me." He stated, It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it." Resident 56 further stated, LVN 5 "approached him and was verbally chastising him," he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on May 5, 2018, at 2:00 PM, LVN 5 stated, I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM). The ADM sent a text which stated "They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere." LVN 5 stated that when she talked to Resident 56 about this, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 43 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 talked to him in a nice way as she explained the text to the resident, but that Resident 56 was "defensive, angry and felt he was being harassed." A review of the "Nurses Notes" indicated, Resident 56 was being monitored as per the "Corrected Action Plan" for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on May 4, 2018. A review of Resident 56's "Short Term Care Plan" entitled 'Risk of psychological distress after verbal altercation with staff members" was initiated on May 5, 2018, two days after the IJ was called. A review of the "Investigation Report" for the allegation of abuse indicates "I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on May 4, 2018. According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on May 5, 2018 and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to "hang in there" for me and to personally contact me if any further issues. LVN was suspended pending investigation." The facility did not provide evidence to show FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 44 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 the implementation of the Corrective Action Plan was put in place. On May 7, 2018, at 5:00 PM an exit conference was held. The facility management was verbally notified that the Immediate Jeopardy would not be lifted, due to sub-standard quality of care and the facility was being placed on a 23 day Fast Track.

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 05/22/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 45 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed ensure for one of 27 sampled Residents (Resident 265) was free from unnecessary physical restraints. This failure had to potential to jeopardize Resident 265's health, safety and well-being and maintain her right to be treated with respect and dignity. Findings: During an observation of Resident 265 on April 30, 2018, at 9:00 AM, the resident was located in her room asleep on top of a mattress on the floor. During an interview with Certified Nurse's Assistant 5 (CNA) on April 30, 2018, at 9:02 AM, she indicated that she heard that the resident did not feel that she deserved a bed and preferred to lay on the ground. During an observation of Resident 265 on April 30, 2018 at 1:20 PM, Resident 265 was seen ambulating, she was up and dressed in a robe with a CNA 5 Following closely behind her. Resident 265 appeared to be pulling at her diapers. The CNA 5 assisted the resident to her room, where she jumped onto the floor and stated that she was going to take a nap. Once the resident lay on the mattress, the CNA left the room. During a review of Resident 265's face sheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 46 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (document that contains demographics and medical information) indicated, Resident 265 was admitted to the facility on April 25, 2018, with diagnoses that included, anxiety (feeling of worry, nervousness, or unease) and dementia. During a review of the admission "Physician's Orders" dated April 25, 2018, did not indicate that the resident had an order for a mattress to be on the floor. The resident had an order to provide a 1:1 sitter, and to monitor the resident for agitation. A review of Resident 265's "Telephone Orders", did not indicate that the resident was to have a mattress on the floor. During an observation of Resident 265 on April 30, at 4:30 PM, she was dressed laying on top of her mattress on the floor, no sitter was present. During a review of the facility's "Admission Assessments" dated April 26, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", the facility identified Resident 265 to be a safety risk for combativeness. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Meds as ordered. A further review of the "Admission Assessment" dated April 27, 2018, section entitled "Actual / Potential Concern" Elopement was identified as a potential concern. The goal indicated that "Resident will remain safely within the facility." The following interventions were listed "Shadow Checks every 30 minutes, and monitor all exits." During an observation on April 30, 2018, at 4:30 PM, Resident 265 was dressed, coved FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 47 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with blankets on top of her mattress on the floor, there was no sitter present. During an observation on May 1, 2018, at 7:50 AM, Resident 265 was not located in the room, and no personal items were present. During an observation on May 1, 2018, at 11:30 AM, Resident 265 was in a high bed, with a full bolster mattress (A mattress with firm arms and legs side which inhibits a resident's freedom of movement.) The resident had been moved to another room, right next to an exit door, no 1:1 sitter was present. During an interview, and concurrent record review of the physician's orders with the Registered Nurse Supervisor 3 (RNS) on May 2, 2018, at 12:10 PM, the RNS 3 confirmed that there was no physician order for the use of the bolster mattress restraint. During an interview, and concurrent record review with RNS 3 on May 2, 2018, at 12:15 PM, a review of all "Nursing Notes" dated April 25, 2017 through May 2, 2018, did not indicate that Resident 265's physician was notified regarding behaviors other than refusal of medication and taking vital signs. The clinical record was reviewed with RNS 3, RNS 3 confirmed that there was no assessment completed to determine if the resident required physical restraints; no interdisciplinary team meeting was held, no consent was obtained from Resident 265's family. RNS 3 also confirmed there was no physicians order for the use of physical restraints with the resident. During the review of the clinical record, RNS 3 stated she could not locate any documentation to indicate that the facility policy and procedures were followed prior to Resident 265 being placed into physical restraints. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 48 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 the interview and concurrent record review with RNS 3 on May 2, 2018, at 12:25 PM, RNS 3 stated Resident 265 on initial assessment was classified as a wanderer. RNS 3 confirmed Resident 265 was ambulatory without any assistive devices. During an observation on May 1, 2018 at 6:20 PM, Resident 265 was observed in the hallway walking toward the nursing station. Resident 265 was heard saying "I'm hungry can I get a cup of coffee". A CNA approached her and assisted her toward the cart that contained coffee and then back to her room. During an observation on May 2, 2018, at 10:45 AM, Resident 265 was seen, naked and attempting to go out of the exit out the door located right next to her room. During a review of Resident 265's care plans, no care plans were created for the identified concern of elopement, or for the use of restraints. During an observation on May 2, 2018, at 5:00 PM, Resident 265's bed was stripped down to the mattress. During an interview on May 2, 2018, at 5:10 with RNS 1, RNS 1 indicated that Resident 265 had been transferred to another facility. During a review of the physicians orders dated May 2, 2018 at 4:06 PM indicated "PT [patient] to dc to [facility name] with medications. During an interview and concurrent record review with the Director of Nurses (DON) on May 3, 2018, at 13:30 AM. The DON explained the facility policy on the use of any restraints in the facility. The DON stated the interdisciplinary group should have been held to assess the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 49 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 risks and benefits of the restraints, she further stated that a physician's order and consent should have be obtained prior to use and that a care plan should have been developed. The DON confirmed that Resident 265 was ambulatory and with the use of the physical restraint, the resident could be put in harm's way she attempted to get out of bed. The DON confirmed that all the above procedures were not taken prior to using physical restraints and that the use of a Bolster mattress in the record that was used, would be considered a physical restraint. She also confirmed that the use of this type of restraint without any documentation for use, and the issue of having her bed on the floor would diminish the Resident's dignity. The facility policy and procedure entitled "Restraints" dated October 2017, indicates "It is the policy of this facility to not use physical restrain for convenience or discipline and not required to treat a resident's medical condition." Procedure indicates "1. Assess resident's need for restrain use and document the assessment; 2. Obtain physician's order for restraint and verify informed consent. Restraints may not be applied until the physician has obtained informed consent and the facility has verified such consent (absent emergencies as to the immediate health and safety danger to a resident or other residents but this must be clearly documented); 3. Develop a plan of care for type of restraint, reason for use, and method of application."

F607 SS=F Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 05/11/2018 §483.12(b) The facility must develop and implement written policies and procedures that: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 50 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure implementation of abuse policies and procedures for three of 27 sampled residents (Resident 211, Resident 56, and Resident 2) in a universe of 92 residents when: 1. The facility failed to report verbal abuse of the physician to Resident 211; 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. The family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted in physical and mental abuse of the residents. Findings: During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 51 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 52 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 53 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job Descriptions-Social Service Designee", FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 54 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 55 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs." During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported.2. During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 56 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 that I was being disruptive to the rest of the staff and the other Residents and I needed to leave." Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, "Why can't I eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..."Resident 56 stated "I said something to CNA 2 who was sitting next to me that wasn't in nice that [Name] got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, "That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff." Resident 56 stated over and over, "What did I do wrong? What did I do wrong?" Resident further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 57 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated "felt as if he was being treated like a child who was being scolded and disrespected." A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), diabetes mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated Resident 56 was "gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members." The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated, "That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD." I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated, the RNA came into tell me that Res 56 was "being disruptive in the dining room and talking to staff and gossiping." She stated, "The resident came in to talk with me and we talked about the dining room rules that he can eat in either FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 58 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, "The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on." I was assisting my resident and listening to Resident 56. The RNA should never have done that, "she should have handled the situation better." During an interview on May 3, 2018, at 11:30 AM with Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor." I talked to Resident 56 and told him that "he should talk to the Administrator or a state surveyor if he had any other issues." The CN further stated, "From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising", of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that "he could not eat in the dining room" and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on May 3, 2018, at 11:45 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 59 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM with Resident 56, the Resident stated "What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, "I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded." He further went on to say that he overheard staff members talking saying that "I'm nothing but a trouble maker" after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me. During an interview on May 3, 2018, 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is "very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated May 3, 2018, indicated "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 60 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the incident. During a review of "Care Plans" Resident 56 is care planned for anxiety and depression. The last review of the care plan was March 3, 2018, with no changes noted. During an interview on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write "The resident was counseled on appropriate behavior". The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 61 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated "The incident yesterday (May 3, 2018) was not reported to me." The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. During an observation and interview on May 5, 2018 at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating "There was another incident last night" (May 4, 2018) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he "felt the staff were targeting him for his complaint to the state earlier," he appeared nervous and anxious about what was going to happen to him. Resident 56 stated "I feel that my previous complaint to the state had backfired on me." He stated "It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it." Resident 56 further stated LVN 5 approached him and was "verbally chastising him," he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on May 5, 2018, at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 62 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 which stated "They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere." LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed." During a review of the "Nurses Notes" indicated, Resident 56 was being monitored as per the "Corrected Action Plan" for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on May 4, 2018. A review of Resident 56's "Short Term Care Plan" entitled 'Risk of psychological distress after verbal altercation with staff members" was initiated on May 5, 2018, two days after the IJ was called. A review of the "Investigation Report" for the allegation of abuse indicates "I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on May 4, 2018. According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on May 5, 2018 and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 63 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 to "hang in there" for me and to personally contact me if any further issues. LVN was suspended pending investigation." A review of the facility policy and procedure entitled, "Abuse Prevention and Prohibition Program", undated, indicates "Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements." "Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. 3. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM, indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. A review of the clinical record of Resident 2 on April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 64 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on May 2, 2018 at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. During an interview with CNA 5 on May 4, 2018, at 11:30 AM, she stated that she witnessed the argument between Resident 2 and her mother. CNA 5 stated that she saw the mother hit Resident 2 on her lower extremities, abdomen, and the left side of her face. Resident 2 had a swollen wound on the left eyebrow and the wound bled after being hit by her mother on the left side of her face. The Facility's policy and procedures titled, "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source ... I, the Facility will report known or suspected instances of physical abuse, including sexual FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 65 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..."

