Health inspection·April 20, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 17's clinical record titled, admission Record indicated, Resident 17's diagnoses included, hypertension, anxiety disorder (feeling of worry), and left hip fracture (break). Residents Affected - Few During a concurrent interview and record review on April 19, 2023, at 3:05 PM, with the MDS Nurse, MDS Command Center (a calendar of the assessment due dates), was reviewed. The document indicated, Resident 17's MDS 3.0 assessment was transmitted by the facility on April 13, 2023. The MDS Nurse acknowledged, Resident 17's MDS 3.0 assessment was transmitted to the Command Center 12 days late. The MDS Nurse stated, she tried to remember the due dates, but she missed this one. During a concurrent interview and P&P April 20, 2023, at 9:00 AM, with the DON, Resident Assessment and Care Planning (Policy) - Skilled Nursing Facility, dated January 18, 2019, was reviewed. The P&P indicated, PURPOSE: To identify resident needs and provide a database used in planning the comprehensive nursing care to meet resident's individual needs and to assist residents in reaching the highest level of independence possible. POLICY: 1. A licensed nurse will coordinate the input of appropriate health care professionals in the completion of a resident assessment form designed to obtain minimum data criteria as established by Federal and State requirements . The DON acknowledged, the P&P was not followed when Resident 17's MDS 3.0 assessment was not transmitted within 14 days. 3. During a review of Resident 10's clinical record titled, History and Physical (H&P- past and current medical history) Examination - Final Report, dated, October 13, 2022, by Physician 1 (Phys. 1) indicated, Resident 10 had a past medical history of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), stroke (occurs when the blood supply is blocked to part of the brain), and seizure disorder (burst of uncontrolled body movements, behaviors, or states of awareness). During a review of Resident 10's clinical record titled, MDS 3.0., dated, September 16, 2022, by RN 1, indicated, Resident 10 had an MDS 3.0 assessment completed on September 16, 2022. During a concurrent interview and record review on April 19, 2023, at 3:20 PM, with the MDS Nurse, MDS Command Center, dated October 1, 2022, was reviewed. The record indicated, Resident 10's MDS 3.0 assessment was transmitted on October 1, 2022. The MDS Nurse stated, she was the person responsible for submitting the MDS 3.0 assessment, which was one day late. During a concurrent interview and P&P reviewed on April 20, 2023, at 9:15 AM, with the DON, Resident Assessment and Care Planning (Policy) - Skilled Nursing Facility), dated January 18, 2019, indicated, PURPOSE: To identify resident needs and provide a database used in planning the comprehensive Page 1 of 9 555467 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing care to meet resident's individual needs and to assist residents in reaching the highest level of independence possible. POLICY: 1. A licensed nurse will coordinate the input of appropriate health care professionals in the completion of a resident assessment form designed to obtain minimum data criteria as established by Federal and State requirements . The DON acknowledged, the P&P was not followed. Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) for transmitting resident's assessment data (tool that provides overview of the resident's condition) within the required timeframe outlined by Federal Regulations for three of four sampled residents (Resident 3, Resident 17, and Resident 10). This failure had the potential to result in a delay in determining the resources necessary to competently care for the residents during the day to day operations and emergencies. Findings: 1.During a review of Resident 3's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (high sugar levels), chronic (long term) back pain, and hypertension (raised pressure against the vessel walls). During a concurrent interview and record review, on April 20, 2023, at 8:20 AM, with the MDS Nurse, Resident 3's Minimum Data Set 3.0( MDS 3.0-an assessment tool for implementing standardized assessment and for facilitating care management), dated March 4, 2023, signed by the Director of Nursing (DON), was reviewed. The document indicated, the assessment was transmitted to Internet Quality Improvement and Evaluation System (iQIES- federal government information tracking website) on April 19, 2023. The MDS Nurse counted the number of days the MDS assessment was late and stated, the assessment was 32 days late. The MDS Nurse stated, the MDS assessment was supposed to have been transmitted on March 18, 2023. During further record review and interview with the MDS Nurse, on April 20, 2023, at 8:23 AM, the MDS Nurse reviewed Resident 3's MDS 3.0 assessment, dated December 1, 2022, signed by the Registered Nurse (RN 