Health inspection·October 19, 2023

F642 Residents Affected - Many Based on interview and record review, the facility failed to ensure proper security measures were in place to protect the use of an electronic signature. When (Licensed Vocational Nurse LVN1) used (Registered Nurse RN 1), electronic signature to sign a (Minimum Data Set MDS) verifying the MDS is complete for 66 residents. This failure had the potential to cause inaccuracies in the completed comprehensive assessment in the MDS's for 66 clinically compromise residents. During an interview on October 4, 2023, at 11:22 AM, with the Activities Director, (Activities Director focuses on creating activities that enrich participants' lives with physical and cognitive exercise and socialization through recreational activities such as sports, dancing, arts, and crafts). The Activities Director stated she assesses residents by filling out the Minimum Data Set Assessment (MDS- a computerized resident assessment instrument) States she goes to the residents' room and uses a paper form, then goes on PCC (PointClickCare, a cloud-based healthcare Software provider) to document and keeps paper form in a binder in her office. She then signs off with her password. She stated if her password does not work, she will talk to DSD (Director of Staff Development) or administrator to reset her password. She also stated she had an in-service and signed a paper that state no sharing of password. During an interview on October 4, 2023, at 1131 AM, with DSD Assistant, she stated she does the supplemented training. She stated she did the training because some passwords were not being protected, that there were issues with information that needs to be shared with other and things were being signed off . Stated that if her password is not working, she would contact information support at Corporate Office through email. States staff usually go to nursing supervisor or administration. During an interview on October 4, 2023, at 1145 AM, with Dietary Supervisor, she stated her MDS documentation part is the letter K, Swallowing and Nutritional status. Stated she does the assessment in the residents' room, once the assessment is done and completed, she documents on PCC, she then signs at the end using her passcode. States if her passcode does not work, she will let administration know. She stated she knows not to share her passcode because that is her signature, and it was told to her on orientation by staff development. During an interview on October 4, 2023, at 1200 PM, with MDS nurse, she stated, her passcode needed to be reset and she asked Medical Records Director, who created a new profile instead of resetting password. States she does her resident assessments in the rooms then goes to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555773 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Canyon Post Acute 57333 Joshua LN Yucca Valley, CA 92284 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0642 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many office and enters data and signs assessment she did. States then the DON (director of nursing) signs for the RN (registered nurse). States he makes sure her sections are completed. During an interview on October 4, 2023, at 1215 PM, with DON, she stated she has not done MDS as an MDS nurse. States she understands there were 66 modifications during September 6, 2023, through September 12, 2023, to make a correction or an adjustment. States that if her passcode was used, she would report to administration that someone used her passcode. She stated she has been employed for a year and in orientation they talked to her about not sharing her passcode. During a concurrent interview on October 4, 2023, at 12:52 PM, with Administrator and DON, the administrator stated his knowledge base of the MDs is the same as a High-level Rehab Director (Director of Rehabilitation). States the Rehab Director puts in the minutes in the MDS, and the rehab Director makes sure the therapy department minutes are accurate before sending them over. States there are 66 modifications on MDS to make sure they are accurate and to make sure an accurate RN signature. Stated they were under the direction of RAI (Resident Assessment Instrument) to modify signatures. Stated before doing that they went to RAI or probably a third-party auditor. Stated the in-service of Policy and Procedure review on September 29, 2023, was to review MDS completion and Passwords and User ID codes. Stated he will have staff come in at all hours to ensure all staff are in serviced. During an interview on October 4, 2023, at 1:00 PM, with a ADON (Acting Director of Nursing), he stated he has been employed for 3 months. Stated he was ADON from July 5, 2023, through September 24, 2023. He stated that while he was acting ADON, he did not do anything with MDS because he probably got 1.5 hours of training. Stated his understanding of signing off the MDS is to make sure MDS is complete since this investigation started. Stated they told him he was signing that each section was completed. His understanding of how his signature got on the MDs was when he raised the flag that his password was being reset. He stated that his password was reset 2 weeks into him being ADON and in July his password was reset a few times. States that in August while he was on vacation his password was also reset a few times. States that it was brought this attention by the medical records that there was 112 pages of documentation with his signature. He states his understanding if his password does not work, he would notify medical records then she would reach out to Corporate office resources, and they would reset it. He stated that he believes it was Medical Records Director. He stated that if he was not able to log on to PCC and would get a notification to reset, it was reset to a default and that way LVN 1 MDS resource, was able to sign off all the MDS under his name. During a review of the facility's Policy and Procedure titled Electronic Signatures and Electronic Orders revised April 2021, the policy and procedure indicated the HCP will receive an individual identifier access code from an appropriate administrative person. The access code is for his/her use only. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555773 If continuation sheet Page 2 of 2