F608 SS=F Reporting of Reasonable Suspicion of a Crime F608 CFR(s): 483.12(b)(5)(i)-(iii) 05/09/2018 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 66 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Act. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure identification and reporting of a suspicion of crime to appropriate agency for three of 27 sampled residents (Resident 211, Resident 56, and Resident 2) in a universe of 92 residents when: 1. The facility failed to report verbal abuse of the physician to Resident 211. 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. The family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted in physical and mental abuse of the residents. Findings: 1. During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 67 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated, "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 68 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 69 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported. A review of facility document titled, "Job Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 70 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 71 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs." 2. During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated, "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was and that I was being disruptive to the rest of the staff and the other residents and I needed to leave." Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, "Why can't I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 72 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..." Resident 56 stated, I said something to CNA 2 who was sitting next to me that wasn't in nice that [Name] got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, "That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and started yelling even more, she told me to quit talking to the staff." Resident 56 stated over and over, "What did I do wrong? What did I do wrong?" Resident further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated "felt as if he was being treated like a child who was being scolded and disrespected." A review of Resident 56's face sheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 73 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), diabetes mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated "That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD." I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, "The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 74 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, "The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on." I was assisting my resident and listening to Resident 56. The RNA should never have done that, "she should have handled the situation better." During an interview on May 3, 2018, at 11:30 AM with Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor." I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, "From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising," of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that "he could not eat in the dining room and talk about other people," she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on May 3, 2018, at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM with Resident 56, the Resident stated "What did I do wrong? I am so FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 75 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, "I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker" after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me.' During an interview on May 3, 2018, 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is "very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated May 3, 2018, indicted "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 76 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 incident. During a review of "Care Plans" Resident 56 is care planned for anxiety and depression. The last review of the care plan was March 3, 2018, with no changes noted. During an interview on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you wrote "The resident was counseled on appropriate behavior." The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated "The incident yesterday (May 3, 2018) was not reported to me." The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 77 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. During an observation and interview on May 5, 2018 at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating "There was another incident last night (May 4, 2018)" between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that "he felt the staff were targeting him"for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated "I feel that my previous complaint to the state had backfired on me." He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was "Verbally chastising him," he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on May 5, 2018, at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated, "They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere." LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was "defensive, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 78 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 angry and felt he was being harassed." During a review of the "Nurses Notes" indicated, Resident 56 was being monitored as per the "Corrected Action Plan" for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on May 4, 2018. A review of Resident 56's "Short Term Care Plan" entitled 'Risk of psychological distress after verbal altercation with staff members" was initiated on May 5, 2018, two days after the IJ was called. A review of the "Investigation Report" for the allegation of abuse indicates "I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on May 4, 2018. According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on May 5, 2018 and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to "hang in there" for me and to personally contact me if any further issues. LVN was suspended pending investigation." A review of the facility policy and procedure entitled, "Abuse Prevention and Prohibition Program", undated, indicates "Purpose: To FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 79 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements." "Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. 3. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. A review of the clinical record of Resident 2 on April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day. Resident 2's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 80 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on May 2, 2018 at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source ... I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..."

F609 SS=F Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 05/09/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 81 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow their policy on investigating and reporting to California Department of Public Health (CDPH) an unusual occurrence when: 1.The facility failed to report physical assault of Resident 2 by a family member. 2.The facility failed to report mental and verbal abuse of Resident 56. 3.The facility failed to report the physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 82 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 verbally abusing Resident 211. These failures had the potential for these three residents be subjected to further types of abuse in a universe of 92 residents. Findings: 1. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM, indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. A review of the clinical record of Resident 2 on April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day. Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 83 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on May 2, 2018 at 3:00 PM, he stated "I was not able to report the incident to California Department of Public Health." The Facility's policy and procedures titled "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source ... I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..." 2. During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated, "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was and that I was being disruptive to the rest of the staff and the other residents and I needed to leave." Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, "Why can't I eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..." Resident 56 stated, I said something to CNA 2 who was sitting next to me that wasn't in nice that [Name] got the promotion. CNA 2, said FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 84 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 something like yes and went back to feeding her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, "That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff." Resident 56 stated over and over, "What did I do wrong? What did I do wrong?" Resident further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated "felt as if he was being treated like a child who was being scolded and disrespected." A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia (paralysis of the legs and lower body, typically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 85 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 caused by spinal injury or disease), diabetes mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated, He got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated, the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping." She stated, "The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 86 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 personnel issues. She further stated, "The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on." I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better." During an interview on May 3, 2018, at 11:30 AM with Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor." I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, "From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising," of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that "he could not eat in the dining room and talk about other people," she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on May 3, 2018, at 11:45 AM, with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM with Resident 56, the Resident stated "What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 87 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Resident 56 continues, "I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me.' During an interview on May 3, 2018, 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is "very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further stated Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated May 3, 2018, indicted "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the incident. During a review of "Care Plans" Resident 56 is care planned for anxiety and depression. The last review of the care plan was March 3, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 88 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with no changes noted. During an interview on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write "the resident was counseled on appropriate behavior". The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated "The incident yesterday (May 3, 2018) was not reported to me." The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 89 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. During an observation and interview on May 5, 2018 at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating "There was another incident last night (May 4, 2018)" between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he "felt the staff were targeting him for his complaint to the state earlier", he appeared nervous and anxious about what was going to happen to him. Resident 56 stated, "I feel that my previous complaint to the state had backfired on me." He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was "verbally chastising him," he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff." During an interview on May 5, 2018, at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated "They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere." LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. During a review of the "Nurses Notes" indicated, Resident 56 was being monitored as per the "Corrected Action Plan" for any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 90 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on May 4, 2018. A review of Resident 56's "Short Term Care Plan" entitled 'Risk of psychological distress after verbal altercation with staff members" was initiated on May 5, 2018, two days after the IJ was called. A review of the "Investigation Report" for the allegation of abuse indicates "I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on May 4, 2018. According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on May 5, 2018 and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to "hang in there" for me and to personally contact me if any further issues. LVN was suspended pending investigation." A review of the facility policy and procedure entitled, "Abuse Prevention and Prohibition Program", undated, indicates "Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 91 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements." "Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. 3. During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 92 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM, she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 93 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 94 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 95 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 96 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs." During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported.

F610 SS=F Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 05/11/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure prevention, identification, thorough investigation, and reporting of abuse, neglect, and mistreatment of three of 27 sampled residents (Resident 211, Resident 56, and Resident 2) when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 97 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 1. The facility staff witnessed verbal abuse by the physician towards Resident 211. 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. A family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted to physical and psychological harm to three residents. Findings: 1. During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 98 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 99 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up and no reported evidence related to Resident 211's encounter with the physician. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 100 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 101 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 102 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs."2. During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was and that I was being disruptive to the rest of the staff and the other Residents and I needed to leave." Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, "Why can't I eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..." Resident 56 stated I said something to CNA 2 who was sitting next to me that wasn't in nice that [Name] got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, "That the RNA walked out FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 103 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff." Resident 56 stated over and over, "What did I do wrong? What did I do wrong?" Resident further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated "felt as if he was being treated like a child who was being scolded and disrespected." A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), diabetes mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 104 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated "That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD." I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, "The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, "The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on." I was assisting my resident and listening to Resident 56. The RNA should never have done that, "she should have handled the situation better." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 105 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 on May 3, 2018, at 11:30 AM with Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor." I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, "From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising," of course when then Resident 56's voice was also getting louder. "I heard the RNA tell the resident that he could not eat in the dining room and talk about other people," she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on May 3, 2018, at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM with Resident 56, the Resident stated "What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, "I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 106 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 still don't know why they did this to me.' During an interview on May 3, 2018, 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is "very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated May 3, 2018, indicted "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the incident. During a review of "Care Plans" Resident 56 is care planned for anxiety and depression. The last review of the care plan was March 3, 2018, with no changes noted. During an interview on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 107 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write "the resident was counseled on appropriate behavior". The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated, "The incident yesterday (May 3, 2018) was not reported to me." The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. A review of the facility policy and procedure entitled, "Abuse Prevention and Prohibition Program", undated, indicates "Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 108 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements." "Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. During an observation and interview on May 5, 2018 at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating "There was another incident last night (May 4, 2018)" between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he "felt the staff were targeting him" for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated, "I feel that my previous complaint to the state had backfired on me." He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was "verbally chastising him," he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on May 5, 2018, at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 109 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (ADM) about the incident. The ADM sent a text which stated "They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere." LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was "defensive, angry and felt he was being harassed." During a review of the "Nurses Notes" indicated, Resident 56 was being monitored as per the "Corrected Action Plan" for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on May 4, 2018. A review of Resident 56's "Short Term Care Plan" entitled 'Risk of psychological distress after verbal altercation with staff members" was initiated on May 5, 2018, two days after the IJ was called. A review of the "Investigation Report" for the allegation of abuse indicates "I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on May 4, 2018. According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on May 5, 2018 and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 110 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 needed to find another place to live. He agreed to "hang in there" for me and to personally contact me if any further issues. LVN was suspended pending investigation." 3. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. A review of the clinical record of Resident 2 on April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on May 2, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 111 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 2018 at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source ... I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 05/22/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure one of 27 sampled residents (Resident 60) had accurate assessments in their clinical record. These failures to accurately assess this resident had the potential to effect the quality of care the resident received while in the facility. Findings: During an observation on April 30, 2018, at 1:57 PM, Resident 60 walked around the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 112 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 hallways without use of a front wheeled walker, a wheelchair, or a cane. Resident 60 did not have any contractures (deformity or rigidity of the joints) or limited range of motion in his arms or legs. A review of the clinical record for Resident 60, the history and physical, dated September 7, 2017, indicated diagnoses of: traumatic brain injury (an injury to the brain), epilepsy (a medical condition causing seizures), and dementia (impairment of memory and judgement). During a review of the clinical record for Resident 60, the medical record dated May 19, 2016, indicated Resident 60 was admitted to the facility on May 19, 2016. During an interview on May 1, 2018 at 9:19 AM, Resident 60 stated everything is okay and he is not concerned about anything. During another review of the clinical record on May 3, 2018 at 9:34 AM, the Resident Assessment Instrument (an assessment tool Quarterly Minimum Data Sets [MDS]) dated March 13, 2018 indicated in Section G0110 Functional Status Activities of Daily Living (ADLs): walks room/corridor with supervision coded (given a rating score) as one, Section G0400 Functional Limitation in Range of Motion was coded as one for impairment on one side for the upper extremity and coded one for impairment on one side for the lower extremity. Section G0600 Mobility Devices was checked for use of a cane/crutch. During an interview on May 3, 2018 at 4:46 PM, the MDS Nurse stated, "Error in coding for limitation of Resident 60's upper extremities and lower extremities (both arms and legs). I will correct the coding. There is no care plan for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 113 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 limited range of motion because Resident 60 was functional with all of his extremities. The facility policy and procedure titled, "Resident Assessment Instrument: Minimum Data Set and Care Plan, dated May 2015, indicated, "Updated as the resident conditions change and revision is needed . . . ."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 05/22/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 114 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure for one of 27 sampled residents (Resident 264) a comprehensive care plan was developed for the elopement potential of the Resident. This failure had the potential to result in harm to the health and safety of Resident 264. Findings: A review of Resident 264's medical record found the history and physical indicated, that Resident 264 was originally admitted to the facility on April 21, 2018, with a current date of admission on April 24, 2018, with diagnoses that included dementia (impairment of memory and judgement), anxiety (a feeling of worry, nervousness, or unease), and violent antisocial behavior (acting in a manner that has caused or was likely to cause harassment, alarm or distress in other persons). During a review of Resident 264's admission document entitled, "Emergency Department (ED)" notes dated, April 20, 2018, from an acute care hospital indicated, "Presents with medics after being put on a 5150 hold by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 115 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 sheriffs (a 72 hold to ensure the Resident was not of harm to herself or others.) .... She was found wandering around confused." During a review of the facility's "Resident Admission Form" dated April 21, 2018, indicated, Resident 264 was admitted from a general acute care hospital. Resident 264 was assessed as being alert, disruptive, and verbally aggressive. A review of the "Nurse's Notes" dated April 21, 2018, at 10:00 PM, indicated, "Resident arrived via gurney, related to new admission, getting signatures, resident in with a sitter (A person, who sits, talks and interacts with patients). During a review of the facility's "Admission Assessments" dated April 21, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", the facility did not identify Resident 264 to be a safety risk for the above issues. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. Adequate monitoring based on the residents condition; 4. Meds as ordered. During a review of the "Nurse's Notes" dated April 23, 2018, at 6:00 PM, indicated, "While passing trays we noticed that the resident was not in her room, did a facility check of all rooms and bathrooms then initiated a perimeter check. Saw an EMS (emergency management system, an ambulance) vehicle at the church, investigated and found that EMS was called and they are transporting (Resident 264) to general acute care hospital. There is no documentation that the physician was notified regarding the elopement of the Resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 116 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a review of the physician's orders, undated, indicated that an order was written for Resident 264 to have a sitter upon admission. Further review of the physician's telephone orders dated April 23, 2018 at 12:45, indicated "DC (discontinue) sitter services." During further review of the clinical record dated April 23, 2018, indicated Resident 264 was discharged to home against medical advice (AMA - when a person who is alert, oriented and able to make their own medical decision leaves a facility against the advice of the their doctor). Another document entitled, "Interdisciplinary Team Conference (ITC)" dated April 24, 2018, indicated Resident 264 AMA / Discharged out of the building without notification to staff. During an observation on April 30, 2018, at 2:00 PM, Resident 264 was up in the hallway being assisted by her one to one sitter. During an observation on May 1, 2018, at 8:30 AM, Resident 264 was seen ambulating in the hallway with the Physical Therapy Aide back towards her room. During an observation on May 2, 2018, at 11:30 AM, Resident 264 was seen lying in her bed watching TV. There was no 1:1 sitter present at the time. The sitter came out of Resident 264's bathroom, stating "I needed to use the restroom." During a review of the facilities "Admission Assessments" dated April 29, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", the facility identified Resident 264 to be a safety risk for "Other behaviors, related to bipolar (mental illness that causes extreme highs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 117 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 and lows). With the following goals: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Meds as ordered. This document did not address Resident 264's "Wandering Behavior" from her previous elopement from the facility on April 23, 2018. During a clinical record review of the "Physician's Orders" dated April 2018, no orders were located to show resident 264 was to be assigned a one to one sitter due to her elopement risk. During an interview and concurrent record review with the Registered Nurse Supervisor 3 (RNS 3) on May 2, 2018, at 3:20 PM, the RNS 3 indicated that she could not locate an order from the physician for a sitter, or that the physician was notified the resident eloped from the facility on April 21, 2018. RNS 3 also confirmed that the initial assessment for wander risk was incomplete. The RNS 3 confirmed that no plan of care was developed for Resident 264 for elopement and/or wandering behaviors. A review of the facility policy and procedure entitled, "Wandering Residents' dated October 2017, indicates, "Procedures 1. The resident suspected of potential wandering behavior shall be assessed per facility policy. . . 3. Residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day." A review of the facility policy and procedure entitled, "Elopement", dated October 2017, indicates, "Procedure 1. Residents who are at risk for elopement (those residents with a clear history of repeated elopements will have an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 118 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 appropriate plan of care developed to identify the risk."

