Jurupa Hills Post Acute

In the surveyor’s words

From the most serious findings on record at Jurupa Hills Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 29, 2024

  Based on observations, interviews, record review, and facility document and policy review, the facility failed to implement a system that allowed staff to quickly and accurately identify code status (describes the type of interventions to be provided when an individual is found without a pulse or not breathing) in the event of an emergency and failed to honor the advance directive of 1 (Resident #32) of 4 sampled residents reviewed for advance directives. Specifically, on [DATE], staff initiated cardiopulmonary resuscitation (CPR) when Resident #32 was found unresponsive, despite the resident having a signed physician's order for life sustaining treatment (POLST) and an advance directive on file that indicated the resident elected do not resuscitate (DNR) in the event they were found not… […]

• Actual harm, isolatedF689Aug 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure, for one of three residents (Resident 1):1. An environment free from accident hazards, when a resident (Resident 1) was able to gain access and ingest a packet of hydrocortisone (steroid ointment) without the staff knowledge. This failure resulted in the hydrocortisone packet getting lodged to the resident's throat causing the resident to choke while eating, which could subsequently obstruct the resident's airway leading to a loss of consciousness and death. Resident 1 was transferred to the general acute hospital (GACH), for evaluation and treatment; and2. The incident related to finding the hydrocortisone packet lodged in the resident's throat was thoroughly investigated. […]

• Actual harm, isolatedF689Sep 11, 2024

  Based on interview and record review, for one of three residents reviewed (Resident A), the facility failed to ensure the effectiveness of the interventions to prevent falls were evaluated, and new interventions were implemented to address Resident A ' s repeated falls due to behavior of getting up unassisted and prevent further falls. These failures resulted in Resident A to have 16 falls from October 16, 2023, to February 13, 2024, while at the facility. Resident A ' s fifth (5th) fall resulted to the resident to sustain a laceration (cut) on the back of his head and was treated in the emergency room (ER) with two staples (used to close wounds) placed on the laceration. Resident A ' s ninth (9th) fall resulted to the resident to sustain a skin tear on the right elbow. […]

• Actual harm, isolatedF689Jun 25, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision while smoking, to one of three sampled residents (Resident C). In addition, the facility failed to ensure smoking paraphernalia was not kept in possession of the residents in accordance with the facility policy and procedure. These failures resulted in Resident C to cause physical harm to Resident A and Resident B. Resident C hit Resident B in the face; and Resident C burnt Resident A's arm with a lit cigarette while at the smoking patio, on June 9, 2024, resulting in Resident A to sustain a cigarette burn on the right arm. Findings: On June 20, 2024, at 8:35 a.m., an unannounced visit to the facility was conducted to investigate a safety concern. […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure professional standards for food safety were upheld when:1. Several kitchen staff did not wear hairnets properly; and2. The Dishwasher did not change gloves after touching dirty kitchenware and before touching the clean and sanitized large SS pans coming from the dishwashing machine. In addition, during the dishwashing process, multiple kitchenware which had crusted food residue on them, were rinsed above and beside beverage cups and glasses.This failure had the potential to cause food-borne illness in a highly susceptible population of residents who could consume food.Findings:On June 30, 2025, at 3:05 p.m., an unannounced visit was conducted at the facility to investigate complaints regarding dietary… […]