Health inspection·November 27, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to remove a building hazard, a threshold (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room) that leads to the patio and is used by residents and families creating a hazard which poses a risk for falls. This failure placed two out of three residents (Resident's 1 and 2) at risk for severe injuries due to falls. Findings: An unannounced visit was made to the facility on November 27, 2023, at 1:19 PM, to investigate a complaint regarding quality of care and Accidents. During review of resident 1's admission Record (general demographics), the document indicated resident 1 was admitted to the facility August 1, 2023, with diagnosis to include Muscle weakness, Hemiplegia(paralysis on one part of the body) and Hemiparesis (weakness or the inability to move on one side of the body) affecting right dominant side following Cerebral Infarction(a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a review of resident 1's progress note, (An ongoing record of a patient's illness and treatment) dated November 19, 2023, at 7:05 AM, the document by Licensed Vocational nurse (LVN 1), it indicated, Another resident was yelling for help. I went to the patio resident was lying on her right side, her right leg was wrapped around the wheelchair that was behind her, she was fully clothed. This happened in the patio entrance into the facility. Resident stated she was trying to get back into the facility and when she reached the doorknob she fell out of her chair, she has a hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel(a network of tubes through which blood is pumped around the body) on her right forehead with 8/10 pain, res on observation could move all extremities, had PERLA (an acronym for pupils are equal, round and reactive to light and accommodation. Healthcare providers use the PERRLA eye test to check if your pupils look and function as they should), hand grasps bilat weak. She was lifted off floor via 2 persons assist and placed back into her wheelchair. Doctor was notified and res was sent to the ER (emergency room) for further eval. BP (blood pressure, the pressure of blood pushing against the walls of your arteries) 183/78, r (respiratory)85, O2 Sat (measures the percentage of oxyhemoglobin (oxygen-bound hemoglobin) in the blood) 96, temp (temperature) 97.5. (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 11/27/2023 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)