F675 SS=F Quality of Life CFR(s): 483.24

F675 05/11/2018 § 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure the wellbeing and feeling of self worth for two of 27 sampled residents (Resident 2 and Resident 211). This failure had the potential to cause psycholgical harm to the Residents. Findings: 1. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. A review of the clinical record of Resident 2 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 119 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on May 2, 2018 at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source ... I. the Facility will report known or suspected FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 120 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..."2. During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:40 AM she stated "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 121 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, 2018 at 9:18 AM, she stated "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further stated "I kept on what I was doing." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 122 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with SW 2, on May 4, 2018 at 9:33 AM, she stated "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up and no reported evidence related to Resident 211's encounter with the physician. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 123 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 A review of facility document titled "Resident Admission Form", dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 124 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 125 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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

F676 Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/22/2018 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 126 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a functional communication system for one of 27 sampled residents (Resident 39) who is non-English speaking. This failure had the potential to result in ineffective communication of needs, problems, and possible low self-esteem. Findings: During an observation of Resident 39, on April 30, 2018 at 8:30 AM, Resident 39 was awake inside her room and in bed. Resident 39 was smiling when greeted. Inside Resident 39's room, there was no pictures or anything posted on the wall. During an attempted interview of Resident 39, on April 30, 2018 at 8:35 AM, Resident 39 responded with a smile and she repeatedly stated, "Arigatou Gozaimasu (Japanese word thank you very much). During an interview with the Social Worker (SW 1), on May 1, 2018 at 6:50 AM, she stated "She is quiet and does not talk much." The SW 1 also stated that Resident 39 was "Chinese". During an interview with the Activity Director (ACT), on May 1, 2018 at 7:25 AM, the ACT stated "We gesture and sometimes we use our phone to translate." When asked what Asian descent Resident 39 was, she stated "Korean." The ACT confirmed that the facility has no resources for a Japanese-speaking resident. She also stated that facility staff use their personal cellphone to look for an internet website for Japanese to English translation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 127 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with Certified Nursing Assistant (CNA 3), on May 1, 2018 at 9:12 AM, she stated "I communicate with gestures. It seems that she's getting it." A review of facility resources for non-English speaking residents (Resident 39) with the ACT, indicated no evidence of available resources with the same language as Resident 39.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/09/2018 §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 observation, interviews, and record review, the facility failed to provide supervision to ensure the safety of two of 92 Residents (Resident 264 and Resident 265). 1. Resident 264 had a history of elopement 2. Resident 265 was at risk for elopement. This failure resulted in the potential for harm to Resident 264 and Resident 265. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 128 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 1. A review of Resident 264's face sheet (document that includes demographics and medical information), indicated that Resident 264 was admitted to the facility on April 24, 2018, with diagnoses that included dementia (a group of thinking and social symptoms that affect memory, interferes with memory, judgement and impaired reasoning). Resident 264 has a Durable Power of Attorney for healthcare (a legal document that lets you name someone else to make decisions about your health care in case you are not able to make those decisions yourself. It gives that person (called your agent) instructions about the kinds of medical treatment you want). During a review of Resident 264's Admission packet "Emergency Department (ED)" notes dated April 20, 2018, from an acute care hospital indicated, "Presents with medics after being put on a 5150 hold by sheriffs (a 72 hold to ensure the Resident was not of harm to herself or others.) .... She was found wandering around confused." During an observation on April 30, 2018, at 8:40 AM, Resident 264 was seen with a gait belt (a belt placed around the waist used to actively assist ambulating patients who have problems with balance) and was assisted by a physical therapy assistant (PTA, aides work under the direction and supervision of a physical therapist), as the Resident was walking in the hallway. During an observation on April 30, 2018, at 2:00 PM, Resident 264 was up in the hallway being assisted by her one to one sitter (1:1 - a person assigned to watch an individual resident at the bedside for a variety of reasons, the sitter generally does not provide direct patient care). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 129 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 observation on May 1, 2018, at 8:30 AM, Resident 264 was seen ambulating in the hallway with the PTA back towards her room. During an observation on May 2, 2018, at 11:30 AM, Resident 264 was seen lying in her bed watching TV, there was no 1:1 sitter present at the time. The sitter came out of Resident 264's bathroom, stating "I needed to use the restroom." During a review of the facility's "Resident Admission Form" dated April 21, 2018, indicated, Resident 264 was admitted from a general acute care hospital. Resident 264 was assessed as being alert, disruptive and verbally aggressive. During a review of the "Nurse's Notes" dated April 21, 2018, at 10:00 PM indicated, "Resident arrived via gurney, related to new admission, getting signatures, resident in with a sitter (A person, who sits, talks and interacts with patients, generally do not any patient care)." During a review of the facility's "Admission Assessments" dated April 21, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", the facility did not identify Resident 264 to be a safety risk for the above issues. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Med's as ordered. A review of the "Nurse's Notes" dated April 23, 2018 at 6:00 PM, indicated, "While passing trays we noticed that the resident was not in her room, did a facility check of all rooms and bathrooms then initiated a perimeter check. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 130 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Saw an EMS (emergency management system, an ambulance) vehicle at the church, investigated and found that EMS was called and they are transporting (Resident) to general acute care hospital." There is no documentation that the physician was notified regarding the elopement of the Resident. A review of the physician's orders, undated, do not indicate that an order was written for Resident 264 to have a sitter upon admission. Further review of the physician's telephone orders dated April 23, 2018 at 12:45, indicated "DC (discontinue) sitter services." During further review of the clinical record dated April 23, 2018, indicated that Resident 264 was discharged to home against medical advice (AMA - when a person who is alert, oriented and able to make their own medical decision leaves a facility against the advice of the their doctor). Another document entitled, "Interdisciplinary Team Conference (ITC)" dated April 24, 2018, indicated the Resident AMA / Discharged out of the building without notification to staff. During an interview and concurrent record review with the Registered Nurse Supervisor (RNS) on May 2, 2018 at 3:20 PM, the RNS indicated that she could not locate an order from the physician for a sitter, or that the physician was notified the resident eloped from the facility. The RNS also confirmed that the initial assessment for wander risk was incomplete. The RNS further confirmed that no plan of care was developed for Resident 264 for elopement and/or wandering behaviors. During an interview with the Physician Assistant on May 2, 2018, at 11:35 (a specially trained person who is certified to provide basic medical services under the supervision of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 131 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 licensed physician - PA), the PA stated he knew she had a history of wandering and she had issues with her daughter who did not want to participate in her care. The PA stated after I spoke with Resident 264, she said "she had not been wandering, but had been locked out of the daughter's house" when she was found wandering and was taken to the hospital. The PA stated, "After we talked awhile, she stated that she was happy here and she had no plans to leave the facility, so I discontinued the one to one sitter." During an interview with the Administrator (ADM) on May 2, 2018, at 11:45 AM, he indicated Resident 264 left the facility AMA. He further stated that given the information that he had on the Resident he did not feel that she had eloped she had just gone next door. The ADM defined the difference between leaving AMA and leaving the facility as an elopement. The ADM stated, "If a resident is someone who has capacity and is of sound mind who decides they would like to leave the facility that they had the right to leave whenever they wanted to." The ADM further stated "If someone was diagnosed with dementia and who is covered by a legal power of attorney, they should not have been allowed to go out AMA," that the staff should not have documented that Resident 264 left the facility AMA, given what I now know, we should have documented it as an elopement and reported it to the California Department of Public Health. During an observation on May 3, 2018, at 8:00, Resident 264 was in her bed watching TV with a 1:1 at the bedside. During an observation on May 7, 2018, at 2:00 PM, Resident 264 was in her bed asleep, with her 1:1 sitting at the bedside reading a book. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 132 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 The facility policy and procedure entitled, "Elopement" dated October 2017, indicates "It is the policy of this facility to minimize the risk of elopement and take action to locate a missing resident." Elopement is defined as "When a resident who has cognitive deficits unexpectedly leaves the facility grounds and the surrounding property of the facility. An alert and orientated and/or otherwise selfresponsible resident may leave the facility at any time consistent with his or her plan of care." The policy indicates in "Procedures 1. Residents who are at risk for elopement (those resident with a clear history of repeated elopements will have an appropriate plan of care developed to address the risk. 6. a. The DON and ADM shall be notified. C. Notify the attending physician. F. The required oversight agencies shall be notified. 2. A review of Resident 265's face sheet (document that contains demographics and medical information) indicated, Resident 265 was admitted to the facility on April 25, 2018, with diagnoses that included, anxiety (feeling of worry, nervousness, or unease) and dementia. During an observation of Resident 265 on April 30, 2018, at 9:00 AM, the resident was located in her room asleep on top of a mattress on the floor. During an interview with Certified Nurse's Assistant 5 (CNA) on April 30, 2018, at 9:02 AM, she indicated that she heard that the resident did not feel that she deserved a bed and preferred to lay on the ground. During an observation of Resident 265 on April 30, 2018 at 1:20 PM, Resident 265 was seen ambulating, she was up and dressed in a robe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 133 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with a CNA 5 following closely behind her. Resident 265 appeared to be pulling at her diapers. The CNA 5 assisted the resident to her room, where she jumped onto the mattress on the floor and stated that she was going to take a nap. A review of Resident 265's physician's orders dated April 25, 2018, indicated the following: a. "Provide a sitter" b. "Monitor agitation as manifested by verbalization of being agitated" A review of Resident 265" physician's telephone orders with various dates, indicated the following: a. April 26, 2018, at 9:00 AM - Clarification: Zyprexa (an antipsychotic medication, used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar disorder.) 5 mg (milligrams) every four hours, IM (intramuscularly - into the muscle), when necessary for 14 days for psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) manifested by verbalizations of not deserving of a bed. DC (DC-discontinue) monitor side effects, DC monitor episodes (no description of given of side effects or episodes.) b. April 28, 2018, undated, indicated, "Lorazepam 1 mg by mouth every at bedtime; Ativan 1 mg by mouth three times a day when needed for combative behavior." c. April 29, 2018, undated, "May have psychologist for evaluation and treatment." During a review of the facility's "Admission Assessments" dated April 26, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 134 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 the facility identified Resident 265 to be a safety risk for combativeness. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Med's as ordered. A further review of the "Admission Assessment" dated April 27, 2018, section entitled "Actual / Potential Concern" Elopement was identified as a potential concern. The goal indicated that "Resident will remain safely within the facility." The following interventions were listed "Shadow Checks every 30 minutes, and monitor all exits." During an observation on April 30, 2018, at 4:30 PM, Resident 265 was in her bed asleep, there was no sitter present. During an observation on May 1, 2018, at 7:50 AM, Resident 265 was not located in the room, and no personal items were present. During an observation on May 1, 2018, at 11:30 AM, Resident 265 was in a high bed, with a full bolster mattress (A mattress with firm arms and legs side which inhibits a resident's freedom of movement.) The resident had been moved to another room, right next to an exit door, no 1:1 sitter was present. During an interview and concurrent record review of the physician's orders with the Registered Nurse Supervisor 3 (RNS 3) on May 2, 2018, at 12:10 PM, the RNS 3 confirmed that there was no physician order for the use of the bolster mattress restraint. During an interview and concurrent review of the "Nursing Notes" with the RNS, dated April 25, 2017 through May 2, 2018, did not indicate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 135 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 that Resident 265's physician was notified regarding behaviors other than refusal of medication and taking vital signs that would led to the physician giving an order for the physical restraint. The remaining portions of the clinical record was reviewed with the RNS 3. The RNS 3 confirmed that there was no assessment completed to determine if the resident required physical restraints, she confirmed that there was no order from the physician and that there was no consent for the use of the physical restraints. During an observation on May 1, 2018 at 6:20 PM, Resident 265 was observed in the hallway walking toward the nursing station. Resident 265 was heard saying "I'm hungry can I get a cup of coffee". A CNA approached her and assisted her toward the cart that contained coffee and then back to her room. During an observation on May 2, 2018, at 10:45 AM, Resident 265 was seen, naked and attempting to go out of the exit out the door located right next to her room. During an interview, concurrent record review and room check with RNS 3 on May 2, 2018, at 5:50 PM the RNS 3 stated, "The recording of the shadow checks should be on a piece of paper in the residents room or in the residents chart." A review of the clinical record and the resident's room indicated there was no documented evidence to show that monitoring by shadow checks every 30 minutes was completed in accordance with the "Admission Assessment" document. During a review of Resident 265's care plans, no care plans were created for the identified concern of elopement. During an observation on May 2, 2018, at 5:00 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 136 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 PM, Resident 265's bed was stripped down to the mattress. During an interview on May 2, 2018, at 5:10 with RNS 1, RNS 1 indicated that Resident 265 had been transferred to another facility. During a review of the physicians orders dated May 2, 2018 at 4:06 PM indicated "PT [patient] to dc to [facility name] with medications. During an interview and concurrent record review with the Director of Nurses (DON) on May 3, 2018, at 13:30 AM, the DON explained the facility policy on the use of any restraints in the facility. The DON stated the interdisciplinary group should have been held to assess the risks and benefits of the restraints, she further stated that a physician's order and consent should have be obtained prior to use and that a care plan should have been developed. The DON confirmed that all the above procedures were not taken prior to using physical restraints and that the use of a Bolster mattress in the record that was used, would be considered a physical restraint. The facility policy and procedure entitled "Restraints" dated October 2017, indicates "It is the policy of this facility to not use physical restrain for convenience or discipline and not required to treat a resident's medical condition." Procedure indicates "1. Assess resident's need for restrain use and document the assessment; 2. Obtain physician's order for restraint and verify informed consent. Restraints may not be applied until the physician has obtained informed consent and the facility has verified such consent (absent emergencies as to the immediate health and safety danger to a resident or other residents but this must be clearly documented); 3. Develop a plan of care for type of restraint, reason for use, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 137 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 method of application." An IJ was called under 483.25 (d) (2) for Quality of Care: Free of Accident, Hazards/ Supervision/ Devices, on May 02, 2018, at 5:10 PM in the presence of the Administrator and the Director of Nursing. The facility failed to ensure that for two residents (Resident 264 and 265) received adequate supervision and assistance to prevent an elopement from the facility. (Refer to F689) The IJ was lifted after an acceptable corrective action plan was received and approved on May 2, 2018, at 9:15 PM in the presence of the Administrator and the Director of Nursing. The corrective action plan included: A. Resident 265 was discharged to a "locked facility" at approximately 5:20 PM. B. Resident 264 will have a sitter 24/7 until a more appropriate facility can be found . C. The Director of Nurses, or designee, will make sure that the facility has adequate staff to ensure the health, safety and well-being, of all residents at risk for elopement. D. Upon admission to the facility the resident history and physical will be reviewed by the Director of Staff Development, or designee, and care staff will be in-serviced to the resident's needs. E. New Admission will be placed on 72 hours monitoring for adaptation to the facility and for exit seeking behaviors. If resident presents with exit seeking behaviors the ITD will review residents need to ensure that the facility can continue to meet the needs of said resident. If residents exit seeking behavior cannot be maintained at facility, then the IDT will find FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 138 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 proper placement.

F695 SS=E Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 05/22/2018 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to follow their policy when four resident's (Resident 168, Resident 35, Resident 167, Resident 212) nebulizer (drug delivery device used to administer medication in the form of mist inhaled into the lungs) and oxygen tubing's were not labeled and dated. These failures had the potential for bacteria (microorganism that causes diseases) to harbor in the tubing and cause infection to four residents. Findings: 1. During an observation on April 30, 201,8 at 8:30 AM, in the room of Resident 168, an oxygen tank with a long tubing that was not labeled was beside her bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 139 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 A concurrent interview with resident 168 stated that the oxygen tank was hers and she uses it whenever she has difficulty of breathing. During an interview with the Licensed Vocational Nurse 4 (LVN 4) on April 30, 2018, at 8:35 AM, she stated that the tubing must be labeled and dated. She stated that it is important for the tubing to be labeled so they will know when to replace the tubing and prevent infections. A clinical record review of Resident 168 indicated she was admitted on March 8, 2018, with diagnoses of chronic obstructive pulmonary disease (A lung disease that block the airflow and makes it difficult to breathe). Resident 168's physician order was reviewed, which indicated an order of oxygen at three liters/minute (unit of measure) via nasal cannula (device used to deliver supplemental oxygen). 2. During an observation on April 30, 2018, at 9:00 AM, in the room of Resident 167, her oxygen tank was attached at the back of her wheelchair. Oxygen tank tubing was not labeled and dated. Resident 167 was asleep in her bed. A clinical record review of Resident 167 indicated, she was admitted on July 7, 2014, with diagnoses of dementia (a brain disease that causes memory loss), and pulmonary fibrosis (a lung disease causing scars in the lungs causing difficulty of breathing). Resident 167's physician order indicated an order of oxygen at two liters/ minute (unit of measure) via nasal cannula. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 140 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 of LVN 4 on April 30, 2018 at 9:30 AM, she stated that oxygen tubing must be replaced every week and dated. 3. During an observation in the room of Resident 35 on May 2, 2018, at 11:00 AM, her nebulizer (drug delivery device used to administer medication in the form of mist inhaled into the lungs) tubing was not labeled. During a concurrent interview with Resident 35, she stated the nebulizer was hers and she uses it often. A clinical record review of Resident 35 indicated, she was admitted on September 15, 2017,with diagnoses of major depression, and asthma (a lung condition were in the lung tubes thickens causing difficulty of breathing). Resident 35's physician order indicated albuterol (medication to help ease breathing), at two liters /minute (unit of measure) via nebulizer. During an interview with LVN 4 on May 2, 2018 at 11:45 AM, she stated that the tubing must be labeled so that they will know when to replace it and prevents infections A review of the facility's policy and procedure titled, oxygen administration and maintenance, dated July, 2013, indicated under oxygen administration set, " ...2. Used oxygen administration sets will be replaced weekly. Nursing staff will label and/ or record dates when administration sets are replaced."3. During a recertification survey of the facility, on April 30, 2018 at 9:16 AM, Resident 212 was sitting in the edge of the bed and had his breakfast. The Resident 212 has oxygen at 4 lpm (liters per minute) via nasal cannula tube. The oxygen tubing has no label and was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 141 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 dated. During an interview with Licensed Vocational Nurse (LVN 2), on April 30, 2018 at 10:15 AM, she stated "If there's no label or not dated, there will be a chance that Resident [Resident 212] will acquire infection." During an interview with the Infection Control Nurse (ICN), on May 2, 2018 at 2:19, she stated "It should be labeled or dated, and must be changed weekly." A review of facility policy and procedure titled, "Oxygen Administration and Maintenance", indicated "Oxygen Administration Sets: 2. Used oxygen administration sets will be replaced weekly. Nursing staff will label and/or record dates when administration sets are placed."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 05/25/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 142 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 27) did not have unauthorized medication, a Schedule II narcotic (medication which is controlled by law due to the potential for misuse/abuse), which was not properly secured, destroyed and documented for medication disposal. This failure had the potential for the Schedule II medication to be unlawfully diverted (medication illegally going to someone without a prescription) from the facility. Findings: A review of the medical record for Resident 27, indicated Resident 27 was admitted to the facility on November 29, 2017. A review of the clinical record for Resident 27, the document titled, "Doctor's Progress Notes," dated February 6, 2018, indicated, "resident in her room screaming and upset . . . staff is useless . . .[want] to get a muscle relaxer . . . FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 143 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 asked if wanted something for breakthrough pain [Resident 27] said no . . .[want] muscle relaxer . . . yelling obscenities to staff. . . pulled out [Resident 27's] medication and taken to her room that's when Licensed Vocational Nurse [LVN 4] noticed a bag of pills (136) Norco 10325 . . . . .staff suspicious of some pills in the room because there was one pill found on the floor two days ago ...." A review of the clinical record for Resident 27, the history and physical dated February 28, 2018, indicated diagnoses of: cerebral vascular accident (stroke) with left sided hemiplegia (unable to use left side), deep vein thrombosis (blood clots in veins), peripheral vascular disease (blood clots and decreased circulation in veins), major depressive disorder, and opioid (a type of controlled class of medication) dependent/abuse. The progress note further indicated ". . . [Resident 27] has been on Norco 10/325 mg (milligram) at least three times a day for several years and is fixated on this pill, no actual pain observed but seems to use it for emotional pain relief. Does have some new contractures and probable some pain, [Resident 27] refused MS Contin after taking every PRN (as needed medication) available and refused muscle relaxers, insists on Norco 10, found in her room 130 Norco tabs from a different pharmacy, unknown if prescribed, since [Resident 27] is paralyzed it is assumed her family supplied her with these. They were destroyed." During a review of the clinical record for Resident 27, the physician orders dated April 1, 2018 to April 30, 2018, indicated: monitor for pain every shift on scale of zero to ten, MS (morphine sulfate) Contin 15 mg (mg- a unit of measurement) 1 tab (one tablet) PO (by mouth) BID (twice daily) for pain, Norco 10/325 mg 1 tab PO q8hr (every eight hours) NTE (not to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 144 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 exceed) 3GM (grams - a unit of measurement)/24hrs (in a 24 hour period). During an interview on May 1, 2018 at 9:30 AM, the Director of Staff Development (DSD) stated, I have "Not heard of this before and the staff should have told the Director of Nurses (DON) . . . and the meds should have been locked up and logged." During a review of the clinical record for Resident 27, the DSD could not show any evidence of the final disposition and destruction of the medication by a pharmacist and the DON in the medication room. During a subsequent interview with the DSD on May 1, 2018, the DSD stated, "Resident 27's family came in and picked them up." During an interview with a Licensed Vocational Nurse (LVN 4), LVN 4 stated they found medication in [Resident 27's] room. We notified [Resident 27's] family not to bring in pills and that they would need to come in and pick them up. LVN 4 also stated that Resident 27 is fixated on her Norco and then stated after thinking about it Resident 27 seemed to not be asking for her Norco as much, was groggy and sleeping more. LVN 4 could not state what to do with the found narcotics medication. LVN 4 acknowledged not informing the DON. LVN 4 stated there were not any documents in the clinical record for disposition of the medication which included a date and time when the medication was given to the family. During an interview with Resident 27's daughter on May 2, 2018, at 4:40 PM, the daughter acknowledged she came into the facility and picked up the medication. During an interview and record review with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 145 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 DON on May 7, 2018, at 10:00 AM, the DON stated she just became aware of the situation regarding a bag of narcotics when she was notified by the DSD. The DON stated the medication was not handled per facility policy and procedure because they should have brought the medication to the DON, and the medication should have been placed in a locked file until the pharmacist came so they could have been destroyed. They never should have given the medication back to the family. The DON acknowledged not having any record of the medication being picked up by the family. The facility policy and procedure titled, "Controlled Drug Disposal," dated July 2013, indicated, "It is the policy of the facility to comply with all Federal and State regulations regarding security, handling, and administration of controlled drugs. Procedures: 1. The DON should be notified as soon as possible after a controlled drug has been discontinued. Until the medication is transferred to the DON, licensed nurses retain it in the narcotic drawer and continue to count the medication at shift change. 