2). The MDS Nurse counted the number of days the MDS assessment was late and stated, the assessment was 16 days late (due December 19, 2022). During a concurrent interview and record review with the DON, on April 20, 2023, at 9:46 AM, the DON reviewed Resident 3's MDS 3.0 assessments and reviewed the Policy and Procedure (P&P) titled, Resident Assessment and Care Planning, dated January 18, 2019, which indicated, .1. A licensed nurse will coordinate the input of appropriate health care professionals in the completion of a resident assessment form designed to obtain minimum data criteria as established by Federal and State requirement . The DON stated, the MDS 3.0 assessments were submitted past the 14 days after the Registered Nurse's signature and acknowledged the P&P was not followed. 555467 Page 2 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a Physician Orders for Life-Sustaining Treatment ([POLST] medical order form that provides instructions to medical staff on what to do in the event of a medical emergency) for one of 18 sampled residents (Resident 15). Residents Affected - Few This failure could have resulted in Resident 15's medical treatment wishes not being followed. Findings: During a review of Resident 15's clinical record titled, History and Physical Examination (H&P- a document that contains past and current medical history) - Final Report, dated, January 15, 2020, at 2:50 PM, by Physician 1 (Phys. 1), indicated, Resident 15 had a past history of stroke (an event where there is oxygen deprivation to the brain), diabetes (inability to control blood sugar), and Chronic Kidney Disease (kidneys do not efficiently filter out waste products). During a review of Patient 15's clinical record titled, Section C Cognitive (thinking, understanding, remembering) Patterns (a section of the Minimum Data Set ([MDS] assessment tool used to assess cognitive skills for decision making), indicated, Resident 15 had a Brief Interview for Mental Status ([BIMS] summary score used to assess for cognitive conditions) score of 10 (score of 8-12 = moderately impaired). During a concurrent interview and record review on April 18, 2023, at 8:30 AM, with the MDS Nurse, Resident 15's clinical record titled, Physician Orders for Life-Sustaining Treatment, dated December 30, 2019, by Resident 15's Legally Recognized Decision Maker ([LRDM] the person assigned by the resident to make medical decisions if the resident is not able to make decisions for themselves) and Physician (Phys. 2), was reviewed. The POLST indicated, Resident 15's primary goal was comfort-focused treatment (relieve pain and suffering with medication). The POLST was not completed when the LRDM's address, phone number, and date of signature was not documented, and whether or not Resident 15 had an advanced directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions independently). The MDS Nurse stated, she is not sure why the POLST was not completely filled out and that the facility needed to update Resident 15's POLST. The MDS Nurse acknowledged, the POLST was supposed to be fully completed and placed in the Resident 15's chart (a folder containing medical information). During a concurrent interview and record review on April 18, 2023, at 11:45 AM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, admission of Resident (Policy) - Skilled Nursing Facility, dated September 15, 2022, indicated, Assessment, Forms and Documents: . 5. Discuss and complete Physician Orders for Life Sustaining Treatment (POLST) with resident and or power of attorney (POA- a legal document that allows for the designation of another person to manage the resident's property, medical, or financial affairs) and have MD (Medical Doctor) sign . The DON stated, the POLST was not completed in its entirety and needed to be updated. The P&P was not followed. 555467 Page 3 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain professional standards for food safety when: 1.The ice machine was found to have black build up. 2.The dishwashing machine was not sanitizing. 3.There was no air gap (a separation between the water supply and potentially contaminated water in a sink or other plumbing fixture) found at the food preparation sink. The facility's failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food-borne illness (food poisoning that can cause nausea, vomiting, and diarrhea) to a population of 18 immuno-compromised (decreased ability to fight off infections and diseases) residents who received food from the kitchen. Findings: 1.During a concurrent observation and interview with the Director of Facilities (DOF) and the Lead Facilities Technician (LFT), on April 17, 2023, at 12:40 PM, the ice machine was observed to have black build up around the motor of the ice machine and the metal part of the ice chute (where ice falls down from the ice maker). A white cloth was used to wipe inside the metal part of the ice chute and a black