Health inspection·March 25, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan (a document outlining how to best care for a resident and meet their needs) for one of three sampled residents (Resident 3) after Resident 3 suffered a fall with injury. This failure had the potential for Resident 3 to suffer a subsequent fall that could result in another injury or worsening of Resident 3's current injury to his left ribs. Findings: During a review of Resident 3's admission Record (a document with basic client information), the admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a disease of the lungs that causes air-flow blockage and breathing-related problems), Epilepsy (abnormal electrical brain activity, also known as a seizure) and History of Falling (resident has fallen in the past). During an observation on February 8, 2024 at 9:48 AM, in the facilities 400 hallway, Resident's 3 room was located at the end of the 400 hallway and not close to the nurses station. During a concurrent observation and interview on February 8, 2024, at 9:52 AM Resident 3's room with Certified Nursing Assistant (CNA 1) Resident 3's call light (device used to call for help and assistance) was tied to the bed rail and hanging near the floor behind his head and not accessible to Resident 3. CNA 1 stated Resident 3 could not reach the call light and Resident 3 could decide to get up to call for help and fall again. During a concurrent interview and record review on February 8, 2024, at 11:00 AM with Licensed Vocational Nurse (LVN 1), Resident 3's Care Plan dated January 31, 2024 was reviewed. The Care Plan indicated, .Interventions Attach call light to bed within access of resident .Place resident close to nursing station for close observation . LVN 1 stated Resident 3's care plan was not fully implemented . She stated Resident 3's room is not close to the nurse's station and the resident should be able to access his call light from his bed. The LVN 1 further stated, Resident 3 would have difficulty requesting help if he needed it and could try to get up and fall again. During a concurrent interview and record review, on February 8, 2024, at 11:30 AM, with Registered Nurse (RN), the facility policy and procedure (P&P) titled, Care Planning, undated, was reviewed. The P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and (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 03/25/2024 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)