2. The DON will pick up discontinued controlled drugs at the medication carts. The DON and licensed nurse will count and cosign the controlled drug disposal log as the drugs are collected. 3. The DON will then transfer the medication to the double-locked cabinet in her office until the pharmacist can assist in the disposal."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/25/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 146 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure: 1. Expired medication was removed from one of four medication carts and the medication storage room. 2. Medication for seven of 27 sampled residents (Resident 221, Resident 2, Resident 274, Resident 1, Resident 314, Resident 33 and Resident 316) were kept stored in the medication refrigerator at a safe temperature between 36° F (Fahrenheit - a unit of measurement for temperatures) to 46° F and free from humidity. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 147 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 3. Keys to medication cart number one were secured at all times and the medication administration record was kept closed from public view. These failures had the potential for residents to receive expired or unsafe medications and not preventing access to medication or viewing a resident's prescribed medication. Findings: 1. During an observation on May 1, 2018, at 8:55 AM, the following expired medications were inside the medication room: one bottle of Magnesium Oxide opened February 4, 2018, containing 500 mg (milligram- unit of measurement) tablets with 100 tablets per bottle with an expiration date of February 18, 2018, one bottle of Gericare (brand name) saline nasal spray with an expiration date of September 2017, four bottles of Folic Acid 400 mcg (micrograms - unit of measurement) with an expiration date of February 2018, and three bottles of Gericare Vitamin E with an expiration date of February 2018. During a subsequent observation of medication cart number one on May 1, 2018 at 9:38 AM, one bottle of Vitamin E opened June 25, 2017 with an expiration date of February 2018 was found in the over the counter medication drawer on the cart. During an interview with a Licensed Vocational Nurse (LVN 3), LVN 3 confirmed the medication was expired and the expiration date was February 2018. The facility policy and procedure titled, "Storage of Medications," indicated under Procedures H. "Outdated, contaminated, or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 148 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the inventory, disposed of according to procedures for medication disposal. Expiration Dating F. No expired medication will be administered to a resident. G. All expired medications will be removed from active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner." 2. During an observation on May 1, 2018, at 8:39 AM, the medication refrigerator door was found open. The thermometer measuring the temperature inside the refrigerator indicted a temperature of 52°F (Fahrenheit - a unit of measurement). The thermometer needle was in the red colored danger zone. Condensation had formed on all storage containers inside the refrigerator. Medications for the following residents were found in the refrigerator: Resident 221 Unasyn (name of medication) three gm (grams - unit of measurement)/NS (normal saline - type of fluid) quantity (qty) seven intravenous (IV) bulbs. Resident 1 Amp/sod (Ampicillin/sodium - name of medication mixture) three gm/100 ml (milliters- unit of measurement) q (every) six hours for seven days - qty two. During a concurrent interview with Registered Nurse Supervisor (RNS 1), RNS 1 confirmed the temperature inside the medication refrigerator was at 52° F in the danger zone. RNS 1 also confirmed moisture and condensation were on medications inside the refrigerator. During an interview with a registered nurse supervisor (RNS 3) on May 1, 2018, at 3:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 149 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 PM, RNS 3 stated she called the pharmacy and was told to destroy the two intravenous (IV) antibiotics and that all other medications were not affected by the elevated temperature. During a review of a facility document titled, "MED Refrigerator Temperature Log" dated May 2018, indicated on May 2, 2018, the refrigerator temperature was signed off by "ST" without any time listed or comments made. The facility policy and procedure titled, "Medication Storage in the Facility," dated October 2012, indicated under "Procedures I. Medication storage areas are . . . free of . . . extreme temperatures and humidity. Temperature C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2° C (36° F) and 8°C (46°F) with a thermometer to allow temperature monitoring." 3. During a medication pass observation on May 1, 2018, at 7:01 AM, a Registered Nurse Supervisor (RNS 4), walked away from medication cart number one to wash her hands leaving the keys on top of the cart unattended with the medication administration record (MAR) book open to public view. During a subsequent observation of medication cart number one on May 1, 2018, at 7:07 AM, a licensed vocational nurse (LVN 6) walked to cart, noticed the keys were on the cart, and placed the keys inside the MAR book and closed the book. During another observation of medication cart number one on May 1, 2018, at 7:10 AM, a registered nurse supervisor (RNS 4) returned to the medication cart and took the keys from the MAR book and opened the cart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 150 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 with RNS 4, RNS 4 stated she was supposed to have the keys on her person at all times. RNS 4 said she did not have the keys with her when she left and was only gone five minutes. During the continuation of the same medication pass on May 1, 2018 07:48 AM, a registered nurse supervisor (RNS 4) again left the keys on top of cart unattended and left medication bubble packs (a pack of pills in a cardboard holder) out unattended. During a subsequent second interview with RNS 4, RNS 4 admitted she left the keys and MAR open. RNS 4 said she should have locked the cart, put the medication away, and closed the MAR book. RNS 4 admitted she should have put the keys in her pocket and kept them with her at all times. The facility policy and procedure titled, "Storage of Medications," dated October 2012 indicated, "Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted access to medications."

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 05/22/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 151 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 temperature. This REQUIREMENT is not met as evidenced by: Based on observation, and interview, the facility failed to follow its policy regarding keeping pureed (pudding like consistency food) lettuce from being served above acceptable temperature range during tray line (Process of serving food on a resident's plate). This failure has the potential for 13 residents on a pureed diet in a universe of 92 to lose appetite and weight due to food served not in a safe and appetizing temperature. Findings: During an observation on May 1, 2018, at 5:35 PM of tray line serving, the temperature of the pureed lettuce was 70 degrees Fahrenheit (F) (unit of measurement) before pouring it on a resident's plate. As the last resident was served to their rooms, the pureed lettuce was retested and it was 70 degrees F. During a concurrent interview with the DFNS (Director of Food/Nutrition Services), he stated that the lettuce should be below 41 degrees F. During an interview with Resident 270 on May 2, 2018, at 10:00 AM, he stated that he was served with pureed lettuce for dinner on May 1, 2018. He stated the salad was bad and warm when served so he did not eat it. A review of the facility's policy and procedure titled," Meal Serving Temperature", dated 2017, indicated under procedure," ...2. Cold food items shall be held at 41 degrees or below and served at not greater than temperatures of 4550 degrees F at bedside or dining room to ensure serving temperatures are palatable." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 152 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/22/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow their policy regarding the following: 1. Multiple opened food items stored that were not labeled. 2. The meat slicer machine had a brownish, sticky substance on the center of knob blade. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 153 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 3. The ice machine's air vent had accumulation of dust. 4. The Dietary Cook ( DC 2) prepared residents food during tray line with an opened fresh wound on his right wrist. 5. Food brought by family was not properly stored and labeled in the resident's room. These failures had the potential for all residents in a universe of 92 to be subjected to foodborne illnesses (any illness resulting from food spoilage, pathogenic bacteria [a germ that causes disease], viruses [a small organism that causes disease], or parasites [a creature that lives off another organism] that can contaminate the food. Findings: 1. During an observation on April 30, 2018, at 8:05 AM, inside the walk in refrigerator and dried food storage, the following opened food items were: A. Five pounds ground pork wrapped in a clear plastic, without a label. B. A piece of ham wrapped in a clear plastic, without a label. C. An open box of tomatoes without a label, with one rotten, dried tomato in it. D. A sliced onion wrapped in plastic, without a label. E. A bunch of chives with its roots dipped in a container of water, without a label. F. A sliced squash wrapped in plastic, without a label. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 154 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 G. A five to six pounds of shredded dried coconut in a clear plastic bag, tied and not labeled. During a concurrent interview with the Director of Food /Nutrition Services (DFNS), he stated that all opened food items must be labeled with dates on it. The DFNS stated it is important to label and date the opened food items so they can keep track of when to discard perishable foods to ensure the food is not served to the residents. The facility policy and procedure titled, "Food Service Management," dated, January 1, 2017, indicated, under Procedure, "1. Any foods removed from original container will be properly labeled as follows: a. the name of the food item being stored and the date the food was removed from its original container and stored ...". 2. During an observation of the facility's meat slicer on April 30, 2018, at 9:00 AM, the Dietary Cook 1 (DC 1) was directed to remove the top blade by loosening the center of the knob blade. A brownish, sticky substance around the center of the knob was noted. During a concurrent interview with DC 1, he stated he needs to remove and clean the center of the knob blade to prevent food contamination. A review of the facility's policy and procedure titled," Food Slicer," dated 2017, indicated," ... Remove top blade by loosening center of knob blade ... wash thoroughly, rinse, sanitize ..." 3. During an observation of on April 30, 2018, at 9:30 AM, of the ice machine, the outside air vent had a thick accumulation of dust particles. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 155 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a concurrent interview with the DFNS, he confirmed the accumulation of dust on the air vent and that he needed the staff to clean the outside of the ice machine to prevent dust accumulation in the air vent. He stated there is a potential for dust particles to mix with ice and contaminate the water of the residents if not being cleaned properly. The facility did not provided a policy and procedure about ice machine cleaning maintenance. 4. During an observation on May 1, 2018, at 5:10 PM, at tray line, the Dietary Cook 2 (DC 2) was putting food on the plates for the residents. DC 2 had a round, dime-size wound with reddish margins and yellowish pinkish center on his right medial side of the wrist. The wound was partially covered by his transparent gloves,but his wound was exposed toward the end of food serving. During a concurrent interview with the DFNS, he stated the wound must be treated and covered by gauze, and wear gloves before dietary staff are allowed to serve food to prevent spread of infection. A review of the facility's policy and procedure titled, "Dietary Department", undated, indicated under personnel requirements that," ... Report accidents, injuries, cuts, skin eruptions and burns to the dietary supervisor, no matter how minor the incident may seem ...Report all infections to the dietary supervisor ..." 5. During an observation May 2, 2018, at 11:00 AM, of Resident's 35 room, an opened bottle of ketchup and an opened container of parmesan cheese, had no labels and were found on the floor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 156 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 a concurrent interview with Resident 35, she stated the food items were brought by her family and had been sitting on the floor for more than a week. During an interview with the Director of Nursing (DON) on May 2, 2018, at 11:30 AM, she stated all open food items brought by family or friends to the residents must be labeled and stored in the kitchen. She stated it is important to properly store food and label it to keep away roaches and rodents and prevent food contamination. A review of the facility's policy and procedure titled, "Purchasing-General Guidelines," dated 2017, indicated, " ...When food is brought into the nursing home, inspection for safe transport and quality upon receipt and proper storage helps ensure its safety. Keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer is indicated ..."

