Yucaipa Hills Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF801Jul 1, 2021

  Based on observation, interview, and record review, the facility failed to employ a full-time (35 hours per week) qualified dietitian or designate a person to serve as director of food and nutrition services when their Dietary Services Supervisor quit on June 11, 2021. This resulted in the food services department lacking in oversight which led to unsanitary conditions in the kitchen when the following were found: A. Shelf was deteriorating from water damage. B. The floors under all shelving and equipment and in the dry storage were dirty with food debris and trash. C. The two stoves had a black grime, and the floor underneath the stoves had a build-up of black grime and rotting food. D. Dead rodents and roaches were found. E. […]

• Immediate jeopardy, widespreadF812Jul 1, 2021

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen were implemented when: 1. The Facility didn't address the broken door sweep that the pest control company identified as a pest entry point and four dead mice were found in the oven stuck to a glue trap. Rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. 2. A glue trap in the dry storage was found with dead roaches. Insects are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. 3. […]

• Immediate jeopardy, isolatedF689Oct 18, 2024

  An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 S483.25(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) S483.25 (d) Accidents. […]

• Actual harm, isolatedF689Sep 13, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF803Feb 24, 2023

  Based 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… […]