substance was noted on the white cloth. During a joint interview with the DOF and the LFT, on April 17, 2023, at 12: 44 PM, the DOF stated, the facilities staff are responsible for cleaning the inside of the ice machine. The facilities staff clean the ice machine monthly and do a deeper cleaning quarterly (every three months). The DOF stated, the ice machine instruction manual is followed when cleaning the ice machine. The DOF and the LFT stated, there should not have been any black build in the ice machine. During a concurrent interview and record review with the DOF, on April 19, 2023, at 10:48 AM, the Cublet Icemaker/ Dispenser manual titled, [Company name] Cubelet Icemaker/ Dispenser Instruction Manual, dated November 15, 2013, was reviewed. The [NAME] indicated, .Sanitizing Procedure .3) Scrub the inside of the storage bin, inside the bin top, the agitator, drip ring, ice chute area, spout A, spout B, grille, and the inside of the drain pan using a nylon scouring pad, brushes, and sanitizing solution. Rise all parts thoroughly with clean water . The DOF stated, the ice machine instruction manual was not followed. During a concurrent interview and record review with the DOF, on April 19, 2023, at 10:50 AM, the Policy and Procedure (P&P) titled, Ice Machine Chute Cleaning Monthly Cleaning, dated January 2022, indicated, .3. Removed screw on chute and remove chute. 4. Mix 1 to 3 ratio De-scaler to warm water. 5. Soak chute in solution for 15 minutes. 6. Rinse chute. 7. Replace chute and screw back in screw . The DOF stated, the P&P was not followed when the ice machine contained black build up, which could result in widespread food borne illness. The DOF stated his expectation for the ice machine is to be clean with no black build up. 555467 Page 4 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a record review of the Federal FDA 2022 Food Code 4-204.17, indicated The potential for mold and algae growth in this area is very likely due to the high moisture environment. Molds and algae that form are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the CDC's (Center for Disease Control) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revised July 2019, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf), microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferal of organisms from hands. Ice from contaminated ice machines has been associated with .blood stream infections, pulmonary (having to do with the lungs) and gastrointestinal (having to do with the stomach and intestinal tract) illnesses. Recommendations for a regular program of maintenance and disinfection have been published. Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. 2.During a concurrent joint observation and interview with the Registered Dietician/ Dietary Supervisor (RD/DS) and kitchen assistant (KA 1), on April 18, 2023, at 8:06 AM, KA 1 stacked food trays in the dish rack. KA 1 then pushed the dish rack into the dishwashing machine and had it run a cleaning cycle. KA 1 checked the sanitation level (parts per million [ppm - unit of measurement] of chlorine [chemical used to kill bacteria] used to reduce the number of microorganisms [bacteria] to a safe level) of the dishwashing machine with a [Company Name] Chlorine Test Paper, but the chlorine test strip did not turn color, which indicated there was no chlorine in the dish machine. The RD/DS verified that the chlorine test strips indicated there was no chlorine, and the dishwashing machine was not sanitizing. The RD/DS stated, the machine gets checked monthly and the staff who run the dishwashing machine is supposed to check the sanitization with the test strips three times a day before meals and record the number of ppm. The chlorine test strip should read at least 50 ppm. During a concurrent interview and record review, on April 19, 2023, at 9:52 AM, the RD/DS reviewed the operation Manual titled, [Company Name] Series Installation/ Operation [NAME], dated October 29, 2007, which indicated, .MINIMUM CHLORINE REQURED (PPM) 50 . The RD/DS stated, the operation [NAME] was not followed. During a concurrent interview and record review, on April 19, 2023, at 9:55 AM, the RD/DS further reviewed the P&P titled, Dishwashing Sanitation, dated March 17, 2022, which indicated, .e. Complete a chlorine test at the start of each scheduled dish washing, breakfast, lunch, and dinner, patient and resident dishes, to measure the sanitizer level to assure the machine is functioning correctly with the correct level of sanitizer being dispensed. Follow the policy and procedure posted by the dish machine . f. The chlorine test must read 50-100 ppm . The RD/ DS stated her expectation is that the chlorine level is at 50 ppm to ensure bacteria is removed from the dishes. The RD/DS stated the P&P was not followed. 