Other·September 6, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to investigate a Facility Reported Incident. Intake Complaint Number: CA00583213. Representing the California Department of Public Health: Surveyor ID number: 33549 Census: 18 Sample: 3 An Immediate Jeopardy (IJ - a situation with the potential to harm the health and safety of the residents) was called under 483.12, Freedom from abuse, neglect, and exploitation (refer to F600 Free from Abuse and Neglect) on April 18, 2018, at 5:10 PM, in the presence of the facility Chief Executive Officer (CEO), the Interim Director of Nursing (IDON) and the Risk Compliance Officer (RCO). The CEO, IDON, and the RCO were verbally notified of the IJ situation identified based on the facility's failure to ensure residents were free from verbal abuse. The corrective action plan was reviewed and accepted on April 19, 2018, at 4:18 PM, in the presence of the Chief Nursing Officer (CNO), IDON, and the CEO. The IJ was lifted on April 20, 2018, at 10:00 AM, in the presence of the CEO, CNO, and the IDON. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F600 Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 SS=L PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/07/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their abuse policy and procedure when one of three sampled residents (Resident 1) was subjected to verbal abuse by a Certified Nursing Assistant (CNA 2) while providing care. This failure caused Resident 1 to experience psychosocial harm and had the potential for other residents residing in the facility to be subjected to abuse. Findings: On April 18, 2018, at 10:45 AM, an interview was conducted with the Interim Director of Nursing (IDON) for the facility's Inpatient Acute Care unit, and the Dependent Part/Long Term Care Skilled Nursing Unit. The IDON stated, on April 12, 2018, she received a report under her office door, describing an event in what appeared to be a potential allegation of verbal abuse involving a Certified Nursing Assistant (CNA 2) and Resident 1 of the Skilled Nursing Unit (SNU). The IDON stated she had not received any other communication from the nursing staff regarding the event. The IDON concurrently stated the contents of the report contained information from CNA 1, who had overheard CNA 2, yelling loudly, "rollover" in order to place a bedpan under Resident 1. During this time, Resident 1 asked CNA 2 to "fix her pillow." CNA 1 overheard CNA 2 yelling "No! It is fine where it is. I am not adjusting it every time I come in here. Do not remove your pillow, I am not fixing it." A review of an email received by the IDON dated, April 13, 2018, revealed the Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Vocational Nurse (LVN 1) informed the IDON of the event that occurred between CNA 2 and Resident 1. LVN 1 wrote in the email of CNA 2's rudeness, condescending attitude, and that CNA 1 can be extremely brusque and unfriendly. On April 18, 2018, at 11:30 AM, during an interview with CNA 1, he confirmed he had placed the written statement, with the allegations of CNA 2's verbal abuse, under the IDON's office door. CNA 1 stated he heard CNA 2 yelling from Resident 1's room "I told you not to touch your pillow, now you fix it." During the interview with CNA 1, he stated that in the past he had made an anonymous call to the Ombudsman (Long Term Care Ombudsman Program, independent, trained and certified advocates for residents living in long-term care facilities) reporting abuse and then reported the abuse to the Director of Nurses (DON). The DON responded by yelling at him, stating he was not to call the Ombudsman; he was to inform her [the DON] first, so she can address the problem. She then pulled a sheet of paper off her office wall with a five star rating and stated "See these stars, thank you, you just dropped us one star." CNA 1 stated the DON crumpled up the paper and threw it at him. CNA 1 stated he left the DON's office and she followed him out of her office, continuing to yell at him in the nursing station, in front of the night and day shift nursing staff. CNA 1 stated the DON then turned to the nursing staff and said "No one is to call the Ombudsman unless you talk to me first. I will take care of the situation." CNA 1 stated after the incident, the Restorative Nurse Assistant (RNA - a nursing assistant who helps with patient mobility and ambulation) told him to go home that the DON did not want him there. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CNA 1 stated he did not go to her for any issues, because her response was always "I'll take care of it, or I don't have time to talk right now, I'm very busy." CNA 1 stated he is fearful of reporting issues of abuse to the DON for fear of "retaliation," and that is why he waited so long to report the event that occurred between CNA 2 and Resident 1. During an interview with the Director of Staff Development (DSD) on April 20, 2018, at 10:30 AM, she stated CNA 2 always tried to change her assignment with other CNA's. CNA 2 always walked by resident's call lights, and other CNAs will have to attend to the resident's needs. The DSD stated after the incident between Resident 1 and CNA 2, she had interviewed Resident 1 who told her she does not feel safe and does not want CNA 2 to care for her. The DSD stated Resident 1 grabbed her hand requesting, "Don't let her touch me." The DSD stated she did not report the conversation to the DON for a couple of days. During an interview with LVN 2, conducted on April 20, 2018, at 11:03 AM, she stated CNA 2 has an aggressive personality, displayed an attitude while providing care, and always wanted to change with another CNA when Resident 1 is assigned to her. During an interview with Certified Nursing Assistant 3 (CNA 3), conducted on April 20, 2018, at 11:50 AM, she stated she was present during the event when the DON was "Mad at CNA 1, she came out of her office stating anytime we call the state, no matter what time of day, we have to call her first." CNA 3 stated this made her uncomfortable and nervous to report anything. During an interview with Resident 1, conducted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on April 20, 2018, at 1:05 PM (with difficulty articulating) she stated, "CNA 2 hates me. All the