Yucaipa Hills Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the use of a respiratory equipment for one of three sampled residents (Resident 1) when an incentive spirometer (a handled device used to encourage deep breathing and to keep the lung expand) remained at Resident 1's bedside without a physician's order for continued use, documented assessment or documented resident and family education. This failure had the potential for Resident 1 to use the device incorrectly, placing her at risk for atelectasis (collapse of small air sacs in the lungs) retained respiratory secretions, and pneumonia (an infection that makes it harder to breathed).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two crash carts (a wheeled cart carrying emergency equipment and medications for use in case of emergency) were checked and documented daily by staff as per facility's policy and procedure (P&P) titled, Emergency Medical supplies and equipment when the crash cart in the upper unit (CCUU) was not checked and documented. This failure had the potential to cause delay in availability and functionality of emergency equipment and medications in case of an emergency which will impact the health and safety of all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for Foods brought by family/visitors when one of 6 sampled residents (Resident 47) reviewed for nutrition received food from a visitor of another resident. This failure had the potential to compromise dietary compliance and risk Resident 47's health and nutritional needsFindings:During an observation on January 7, 2026, at 12:45 PM, in activity/dining room, Resident 47 was sitting on table one with other residents . One of the resident's (Resident 19) wife (not a resident in the facility/visitor) brought snacks including potato chips, marshmallows, a packet of hot [NAME] powder (a package of powder which contains chocolate and sugar and can be mixed with water or milk to make hot chocolate) were handed by the visitor to Resident 47. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure (P&P) titled, Oxygen Administration, for one out of one sampled resident (Resident 7) when oxygen was not administered according to the physician's order. This failure had the potential to compromise Resident 7's respiratory status which would risk resident 7's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when there was visible accumulation of grime and debris within an actively used oven and the continued presence of a non-functional refrigerator in the food preparation area. This failure had the potential to result in accumulating pathogenic microorganisms (germs or infectious agents that can cause disease) and to attract insects or rodents, which could place the health and safety of 81 highly vulnerable residents who receive food from the kitchen at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control practices for one of 18 sampled residents (Resident 6) when an indwelling urinary catheter (Foley-a tube that stays inside the bladder to drain the urine into a bag) drainage bag was observed resting on the floor. This failure had the potential to promote the transmission of infection by allowing contamination of the urinary catheter drainage system and increasing the risk of urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to negatively impact resident comfort, dignity, and safety by limiting adequate space for movement, equipment placement and staff assistance of four residents (Resident 1, 27, 35, and 57) who reside in the two rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1) when Resident 1, a resident who was at high risk for falls and fully dependent upon staff for mobility while in bed, fell from his bed while being changed by Certified Nursing Assistant 1 (CNA 1). This failure resulted in Resident 1 to sustain a head injury which included a bleeding laceration to his right eyebrow and a subarachnoid hemorrhage (bleeding in the area between your brain and the thin tissues that cover and protect it).

Inspectors wroteAn immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 16, 2024, at 4:53 PM, regarding the elopement of Resident 27 from the facility on October 16, 2024. An IJ was called in the presence of the Administrator. A corrective action plan was requested on October 16, 2024, at 4:53 PM. The immediate Jeopardy was removed after the corrective action plan was verified to be implemented through observations interviews, and record reviews on October 17, 2024, at 2:46 PM in the presence of the Administrator. Free of Accident Hazards / Supervision/Devices CFR (s): 483.25(d)(2)(2) §483.25 (d) Accidents. The facility must ensure that. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for thirteen of thirteen residents (Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76) reviewed for residents' assessment. These failures resulted in inadequate monitoring of progress or decline for Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76 and the lack of resident specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eighteen residents (Resident 36) reviewed for advanced directives had a Physician Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) accurately completed when there was conflicting information documented regarding medical interventions. This failure had the potential for Resident 36 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the resident wanted.