3.During a concurrent joint observation and interview with the RD/DS and the DOF, on April 19, 2023, at 8:27 AM, in the kitchen, one sink used for food preparation did not have an air gap. The DOF verified the sink drainpipes did not have an air gap. The DOF stated, that he did not know there should have been an air gap. The DOF stated, without an air gap, dirty water can back up into the sink and contaminate the food preparation sink. During an interview with the RD/DS on April 19, 2023, at 9:54 AM, the RD/DS verified there was no P&P regarding air gaps for the food preparation sink or the kitchen area. The RD/DS stated, her 555467 Page 5 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many expectation is there should be an air gap where the food is prepared and where meats and poultry are defrosted. The RD/DS stated, an air gap is important because of the risk of pipes back flowing into the sink and contaminating the food preparation sink. A review of the FDA Federal Food Code 2022 5-202.13 indicated, .Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . A review of the FDA Federal Food Code 2022 5-202.13 indicated, .Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow . 555467 Page 6 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to properly close the dumpster (large outdoor trash container) lids when two of eight dumpsters were found with trash bags exceeding the fill line of the dumpster. Residents Affected - Many This failure had the potential to attract vermin (pest or animals that spread diseases) in the facility that cares for 18 medically compromised residents. Findings: During a concurrent observation and interview with the Registered Dietician/ Dietary Supervisor (RD/ DS), on April 17, 2023, at 12:04 PM, the outdoor garbage storage area had two dumpsters with trash bags exceeding the fill line of the dumpster, with the lids not fully closed. The RD/DS stated, the lids should be fully closed. During a concurrent observation and interview with the Environmental Service Manager (ESM), on April 17, 2023, at 12:07 PM, the ESM verified the two dumpsters had trash bags exceeding the fill line, preventing the lids from being fully closed. The ESM stated, the dumpster lids should always be closed because of the risk of attracting vermin. During an interview with the ESM, on April 17, 2023, at 12:30 PM, the ESM stated, they do not have a Policy and Procedure (P&P) for the outdoor garbage storage area. During a review of the FDA Federal Food Code, 2022, it indicated in 5-501.113, .Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT . 555467 Page 7 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to follow their Policies and Procedures (P&P) regarding infection control practices during an eye drop medication administration for one of eighteen sampled residents (Resident 16). Residents Affected - Few This failure had the potential to introduce bacteria into one resident's eyes in a population of eighteen sampled residents (Resident 16). Findings: During a review of Resident 16's clinical record titled, History and Physical (H&P- past and current medical history) Examination- Final Report , dated, July 19, 2021, at 2:26 PM, by Physician (Phys. 1) indicated, Resident 16's diagnoses included Type 2 Diabetes (inability to control blood sugar), Congestive Heart Failure (CHF- condition in which the heart does not pump blood efficiently), and yeast dermatitis (fungal infection on the skin). During an observation on April 19, 2023, at 6:44 AM, inside Resident 16's room, with the Licensed Vocational Nurse (LVN 1), observed the LVN 1 put on gloves, electronically scan (hand held scanner) Resident 16's name card (card that contains the resident's name and a bar code), and scan the medications Famotidine oral medication (decreases stomach acid) and Olopatadine Solution (0.2% - eye drop medication - used to treat eye infections). The LVN 1 proceeded to administer the oral medication (Famotidine) to Resident 16 and then adjusted the side bed rails (plastic rails attached to the bed used for repositioning and safety) and bed blankets. The LVN 1 then administered Resident 16's eye drop medication (Olopatadine). The LVN did not wash her hands or change her gloves prior to administering the eye drop medication. During an interview on April 19, 2023, at 6:55 AM, with the LVN 1, acknowledged, after the oral medication was administered to Resident 16, the LVN 1 should have taken off her dirty gloves, washed her hands, and put on clean gloves prior to administering the eye drop medication. The LVN 1 stated, by not washing her hands and changing her gloves prior to eye drop medication administration, Resident 16 was placed at risk for infection. During a review of Resident 16's clinical record titled, Patient Chart Orders, dated February 18, 2023 at 2:12 pm, by Phys. 1, indicated, Olopatadine Ophthalmic Solution (0.2% - eye drops) was ordered to be given to Resident 16 every 12 hours, one drop of medication in both eyes. During a review of Resident 16's clinical record titled, Patient Chart Orders, indicated, