Other·June 15, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey to investigate a complaint. Complaint Number: CA00667155 Representing the California Department of Public Health: 36321 The investigation was limited to a specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the complaint: CA00667155

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

F600 05/27/2020 §483.12 Freedom from Abuse, Neglect, and Exploitation 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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 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: IPQS11 Facility ID: CA240000682 If continuation sheet 1 of 12 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 05/14/2020 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 safe environment free from abuse and neglect for one of 88 residents (Resident 1) when a Licensed Vocational Nurse 1 (LVN 1) failed to do the following for a resident who had just returned from the general acute care hospital for a complaint of chest pain: 1. Failed to assess Resident 1 upon readmission from the emergency room for pain and to take vital signs (temperature, pulse, respirations and blood pressure). 2. Failed to medicate Resident 1 for repeated episodes of nausea and vomiting for several hours as per physician's orders, or to offer pain medication for severe abdominal pain which caused Resident 1 to be heard screaming by her roommate and staff. 3. Failed to notify Resident 1's physician that Resident 1 had returned from the emergency room with vomiting, severe abdominal pain, high blood glucose level and the prescribed insulin coverage had not been given. These failures resulted in Resident 1 suffering unnecessary pain, having a rapid decline in her health which ended in her death within eight hours of returning to the facility. Findings: 1. A review of Resident 1's clinical record, the face sheet (Contains demographic information), indicated Resident 1 was admitted to the facility on November 5, 2019, and died in the facility on December 12, 2019, with diagnoses which included Type 1 diabetes mellitus (chronic condition where the pancreas produced little to no insulin), end stage renal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 2 of 12 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 05/14/2020 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 disease (ESRD- end stage kidney disease resulting in loss of kidney function) and dependence on renal dialysis (a machine that filters the toxins from blood when the kidneys do not work). A review of Resident 1's history and physical dated November 20, 2019, indicated Resident 1 was deaf (impaired hearing or unable to hear) and had an arteriovenous fistula (AV shunt, a surgically created connection between an artery [a blood vessel that carries blood away from the heart to the rest of the body] in left upper arm (LUE). Resident 1 was alert and capable of making decisions. During a review of Resident 1's Nurses Progress Notes indicated the following: a. December 10, 2019 at 2:10 PM, Resident 1 has not returned from the dialysis center. Charge Nurse/Registered Nurse Supervisor (CN/RNS) called the center and informed Resident 1 complained of (C/O) chest pain and [was]transported to the hospital. b. December 11, 2019 at 6:54 AM, Resident 1 returned from Emergency Room (ER) on December 10, 2019 at 11:20 PM, in a wheelchair (W/C) accompanied by one attendant. All labs came back within normal limits (WNL). Resident 1 was treated for musculoskeletal pain. After arriving back from ER Resident 1 had emesis (vomiting) x 2 (two times) clear liquid. Zofran (medication for nausea and vomiting) given x1. No medications taken by Patient. Will continue to monitor. There was no documented assessment of Resident 1's vital signs, or level of pain upon return from the general acute care hospital. A review of Resident 1's, "Weights and Vitals [vital signs] Summary," dated November 2, 2019 through December 10, 2019, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 3 of 12 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 05/14/2020 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 no vital signs had been documented after December 10, 2019, at 5:21 AM, when Resident 1 left for dialysis. During an interview with the Director of Nurses (DON), on December 20, 2020, at 12:25 PM, the DON confirmed Resident 1 had no assessment or V/S completed after returning from the hospital on December 10, 2019 at 11:20 PM. The DON stated, "Resident 1 should have been placed on 72- hour charting when returning from the hospital with chest pain and the physician should have been notified." During a telephone interview with LVN 1 on December 20, 2019, at 2:30 PM, LVN 1 confirmed, Resident 1 returned from [Name of Hospital] on December 10, 2019 at 11:20 PM, after being evaluated in the emergency for complaint of chest pain. LVN 1 stated she did not complete an assessment or take V/S when Resident 1 returned. When asked the reason an assessment of Resident 1 and vital signs was not completed upon return from the emergency room, LVN 1 stated, "I was too busy to complete an assessment and take V/S and then ran out of time." 2. During further review of Resident 1's Nurses Progress Notes the notes indicated the following: a. December 9, 2019 at 9:07 AM, Resident 1 was administered Imodium (medication to treat diarrhea) A-D Tablet 2 Milligrams (MG-unit of measure) twice for diarrhea. b. December 9, 2019 at 4:32 PM, Resident 1 did not go to dialysis due to her stomachache. Informed a new chair time (reservation at the dialysis center) was arranged for tomorrow at 8:00 AM. Social Services Worker (SSW) will continue to follow. RNS (Registered Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 4 of 12 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 05/14/2020 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 Supervisor) and CN (Charge Nurse) made aware. c. December 9, 2019 at 8:36 PM, Resident 1 refused to go to dialysis, different staff came to try and convince her to go, and still refused. Called dialysis and got her rescheduled for Tuesday at December 10, 2019 at 8:00 AM. There was no documented evidence the physician had been notified that Resident 1 refused her dialysis due to abdominal pain and diarrhea. During a review of Resident 1's physician's order summary dated December 1, 2019 through December 31, 2019 indicated the following medications had been ordered for pain and nausea or vomiting: a. Acetaminophen (medication given for pain or to reduce fevers) 1 Tablet 325 MG by mouth (PO) every (Q) 4 hours as needed for general discomfort. Order date November 10, 2019. b. Zofran (Medication for nausea and vomiting) Tablet 4 MG- Give 1 tablet by PO Q 8 hours as needed for nausea and vomiting (N/V). Order date November 10, 2019. A review of Resident 1's Medication Administration Record (MAR) dated December 1, 2019 through December 31, 2019 indicated the following: a. Acetaminophen Tablet 325 MG PO last administered on December 8, 2019 at 10:05 AM. b. Zofran 4 MG PO administered on December 11, 2019 at 6:02 AM (Seven hours after Resident 1 returned from the ER and had started vomiting). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 5 of 12 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 05/14/2020 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 Review of Resident 1's Nurses Progress Notes dated December 11, 2019 at 6:02 AM, indicated Resident 1 given 1 tablet of Zofran 4 MG PO Q 8 hours as needed for N/V. During an interview with the Social Service Worker (SSW) on December 20, 2019 at 12:15 PM, the SSW stated she had been helping Resident 1 who had been complaining of a stomachache the last two days before she died. The SSW stated she had to reschedule Resident 1's dialysis appointment to December 10, 2019. The SSW further stated when speaking with Resident 1's room-mate, she expressed concerns about Resident 1's death and stated, "Resident 1 yelled in pain and vomited all night." A review of Licensed Vocational Nurse 1 (LVN 1) statement provided to the Director of Staff Development (DSD) dated December 13, 2019, indicated, "During the evening of December 11 2019, while taking care of Resident 1, Resident 1 had vomited clear emesis and complained of a stomachache." My Certified Nurses Assistants (CNA) were instructed to clean up Resident 1 and the floor many times during the night. LVN 1 went into Resident 1's room to check on her and stated, "Resident 1 was moaning loudly and continued to say she had a stomachache." During an interview with the Director of Nurses (DON), on December 20, 2019, at 12:25 PM, the DON confirmed Resident 1 was not appropriately monitored after returning from the hospital. The DON stated, "Resident 1 was not provided good care by LVN 1." The DON further stated, "Resident 1 should have been administered medication in a timely manner for vomiting and offered medication for C/O abdominal pain." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 6 of 12 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 05/14/2020 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 telephone interview with LVN 1 on December 20, 2019, at 2:30 PM, LVN 1 confirmed Resident 1 returned from [Name of Hospital] on November 10, 2019 at 11:20 PM, and had vomited multiple times before she had administered any anti-nausea medication and she had not offered any pain medication when Resident 1 had C/O pain several times that night. LVN 1 further stated, "I was too busy, and I was sending my CNA's (certified nursing assistants) to check on her." During an interview with Resident 2, (Resident 1's room-mate), on December 20, 2019, at 3:00 PM, Resident 2 confirmed Resident 1 came back from the hospital on December 10, 2019 late in the evening, vomiting and C/O a stomachache. Resident 2 stated, "Resident 1 was deaf, kept vomiting and cried all night long of a severe stomachache." When staff would come in, "they would yell at both of us to be quiet." Resident 2 stated in the early morning, when Resident 1 had vomited, LVN 1 came in and said, "We are too busy to clean you up." When staff left the room someone said, "Bitch." Resident 2 further stated, "I knew when the room was quiet Resident 1 had passed away and I could not help her." 3. Review of Resident 1's Nurses Progress Notes dated December 11, 2019 at 7:58 AM, indicated Resident 1 during morning medication pass was in bed rocking back and forth and had emesis x1. Zofran 4 MG was given to Resident 1. Her 6:00 AM Blood Sugar (BS) was 397. No insulin was administered to Resident 1. Resident 1 was heard in every room yelling until around 6:50 AM. Change of shift the CNA stated she was not sure if Resident 1 was breathing. Oncoming nurse and this nurse ran down to Resident 1's room to check. Resident 1 was unresponsive. No FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 7 of 12 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 05/14/2020 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 pulse, or Blood Pressure (B/P), was found. Cardio-Pulmonary Resuscitation (CPRemergency procedure that combines chest compressions with ventilation to manually preserve brain function) was started and 911 was called. Paramedics arrived, CPR was done for 20 minutes and they were unable to revive Resident 1. It was called a 7:38 AM [Resident 1 was pronounced dead]. Resident 1's sister was notified at 8:00 AM. Review of Resident 1's physician's order summary dated December 1, 2019 through December 31, 2019 indicated an order for Resident 1 to receive a routine insulin: Insulin Glargine Solution (long acting medication to manage BS) 100 U/ML-Inject 50 U subcutaneous (S.Q.-inject right under the skin) every day (QD). In addition, Resident 1 had an order to receive sliding scale insulin meaning orders for insulin are to be administered based on the results of Resident 1's finger stick blood sugars (BS) with Novolog (medication used to control high BS) insulin- Flex-Pen Solution Pen-Injection 100 Units (U)/Milliliters (ML-unit of measure) inject per sliding scale 70-140- no insulin. Before meals (AC) and at bed time (HS) as follows: a. Blood sugar 150-199- give -8 U of insulin b. Blood sugar 200-249- give 12 U of insulin c. Blood sugar 250-299-give 15 U of insulin d. Blood sugar 300-349-give 18 U of insulin e. Blood sugar 350-399- give 20 U of insulin f. Blood sugar 400 or greater call MD A review of Resident 1's MAR dated December 1, 2019 through December 31, 2019 revealed the last dose of insulin was administered on December 10, 2019 at 6:00 AM before going to dialysis. The BS documented on December 11, 2019 at 6:00 AM was 397 and the prescribed dose of 20 units of Novolog insulin was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 8 of 12 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 05/14/2020 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 administered. There was no documentation to indicate the physician was notified it was not given nor that she had been vomiting all night. During a telephone interview with LVN 1 on December 20, 2019, at 2:30 PM, LVN 1 confirmed, she did not notify Resident 1's physician during the night that she had been vomiting and had been yelling out in severe abdominal pain. LVN 1 stated she did not notify Resident 1's physician that her BS was 397 and withheld her insulin because she was vomiting. When LVN 1 was asked if the protocol would be to notify the physician when a resident has a change of condition (COCsignificant change in the resident's physical/emotional/emotional/mental condition), LVN 1 stated, "I should have called but, I was too busy." During an interview with Director of Staff Development (DSD), on January 20, 2019, at 3:20 PM, the DSD stated LVN 1 should have initiated a, "COC, placed on 72-hour charting, called Resident 1's physician and notified him regarding her vomiting, severe abdominal pain and her BS being 397." The DSD stated he is in- charge of training staff and provided no additional training for LVN 1 after an allegation for abuse was made by Resident 2 and no COC was completed for Resident 1 A review of LVN 1's employee file for training since hire date indicated she was hired on October 8, 2019. She had signed as having received the following trainings: a. Mandated Reporter [related to abuse and neglect]-dated October 8, 2019 b. Staff Abuse Training/Elder Abuse-dated October 8, 2019 c. Pre/Post Elder Abuse Test-dated October 8, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 9 of 12 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 05/14/2020 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 2019 d. Resident Rights/Abuse Prevention- dated October 8.2019 A review of the disciplinary action form dated January 6, 2020 for LVN 1 indicated "[Name of Facility and Rehabilitation Education/Counseling Notice], Violations: Safety issue. Any further occurrences will result in Termination." During an interview with the DON on January 27, 2020, at 3:45 PM, the DON confirmed LVN 1 was terminated on January 6, 2020. An Interview with the DON and DSD and review of policies and procedures on January 27, 2020, indicated the following: A review of facility's 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 14, 2016, indicated, "Current Employees, or more often as deemed appropriate by the Administrator, the DON, or the DSD current employees will be educated about the contents and requirements of these policies and procedures as well as the laws relating to the issues." A review of the facility's policy and procedure titled." Abuse Investigation and Reporting, "Revised 2017, indicated ..." All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly invested by facility management: Findings of abuse investigation will also be reported. Role of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 10 of 12 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 05/14/2020 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 Investigator: 1. Individual conducting the investigation will, as a minimum. b. Review the Resident's medical record to determine events leading up to the incident. J. Review all events leading up to the alleged incident. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property for will be reported by the facility Administrator or designee." A review of the facility's policy and procedure titled, "Charge Nurse" undated, indicated ..." The primary purpose of your job position is to provide direct nursing care to supervise the day to day nursing activities performed by nurse's assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and degree of quality care is always maintained. Must not pose a direct threat to health or safety of individuals in the workplace." A review of the facility's policy and procedure titled, "Resident Rights" dated December 2016, indicated ..." Employees shall treat all residents with kindness, respect, and dignity." A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status." Revised 2017, indicated, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/ or status; 2. A, "Significant Change" of change is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions: b. Impacts more than one area of the Resident's health status." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 11 of 12 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 05/14/2020 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 facility's policy and procedure titled," Administering Medications," dated December 2012 indicated. "Medications shall be administered in a safe and timely manner, and as prescribed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IPQS11 Facility ID: CA240000682 If continuation sheet 12 of 12