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff reported an allegation of abuse to the required parties and in the timelines specified by the facility's policy and procedures (P&P) and as required by federal regulations. This failure resulted in an allegation of abuse to not be reported and subsequently investigated which had the potential to place Residents 36 at risk for ongoing abuse or mistreatment due to a delay in the reporting and investigation of the alleged incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents 14 and 11) received care and services as specified In their care plans (individualized plans for the medical care of a resident) when: 1) For Resident 14, the facility did not ensure staff kept the resident's smoking materials. This failure had the potential to result in in accident or injury to Resident 14 and other residents residing in the facility as a result of increased fire hazard. 2) For Resident 11, the facility did not ensure staff checked the residents blood sugar before meals. This failure has the potential to affect Resident 11's blood sugar management and could lead to inaccurate blood sugar readings, which may result improper insulin administration (medication use in the treatment and management of diabetes) and increased risk of hyperglycemia (elevated blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document the low air loss mattress (specialized mattress designed to help prevent and treat pressure ulcers) according to the physician's order for one of two sampled residents (Resident 40) who had a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential for Resident 40 not to receive the necessary treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a gradual dose reduction (GDR) for one of eight sampled residents (Resident 55) when a recommended a decrease in Trazadone (a medicine that helps people who are feeling very sad or having trouble to sleep) from 100 mg (milligrams unit of measurement) to 50 mg was not done and documented. This failure has the potential to result in over medication and increased risk of side effects for Resident 55.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for labeling and dating of food items when a bottle of [brand name] creamer was found on top of a table inside the kitchen at room temperature without an open date. This failure has the potential to increase the risk of foodborne illness or contamination due to improper storage practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Resident 55, 28, 64, and 44) who reside in the two rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a system for controlling the spread of a communicable disease for one of four sampled residents (Resident 1) when Resident 1 was on transmission-based droplet precautions (a set of measures used to prevent the spread of organisms that cause disease through respiratory secretions) for a coronavirus disease (COVID-19-an infectious disease caused by a virus) exposure and was allowed to participate in activities with 11 other residents. This failure had the potential to cause the spread of COVID-19 to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s call light was found hanging from a light fixture on a wall. 2. Resident 3 ' s call light was found behind a nightstand on the floor. These failures had the potential to result in resident harm and unmet needs for Residents 1 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for Fall Risk Assessment for one of three sampled residents (Resident 1) when Resident 1 was not accurately assessed for fall risk. This failure resulted in Resident 1 to experience a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure one on one (1:1) supervision (direct one on one monitoring of a resident by a staff member) was implemented for one of 80 residents (Resident 1) as ordered by a physician on April 13, 2023 when Resident 1 was found on the floor of his room with his door closed and unaccompanied by staff with a laceration (a cut or skin wound) injury to his head after he sustained an unwitnessed fall. This failure resulted in Resident 1 sustaining a head injury which required treatment and evaluation in a hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lunch menu was being followed on February 21, 2023, when: 1. Six residents on a Pureed Diet (texture modified diet where all foods are blended to a mashed potato consistency) received a half-cup serving of Chicken Jambalaya (meat and rice dish), when the menu indicated a one-cup serving of Chicken Jambalaya should have been provided. 2. 62 Residents on a Regular Diet (diet that does not include any meal restrictions), Mechanical Soft Diet (altered-texture diet for people who have difficulty chewing and swallowing), and a CCHO Diet (consistent carbohydrate - diet indicated for people with diabetes mellitus, a disease that alters how the body processes sugar) received the wrong meal portion of Chicken Jambalaya. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prepared for residents on a Pureed Diet (texture modified diet where all foods are blended to a mashed potato consistency) was palatable for lunch on February 22, 2023, when five out of five residents (Resident 4, 56, 28, 27, and 25) on a Pureed Diet were served pureed meatloaf that was not palatable and did not taste comparable to the meatloaf that was served to the residents receiving a Regular Diet (diet with no restrictions). This failure had the potential to cause the residents on a Pureed Diet to experience a decrease in food intake which could lead to poor nutrition and health outcomes for these vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form that met individual needs when 28 of 28 residents on a Mechanical Soft Diet (altered-texture diet for people who have difficulty chewing and swallowing) were served toasted bread with crust when the menu indicated they should have received soft bread with no hard crusts. This failure had the potential for the affected residents to choke and/or aspirate (accidental breathing of food or fluid into lungs) with the restricted food forms, which could have resulted in resident harm.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change Assessment (SCA) within 14 days for two of three sampled residents (Residents 31 and 27) who were reviewed for hospice (a program providing services for the care of terminally ill residents and their family) services as evidenced by: 1. The facility did not complete a MDS SCA for Resident 31 within 14 days of admission to hospice services. 2. The facility did not complete a MDS SCA for Resident 27 within 14 days of admission to hospice services. This failure had the potential to delay identification and implementation of necessary interventions to address the resident's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS - Computerized resident assessment completed by a licensed nurse) Assessments when Section H: Bowel and Bladder was inaccurately coded for one sampled resident (Resident 59). This failure to correctly notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents, has the potential for monies to continue to be paid to the facility for services not rendered to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess and address pain levels, by not following physician's orders for pain medication, for one sampled resident (Resident 4). This failure had the potential to cause the resident to experience avoidable discomfort and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for two (2) of six (6) residents (Resident 48 and Resident 62) observed during medication passes as follows: 1. For Resident 48 the manufacturer's specifications were not followed when Pantoprazole Sodium Delayed Release was crushed. 2. For resident 62 the physician's order for the Cranberry Supplement was not followed. This resulted in a medication error rate of 6.06 % in the 33 opportunities observed and had the potential to reduce the efficacy of the medications and to cause stomach irritation for Residents 48 and gave the wrong dose for Resident 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer's specifications for Pantoprazole Sodium Delayed Release tablet ordered for Resident 48. This failure had the potential for Resident 48 not to receive the maximum effect of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 46 resident rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Residents 71, 68, 57, and 229) who reside in the two rooms.