F835 SS=F Administration CFR(s): 483.70

F835 05/22/2018 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: 3. A review of Resident 264's face sheet (document that includes demographics and medical information), indicated that Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 157 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 264 was admitted to the facility on April 24, 2018, with diagnoses that included dementia (a group of thinking and social symptoms that affect memory, interferes with memory, judgement and impaired reasoning). Resident 264 has a Durable Power of Attorney for healthcare (a legal document that lets you name someone else to make decisions about your health care in case you are not able to make those decisions yourself. It gives that person (called your agent) instructions about the kinds of medical treatment you want). During a review of Resident 264's Admission packet "Emergency Department (ED)" notes dated April 20, 2018, from an acute care hospital indicated, "Presents with medics after being put on a 5150 hold by sheriffs (a 72 hold to ensure the Resident was not of harm to herself or others.) .... She was found wandering around confused." During an observation on April 30, 2018, at 8:40 AM, Resident 264 was seen with a gait belt (a belt placed around the waist used to actively assist ambulating patients who have problems with balance) on being assisted by a physical therapy assistant (PTA, aides work under the direction and supervision of a physical therapist), as the Resident was walking in the hallway. During an observation on April 30, 2018, at 2:00 PM, Resident 264 was up in the hallway being assisted by her one to one sitter (1:1 - a person assigned to watch an individual resident at the bedside for a variety of reasons, the sitter generally does not provide direct patient care). During an observation on May 1, 2018, at 8:30 AM, Resident 264 was seen ambulating in the hallway with the PTA back towards her room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 158 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 observation on May 2, 2018, at 11:30 AM, Resident 264 was seen lying in her bed watching TV, there was no 1:1 sitter present at the time. The sitter came out of Resident 264's bathroom, stating "I needed to use the restroom." During a review of the facility's "Resident Admission Form" dated April 21, 2018, indicated, Resident 264 was admitted from a general acute care hospital. Resident 264 was assessed as being alert, disruptive and verbally aggressive. During a review of the "Nurse's Notes" dated April 21, 2018 at 10:00 PM, indicated, "Resident arrived via gurney, related to new admission, getting signatures, resident in with a sitter (A person, who sits, talks and interacts with patients, generally do not any patient care)." During a review of the facility's "Admission Assessments" dated April 21, 2018, in the section entitled, "Safety Risk due to: Wandering; Combativeness; Other behaviors", the facility did not identify Resident 264 to be a safety risk for the above issues. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Med's as ordered. During a review of the "Nurse's Notes" dated April 23, 2018 at 6:00 PM, it indicated, "While passing trays we noticed that the resident was not in her room, did a facility check of all rooms and bathrooms then initiated a perimeter check. Saw an EMS (emergency management system, an ambulance) vehicle at the church, investigated and found that EMS was called FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 159 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 and they are transporting (Resident) to general acute care hospital." There is no documentation that the physician was notified regarding the elopement of the Resident. A review of the physician's orders, undated, did not indicate that an order was written for Resident 264 to have a sitter upon admission. Further review of the physician's telephone orders dated April 23, 2018 at 12:45, indicated "DC (discontinue) sitter services." During further review of the clinical record dated April 23, 2018, indicated that Resident 264 was discharged to home against medical advice (AMA - when a person who is alert, oriented and able to make their own medical decision leaves a facility against the advice of the their doctor). Another document entitled, "Interdisciplinary Team Conference (ITC)" dated April 24, 2018, indicated the Resident AMA / Discharged out of the building without notification to staff. During an interview and concurrent record review with the Registered Nurse Supervisor (RNS) on May 2, 2018 at 3:20 PM, the RNS indicated that she could not locate an order from the physician for a sitter, or that the physician was notified the resident eloped from the facility. The RNS also confirmed that the initial assessment for wander risk was incomplete. The RNS further confirmed that no plan of care was developed for Resident 264 for elopement and/or wandering behaviors. During an interview with the Physician Assistant on May 2, 2018, at 11:35 (a specially trained person who is certified to provide basic medical services under the supervision of a licensed physician - PA.) The PA stated he knew she had a history of wandering and she had issues with her daughter who did not want FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 160 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 to participate in her care. The PA stated, after I spoke with Resident 264, she said "she had not been wandering, but had been locked out of the daughter's house" when she was found wandering and was taken to the hospital. After we talked awhile, she stated that she was happy here and "she had no plans to leave the facility, so I discontinued the one to one sitter." During an interview with the Administrator (ADM) on May 2, 2018, at 11:45 AM, he indicated Resident 264 left the facility AMA. He further stated that given the information that he had on the Resident he did not feel that she had eloped she had just gone next door. The ADM defined the difference between leaving AMA and leaving the facility as an elopement. The ADM stated, "If a resident is someone who has capacity and is of sound mind who decides they would like to leave the facility that they had the right to leave whenever they wanted to." The ADM further stated "If someone was diagnosed with dementia and who is covered by a legal power of attorney, they should not have been allowed to go out AMA," that the staff should not have documented that Resident 264 left the facility AMA, given what I now know, we should have documented it as an elopement and reported it to the California Department of Public Health. During an observation on May 3, 2018, at 8:00, Resident 264 was in her bed watching TV with a 1:1 sitter at the bedside. During an observation on May 7, 2018, at 2:00 PM, Resident 264 was in her bed asleep, with her 1:1 sitting at the bedside reading a book. The facility policy and procedure entitled, "Elopement" dated October 2017, indicates "It is the policy of this facility to minimize the risk of elopement and take action to locate a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 161 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 missing resident." Elopement is defined as "When a resident who has cognitive deficits unexpectedly leaves the facility grounds and the surrounding property of the facility. An alert and orientated and/or otherwise selfresponsible resident may leave the facility at any time consistent with his or her plan of care." The policy indicates in "Procedures 1. Residents who are at risk for elopement (those resident with a clear history of repeated elopements will have an appropriate plan of care developed to address the risk. 6. a. The DON and ADM shall be notified. C. Notify the attending physician. F. The required oversight agencies shall be notified. 4. During an observation and interview on May 3, 2018, at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated "I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and [Name] started yelling at me across the room and told me I could not eat in the dining room. [Name] told me that I was and that I was being disruptive to the rest of the staff and the other Residents and I needed to leave." Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, "Why can't I eat in the dining room." He also stated, "What did I do wrong, what did I do wrong ..."Resident 56 stated "I said something to CNA 2 who was sitting next to me that wasn't in nice that [Name] got the promotion. CNA 2, said something like yes and went back to feeding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 162 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 her resident. This is when [Name] (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, "That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, "What did I do wrong? What did I do wrong?" Resident further stated that [Name] came in and told me to quiet down and told the RNA to leave. [Name] and the Charge Nurse (CN). "The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong." Resident 56 continued with interview, "I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room." Resident 56 stated "felt as if he was being treated like a child who was being scolded and disrespected." A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on December 2, 2017, with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), diabetes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 163 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 mellitus, anxiety (feeling of worry, nervousness, or unease), insomnia (habitual sleeplessness; inability to sleep) and depression. During an interview on May 3, 2018, at 8:45 AM with the RNA, the RNA stated "Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members." The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated "That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened." During an interview on May 3, 2018, at 8:55 AM with the SSD, the SSD stated "The RNA came into tell me that Resident 56 was being disruptive in the dining room and talking to staff and gossiping." She stated, "The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors." During an interview on May 3, 2018, at 9:00 AM with CNA 1, the CNA stated, "I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues." She further stated, "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 164 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better." During an interview on May 3, 2018, at 11:30 AM with Charge Nurse (CN), the CN stated "I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues." The CN further stated, "From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room." The CN confirmed that she had not reported the incident with anyone. During an interview on May 3, 2018, at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated "What incident?" During an observation and interview on May 3, 2018, at 11:55 AM, with Resident 56, the Resident stated "What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them." Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, "I always try to do the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 165 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me." During an interview on May 3, 2018, 12:20 PM, with the facility contracted Psychologist (PhD), the PhD stated "I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child." The PhD further states "Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it." A review of the PhD note dated May 3, 2018, indicted "Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom." He further noted that Resident 56 was uncertain as to exactly what he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of "Nursing Notes" for May 3, 2018, nothing was documented regarding the incident. During a review of "Care Plans" Resident 56 is care planned for anxiety and depression. The last review of the care plan was March 3, 2018, with no changes noted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 166 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 on May 4, 2018, at 9:15 AM with CNA 2, CNA 2 stated "Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on May 4, 2018, at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write "the resident was counseled on appropriate behavior". The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on May 4, 2018, at 10:20 AM, the DON stated "The incident yesterday (May 3, 2018) was not reported to me. The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 167 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 physician was notified, that no change or condition or care plans were completed. A review of the facility policy and procedure entitled, "Abuse Prevention and Prohibition Program", undated, indicates "Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements." "Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. During an observation and interview on May 5, 2018 at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating "There was another incident last night (May 4, 2018) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4." Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated "I feel that my previous complaint to the state had backfired on me." He stated "It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it." Resident 56 further stated "LVN 5 approached him and was verbally chastising him, he stated that when LVN 5 talked to him, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 168 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 he was told he was being verbally abusive to the staff." During an interview on May 5, 2018 at 2:00 PM, the, LVN 5 stated "I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated "They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere." LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed." During a review of the "Nurses Notes" indicated, Resident 56 was being monitored as per the "Corrected Action Plan" for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on May 4, 2018. A review of Resident 56's "Short Term Care Plan" entitled 'Risk of psychological distress after verbal altercation with staff members" was initiated on May 5, 2018, two days after the IJ was called. A review of the "Investigation Report" for the allegation of abuse indicates "I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on May 4, 2018. According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 169 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on May 5, 2018, and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to "hang in there" for me and to personally contact me if any further issues. LVN was suspended pending investigation." 5. During an observation on April 30, 2018, at 9:00 AM, Resident 20 was sleeping on top of his bed, he had multiple visual skin lesions to his face and arms. A medical record review of Resident 20's indicates, Resident 20 was admitted to the facility on August 21, 2014, with diagnoses that included hospice with a start of care (SOC, when a patient is first admitted to a hospice agency) of November 14, 2014, with a terminal diagnoses of Acquired Immune Deficiency Syndrome (AIDS, were there is a severe loss of the body's immunity, greatly lowering the resistance to opportunistic infections), and chronic obstructive respiratory disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During an interview on May 3, 2018, at 1:30 PM, with Registered Nurse Supervisor (RNS 1), RNS 1 did not know where to locate any documents as they related to Resident 20's hospice care. She further stated that she could not tell who or when anyone comes in, but that she thinks there might be a sign in book. During an interview on May 3, 2018, at 7:30 PM, with Registered Nurse Supervisor (RNS 3), RNS 3 did not know where to locate any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 170 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 documents as they related to Resident 20's hospice care. She said we used to have a separate chart for the hospice, but I don't know what happened to them. During an interview on May 4, 2018 at 8:30 AM, with the Medical Records clerk, she indicated the individual hospice charts are located in the medical records office. She indicated that when she was not on site limited people have access to her office. During an interview and concurrent record review on May 4, 2018, at 9:12 AM, with the Director of Nurses (DON), Resident 20's facility clinical record and the contracted Hospice clinical record were reviewed. The DON stated that the purpose of having hospice in the facility is for the coordination of hospice care and the services they provide for a resident at the end of their life. During a review of both records the DON could not locate any documents that indicated who and when staff from the hospice come into the facility. She states that the hospice is to sign in whenever they come in to give care. She also stated that the hospice should be putting notes in our clinical record, so that we know what is going on with our Resident. The DON stated that the hospice is to provide the facility with a calendar that should show what days of the week the hospice comes out so that the facility staff can coordinate care for the resident. The DON confirmed that she could not locate a calendar that indicates when and what staff are coming into the facility. The DON confirmed she could not locate any communication notes from the hospice regarding patient care. During the interview the DON was asked how often Resident 20 was to been seen by hospice staff and who came into see him. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 171 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 stated that she was not sure where that information was to be found, and that she would have to go to the nurse's station to see if that kind of information is kept there or possibly it might be located in the chart. The DON located the Hospice Interdisciplinary Comprehensive Assessment and Plan of Care (IDG/POC, document that the hospice provides that includes the benefit period of the Resident; the medical diagnosis; the Residents identified problems list which include medical, spiritual and teaching needs; medications; and the scope and frequency of the visits to be made to the resident by each discipline), she stated she knew this was one of the hospice documents but she was unable to describe what the purpose of the document was and she could not locate the scope and frequency of visits for each discipline. During a concurrent review of the IDG/POC with the DON, she was shown the scope and frequency of visits. The IDG/POC indicated that for the benefit period of March 2, 2018 through April 30, 2018, indicated that Resident 20 was to have been seen by a skilled nurse (SN) twice a week; a certified home health aide (CHHA) twice a week; a medical social worker one time per month; and a spiritual advisor two times a month. The DON reviewed the facility and hospice clinical record and confirmed that there was no documented evidence that any of these visits were made. A review of the hospice physician notes were reviewed with the DON. The DON was able to locate one visit that was made by the doctor on February 26, 2018 as a monthly visit. During a review of the IDG/POC with the DON, the DON could not provide any documentation as to the coordinated plan of care that the facility and the hospice are supposed to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 172 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 working towards the care of Resident 20. The DON provided the facility plans of care for Resident 20. These were compared to the problems list on the IDG/POC. The facility had identified more issues with the resident than the hospice agency. The DON was unable to provide documentation that the hospice participates with the facility interdisciplinary team meetings. A document was located in the hospice notebook entitled "Comprehensive Plan of Care" dated November 18 2018, with the following identified problems, outcome/goals; and interventions: a. Problem - The professional management of a patient in a skilled nursing facility. b. Outcomes/Goals - includes, Patient needs will be met through care coordination between the facility, patient family/caregiver, Case Manager, Attending Provider, and Hospice Interdisciplinary Group. c. Interventions - Patient's Hospice Comprehensive Plan of Care will be integrated with the facility plan of care and will be available to the nursing facility for all caregivers to access to facilitate continuity of care. A review of the hospice sign in notebook was conducted with the DON, she confirmed that the book covered a year in time, she also confirmed that the only dates that [Name of Hospice] signed in were for May 5, 2017; August 10, 2017; September 12, 2017; and March 23, 2018. An interview and concurrent record review on May 3, 2018, at 10:30 AM, with the DON of the facility contract with [Name of Hospice Company] and the Facility was reviewed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 173 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Hospice responsibilities included but not limited to the following: - Hospice resumes responsibility for professional management of the resident's hospice service provided, in accordance with the hospice plan of care (POC) and the hospice conditions of participation, and make any arrangements necessary for hospice related inpatient care in a participating Medicare/Medicaid facility. - Providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement; social work. - Coordinating the care of the hospice patient by developing, implementing and overseeing the integrated plan of care (POC) with the interdisciplinary group in coordination with the facility staff ... Plan is revised and update as needed. - Hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. - Authorizing all services, medications and treatments related to the terminal illness and related conditions. - Communicating with the facility's skilled nurse/representative, and other staff as appropriate, any changes in the integrated plan of care. The facilities contracted responsibilities included but not limited to the following: - Follow the hospice medical direction - Follow the agreed upon integrated POC including notification for any changes in patient's conditions, or family/resident concerns to hospice. Medication administration and documentation of all care and services provided. - Notify the hospice to obtain prior authorization for treatments or orders as related to the terminal illness and related FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 174 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 conditions. - Notify the hospice staff for any changes in condition, including death. - Supporting the hospice training of staff. - Timely notification to the hospice of upcoming conferences. - Reinforcing information provided to the resident and family regarding the resident's condition and POC in collaboration with the hospice staff. The terms and responsibilities of the contract were discussed from both from the facility and the hospice agency perspective. The DON stated that given everything that she has reviewed today with Resident 20's chart that there is no indication that there is coordination of care between the two companies. The DON stated, "Clearly we don't have any idea when or if the hospice comes into the facility." The DON confirmed that it is the responsibility of the facility to ensure they know what services are being provided and from what she see's there is no integration with this hospice in regards to Resident 20's care. She states in fact it looks like we provide all the care and they are getting all the reimbursements. During an interview and concurrent record review on May 3, 2018, at 10:50 AM, with the Administrator (ADM), he states that the facilities role is to provide services and care to the patients. He states that we render most of the residents care. The ADM was not able to provide documentation as to how the facility knows who provides care to Resident 20 and how frequently. The ADM states that they come in whenever the schedule says they should be here. The ADM was unable to provide any documentation regarding how he monitors or coordinates the care between the facility and hospice. The ADM was unable to say if the facility staff go to the Hospice IDG/POC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 175 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 meeting or if the Hospice comes to his facility Interdisciplinary Team Meetings. After a review of the responsibilities of the contract between [Name of Hospice] and the facility, the ADM states that they don't seem to be in compliance with the contract and that seems as if we are providing all the services to Resident 20. Based on observation, interview, and record reviews, the facility administration failed to maintain the highest practicable physical, mental, and psychosocial well-being of five of 27 sampled residents (Resident 2, Resident 211, Resident 264, Resident 56, and Resident 20) and failed to prevent, report, and investigate the following: 1. Facility staff witnessed verbal abuse by the physician towards Resident 211. 2. Family member struck Resident 2 multiple times as witnessed by facility staff. 3. Resident 264 was found outside facility premises, and was hospitalized. 4. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 5. Facility failed to coordinate, monitor, and evaluate the provision of hospice services for Resident 20. These failures resulted in harm and had the potential for five Residents (Resident 2, Resident 211, Resident 264, Resident 56, and Resident 20) in the universe of 92 residents to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 176 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 experience continued physical and psychological harm. Findings: 1. During a recertification survey of the facility, on April 30, 2018 at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on April 30, 2018 at 8:05 AM, he stated, "I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here." Resident 211 stated that a month ago while in the social services office, when the doctor called him an "f****** (expletive) idiot" and was witnessed by the social workers inside the office. Resident 211 also stated "Doctor [name of the physician] was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small." Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, "Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him." During an interview with the Director of Nursing (DON), on April 30, 2018 at 2:49 PM, the DON stated that she was not aware of the incident and stated, "Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know." During an interview with the Social Worker (SW FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 177 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 1), on May 1, 2018 at 6:40 AM, she stated "The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM)." During an interview with the Social Worker Assistant (SWA 1), on May 2, 2018 at 11:08 AM, she stated, "I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all." During an interview with the SW 1, on May 2, 2018 at 11:02 AM, she stated "Doctor [name of the physician] and the Resident [Resident 211] were bickering each other." The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state [California Department of Public Health]." During an interview with ADM, on May 2, 2018 at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated, "Doctor [name of the physician] did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it." During an interview with SWA 1, on May 4, 2018 at 9:18 AM, she stated, "I was typing on my computer when the Doctor [name of the physician] and [name of SW 1] came in the office with the Resident [Resident 211] to the doorway in a wheelchair." The SWA 1 further stated "Doctor [name of the physician] said to the Resident [Resident 211] 'You are acting like an idiot'. Then they [physician and Resident 211] left the office and went to the nurse station." The SWA 1 was asked about what she did after witnessing the incident, she further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 178 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 stated "I kept on what I was doing." During an interview with SW 2, on May 4, 2018 at 9:33 AM, she stated, "I was in the DSD (Director of Staff Development) office when I heard the resident [Resident 211] arguing with someone." When the SW 2 was asked if she saw the situation she further stated, "I did not look. I stayed in the DSD office." During a record review of Resident 211's medical records, on May 4, 2018 at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SW 1, dated March 13, 2018, it indicated that Resident 211 and the physician were "bickering [arguing] back and forth", It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, "Investigative Interview Transcript Employee" signed by SWA 1, dated March 13, 2018, it indicated that SWA 1 did hear the physician stated "You [Resident 211] are acting like an idiot". During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on February 23, 2018 with admitting diagnoses of unilateral primary osteoarthritis (inflammation of joints), post-surgery for right hip replacement, and schizophrenia-bipolar (mental illness). A review of facility document titled "Resident Admission Form," dated February 23, 2018 at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 179 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 A review of Minimum Data System (MDSassessment tool for Resident), dated April 20, 2018, the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, "Job Descriptions-Social Service Designee", indicated "Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care." A review of facility document titled, "Job Descriptions-Director of Nursing Services", indicated "Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated "Policy: It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 180 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 agencies serving the resident, family members or legal guardians, friends, or other individuals." A review of facility policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin" dated April 2016, indicated on page 1 of 7 "Definitions: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or to within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language." And also indicated on page 7 of 7 "Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act." A review of the facility policy and procedure titled, "Resident Rights" dated October 2017, indicated "Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually." A review of facility document titled, "Resident Bill of Rights", indicated "The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs."2. A review of the clinical record of Resident 2 on April 30, 2018 at 11:00 AM indicated she was admitted to the facility on July 28, 2016 with diagnoses of major depression, and an infected left eyebrow wound. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 181 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 A review of the clinical record of Resident 2 on April 30, 2018 at 11:30 AM, indicated on April 20, 2018, two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on April 30, 2018 at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. In an interview with the Licensed Vocational Nurse 1 (LVN 1) on May 2, 2018 at 1:00 PM, she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. In an interview with the Director of Social Services (DSS) on May 2, 2018 at 2:00 PM, she stated that she was not able to complete her investigation about the incident. The DSS stated that Adult Protective Services (APS) and police were not notified of the incident. During an interview with the Administrator on May 2, 2018 at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled, "Abuse Prevention and Prohibition Program", undated, indicated under Investigation, "a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 182 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 neglect, or injuries of an unknown source ... I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations ..."

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 05/22/2018 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 183 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 184 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 185 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 186 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Based on observation, interview, and record review, the facility failed to ensure for one of 27 sampled resident's (Resident 20) hospice services care was coordinated in accordance with the Facility and Hospice Company's contract. This failure had the potential to jeopardize the health and well-being of Resident 20 by not providing all the services that he was entitled to receive. Findings: During an observation on April 30, 2018, at 9:00 AM, Resident 20 was sleeping on top of his bed, he had multiple visual skin lesions to his face and arms. A medical record review of Resident 20's indicates, Resident 20 was admitted to the facility on August 21, 2014, with diagnoses that included hospice with a start of care (SOC, when a patient is first admitted to a hospice agency) of November 14, 2014, with a terminal diagnoses of Acquired Immune Deficiency Syndrome (AIDS, were there is a severe loss of the body's immunity, greatly lowering the resistance to opportunistic infections), and chronic obstructive respiratory disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During an interview on May 3, 2018, at 1:30 PM, with Registered Nurse Supervisor (RNS 1), RNS 1 did not know where to locate any documents as they related to Resident 20's hospice care. She further stated that she could not tell who or when anyone comes in, but that she thinks there might be a sign in book. During an interview on May 3, 2018, at 7:30 PM, with Registered Nurse Supervisor (RNS 3), RNS 3 did not know where to locate any documents as they related to Resident 20's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 187 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 hospice care. She said we used to have a separate chart for the hospice, but I don't know what happened to them. During an interview on May 4, 2018 at 8:30 AM, with the Medical Records clerk, she indicated the individual hospice charts are located in the medical records office. She indicated that when she was not on site limited people have access to her office. During an interview and concurrent record review on May 4, 2018, at 9:12 AM, with the Director of Nurses (DON), Resident 20's facility clinical record and the contracted Hospice clinical record were reviewed. The DON stated that the purpose of having hospice in the facility is for the coordination of hospice care and the services they provide for a resident at the end of their life. During a review of both records the DON could not locate any documents that indicated who and when staff from the hospice come into the facility. She states that the hospice is to sign in whenever they come in to give care. She also stated that the hospice should be putting notes in our clinical record, so that we know what is going on with our Resident. The DON stated that the hospice is to provide the facility with a calendar that should show what days of the week the hospice comes out so that the facility staff can coordinate care for the resident. The DON confirmed that she could not locate a calendar that indicates when and what staff are coming into the facility. The DON confirmed she could not locate any communication notes from the hospice regarding patient care. During the interview the DON was asked how often Resident 20 was to been seen by hospice staff and who came into see him. The DON stated that she was not sure where that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 188 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 information was to be found, and that she would have to go to the nurse's station to see if that kind of information is kept there or possibly it might be located in the chart. The DON located the Hospice Interdisciplinary Comprehensive Assessment and Plan of Care (IDG/POC, document that the hospice provides that includes the benefit period of the Resident; the medical diagnosis; the Residents identified problems list which include medical, spiritual and teaching needs; medications; and the scope and frequency of the visits to be made to the resident by each discipline), she stated she knew this was one of the hospice documents but she was unable to describe what the purpose of the document was and she could not locate the scope and frequency of visits for each discipline. During a concurrent review of the IDG/POC with the DON, she was shown the scope and frequency of visits. The IDG/POC indicated that for the benefit period of March 2, 2018 through April 30, 2018, indicated that Resident 20 was to have been seen by a skilled nurse (SN) twice a week; a certified home health aide (CHHA) twice a week; a medical social worker one time per month; and a spiritual advisor two times a month. The DON reviewed the facility and hospice clinical record and confirmed that there was no documented evidence that any of these visits were made. A review of the hospice physician notes were reviewed with the DON. The DON was able to locate one visit that was made by the doctor on February 26, 2018 as a monthly visit. During a review of the IDG/POC with the DON, the DON could not provide any documentation as to the coordinated plan of care that the facility and the hospice are supposed to be working towards the care of Resident 20. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 189 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 DON provided the facility plans of care for Resident 20. These were compared to the problems list on the IDG/POC. The facility had identified more issues with the resident than the hospice agency. The DON was unable to provide documentation that the hospice participates with the facility interdisciplinary team meetings. A document was located in the hospice notebook entitled "Comprehensive Plan of Care" dated November 18, 2018, with the following identified problems, outcome/goals; and interventions: a. Problem - The professional management of a patient in a skilled nursing facility. b. Outcomes/Goals - includes, Patient needs will be met through care coordination between the facility, patient family/caregiver, Case Manager, Attending Provider, and Hospice Interdisciplinary Group. c. Interventions - Patient's Hospice Comprehensive Plan of Care will be integrated with the facility plan of care and will be available to the nursing facility for all caregivers to access to facilitate continuity of care. A review of the hospice sign in notebook was conducted with the DON, she confirmed that the book covered a year in time, she also confirmed that the only dates that [Name of Hospice] signed in were for May 5, 2017; August 10, 2017; September 12, 2017; and March 23, 2018. An interview and concurrent record review on May 3, 2018, at 10:30 AM, with the DON of the facility contract with [Name of Hospice Company] and the Facility was reviewed. The Hospice responsibilities included but not limited to the following: - Hospice resumes responsibility for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 190 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 professional management of the resident's hospice service provided, in accordance with the hospice plan of care (POC) and the hospice conditions of participation, and make any arrangements necessary for hospice related inpatient care in a participating Medicare/Medicaid facility. - Providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement; social work. - Coordinating the care of the hospice patient by developing, implementing and overseeing the integrated plan of care (POC) with the interdisciplinary group in coordination with the facility staff ... Plan is revised and update as needed. - Hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. - Authorizing all services, medications and treatments related to the terminal illness and related conditions. - Communicating with the facility's skilled nurse/representative, and other staff as appropriate, any changes in the integrated plan of care. The facilities contracted responsibilities included but not limited to the following: - Follow the hospice medical direction - Follow the agreed upon integrated POC including notification for any changes in patient's conditions, or family/resident concerns to hospice. Medication administration and documentation of all care and services provided. - Notify the hospice to obtain prior authorization for treatments or orders as related to the terminal illness and related conditions. - Notify the hospice staff for any changes in condition, including death. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 191 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 - Supporting the hospice training of staff. - Timely notification to the hospice of upcoming conferences. - Reinforcing information provided to the resident and family regarding the resident's condition and POC in collaboration with the hospice staff. The terms and responsibilities of the contract were discussed from both from the facility and the hospice agency perspective. The DON stated that given everything that she has reviewed today with Resident 20's chart that there is no indication that there is coordination of care between the two companies. The DON stated, "Clearly we don't have any idea when or if the hospice comes into the facility."The DON confirmed that it is the responsibility of the facility to ensure they know what services are being provided and from what she see's there is no integration with this hospice in regards to Resident 20's care. She states in fact it looks like we provide all the care and they are getting all the reimbursements. During an interview and concurrent record review on May 3, 2018, at 10:50 AM, with the Administrator (ADM), he states that the facilities role is to provide services and care to the patients. He states that we render most of the residents care. The ADM was not able to provide documentation as to how the facility knows who provides care to Resident 20 and how frequently. The ADM states that they come in whenever the schedule says they should be here. The ADM was unable to provide any documentation regarding how he monitors or coordinates the care between the facility and hospice. The ADM was unable to say if the facility staff go to the Hospice IDG/POC meeting or if the Hospice comes to his facility Interdisciplinary Team Meetings. After a review of the responsibilities of the contract between FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 192 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 [Name of Hospice] and the facility, the ADM states that they don't seem to be in compliance with the contract and that seems as if we are providing all the services to Resident 20.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 05/22/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 193 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 4. During a recertification survey of the facility, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 194 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 on April 30, 2018 at 9:16 AM, Resident 212 was sitting in the edge of the bed and just finished eating his breakfast. The Resident 212 has oxygen at 4 lpm (liters per minute) via nasal cannula tube. The oxygen tubing has no label and was not dated. During an interview with Licensed Vocational Nurse (LVN 2), on April 30, 2018 at 10:15 AM, she stated, "If there's no label or not dated, there will be a chance that Resident [Resident 212] will acquire infection." During an interview with the Infection Control Nurse (ICN), on May 2, 2018 at 2:19, she stated, "It should be labelled or dated, and must be changed weekly." A review of facility policy and procedure titled, "Oxygen Administration and Maintenance, dated July, 2013, indicated "Oxygen Administration Sets: 2. Used oxygen administration sets will be replaced weekly. Nursing staff will label and/or record dates when administration sets are placed." Based on observation, interviews, and record review, the facility failed to follow their policy when four resident's (Resident's 168, 167, 35 and 212) nebulizer (drug delivery device used to administer medication in the form of mist inhaled into the lungs) and oxygen tubing's were not labeled and dated. These failures had the potential for bacteria (microorganism that causes diseases) to harbor in the tubing and cause an infection for four residents. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 195 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 1. During an observation on April 30, 2018 at 8:30 AM, in the room of Resident 168, an oxygen tank with a long tubing that was not labeled was beside her bed. A concurrent interview with resident 168 stated that the oxygen tank was hers and she uses it whenever she was having difficulty of breathing. During an interview with the Licensed Vocational Nurse 4 (LVN 4) on April 30, 2018, at 8:35 AM, she stated that the tubing must be labeled and dated. She stated that it is important for the tubing to be labeled so they will know when to replace the tubing and prevent infections. A clinical record review of Resident 168 indicated she was admitted on March 8, 2018, with diagnoses of chronic obstructive pulmonary disease (a lung disease that blocks the airflow and makes it difficult to breathe). Resident 168's physician order was reviewed ,it indicated an order of oxygen at three liters/minute (unit of measure) via nasal cannula (device used to deliver supplemental oxygen). 2. During an observation on April 30, 2018, at 9:00 AM, in the room of Resident 167, her oxygen tank was attached at the back of her wheelchair. Oxygen tank tubing was not labeled and dated. Resident was asleep in her bed. A clinical record review of Resident 167 indicated, she was admitted on July 7, 2014, with diagnoses of dementia (a brain disease that causes memory loss), and pulmonary fibrosis (a lung disease causing scars in the lungs causing difficulty of breathing). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 196 of 197 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: _______________ 555773 (X3) DATE SURVEY COMPLETED 05/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INDIAN CANYON POST ACUTE 57333 Joshua Ln 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 Resident 167's physician order indicated an order of oxygen at two liters/ minute (unit of measure) via nasal cannula. During an interview of LVN 4 on April 30, 2018 at 9:30 AM, she stated that oxygen tubing must be replaced every week and dated. 3. During an observation in the room of Resident 35 on May 2, 2018, at 11:00 AM, her nebulizer (drug delivery device used to administer medication in the form of mist inhaled into the lungs) tubing was not labeled. During a concurrent interview with Resident 35, she stated the nebulizer was hers and she uses it often. A clinical record review for Resident 35 indicated, she was admitted on September 15, 2017,with diagnoses of major depression, asthma (a lung condition were in the lung tubes thickens causing difficulty of breathing). Resident 35's physician order indicated albuterol (medication to help ease breathing), at two liters /minute (unit of measure) via nebulizer. During an interview with LVN 4 on May 2, 2018 at 11:45 AM, she stated that the tubing must be labeled so that they will know when to replace it and prevent infections. A review of the facility's policy and procedure titled, oxygen administration and maintenance, dated July, 2013, indicated under oxygen administration set, " ...2. Used oxygen administration sets will be replaced weekly. Nursing staff will label and/ or record dates when administration sets are replaced." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LK4211 Facility ID: CA240000682 If continuation sheet 197 of 197