time, she is mean to me, and to others too. A lot of the time, she puts me down. It is a million things. She yells at me and puts me down all the time. I do not want her when I need to go to the bathroom. It's the words she says, she doesn't like me, she told me that ..." During an interview with LVN 2, conducted on April 20, 2018, at 1:20 PM, she stated CNA 2 has a hostile attitude toward Resident 1 and she is extremely unfriendly to the residents. LVN 2 stated Resident 1 did not want CNA 2 to care for her, stating, "I don't want her touching me, she is mean to me, she calls me names and I do not feel safe." During an interview with Resident 2 (roommate of Resident 1), conducted on April 20, 2018, at 4:15 PM, she stated CNA 2 was "yelling really loud, and it was upsetting." Resident 2 stated she finally had enough and through the drawn curtain requested CNA 2 to lower her voice. Resident 2 said CNA 2 told her to "Shut-up." Resident 3 stated this "made her feel angry and embarrassed." She said CNA 2 offered no apology. During an interview with Resident 3 conducted on April 20, 2018, at 4:40 PM, he stated there were times when CNA 2 does not understand, accept, or was empathetic with our limitations. Resident 3 stated when he would ask her to do something for him, CNA 2 would respond by stating she was here to do what she needs to do, "I'll take care of my responsibilities." Resident 3 stated he felt like she was on her own agenda and she does not respond to interruption. She is different from the others, she is authoritative." A review of the facility document titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "California Department of Aging-Long -Term Care Ombudsman Program - Elder Abuse" with a Copyright date of 2007 State of California, revealed the following: "...California State Law and the Federal Nursing Home Reform Act clearly state that the resident has the right to be free from abuse. Ombudsman must view elder abuse as a priority and constantly be on the alert of its occurrence, as well as work to prevent any and all elder abuse...California law also requires Ombudsmen to receive reports of alleged and suspected abuse of dependent adults in longterm care facilities..." A review of the facility document titled "Bear Valley Community Healthcare District - New Employee Receipt Checklist" dated February 8, 2005, and signed by [name of CNA 2,] acknowledged by signature receipt of the "Employee Statement - Dependent Adult Abuse Reporting." A review of the facility policy titled "ElderDependent Abuse Policy - SNF -SNF" revised, and approved date of June 25, 2015, defines the following: "Purpose: To insure proper reporting of resident/patient abuse. Policy: It is the policy of the facility to maintain an environment free of abuse and neglect. The resident/patient has the right to be free from verbal ...mental abuse ...Residents/patients will not be subjected to abuse by any one including ...facility staff ...Procedure: A. All potential new employees and volunteers will be screened for a history of abuse, neglect or mistreatment of residents/patients ...Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents/patients ...within their hearing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE distance, regardless of their age, ability to comprehend, or disability ...Mental Abuse: This includes, but is not limited to humiliation ...D. All employees or volunteers will receive education, training, and periodic in-service training, about: 2. How staff should report their knowledge of allegations without fear of reprisal ...F. The facility will identify, correct and intervene in situations in which abuse, neglect ...A general analysis of the facility's risk for those incidents will include: ...3. The Supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, and ignoring residents during care ...I ...All allegations of abuse will be reported by telephone immediately, or within 24 hours, to the proper authorities by the employee who witnessed the incident: For the Skilled Nursing Facility report to the Ombudsman or local law enforcement ..." On April 18, 2018 at 5:10 PM, an Immediate Jeopardy (IJ- a situation with the potential to harm the health and safety of the residents) was called under 483.12, Freedom from abuse, neglect, and exploitation, in the presence of the facility Chief Executive Officer (CEO), the Interim Director of Nursing (IDON) and the Risk Compliance Officer (RCO). The CEO, IDON, and the RCO were verbally notified of the IJ situation identified based on the facility's failure to ensure residents were free from verbal abuse. An acceptable corrective action plan was provided by the facility on April 19, 2018, at 4:18 PM. The corrective action plan included the following components: 1. The facility has implemented a Just Culture (a culture of behavior that encourages employee self-disclosure and continual delivery FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of high quality services for patients, employees, and the community it serves) program to promote a non-punitive environment that encourages a culture of reporting suspected forms of abuse. 2. Coaching of all Skilled Nursing Facility (SNF) staff and staff involved, on reporting abuse, timeliness of reporting, mandated reporter requirements and chain of command. 3. Punitive Action for [name of CNA 2]. 4. Formal coaching with [name of CNA 1] and the Licensed Vocational Nurse (LVN) involved with the incident to include the following: a. Mandated Reporter guidelines and duties, b. Timeliness of reporting abuse, c. Avenues/options for reporting abuse d. Chain of command at the facility. After review and verification that each component of the corrective action was in place, the IJ was lifted on April 20, 2018 at 10:00 AM, in the presence of the CEO, CNO, and the IDON. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VWXW11 Facility ID: CA240000979 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555468 (X3) DATE SURVEY COMPLETED 08/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEAR VALLEY COMMUNITY HOSPITAL D/P SNF 41870 Garstin Dr Big Bear Lake, CA 92315 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: VWXW11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000979 (X5) COMPLETE DATE If continuation sheet 10 of 10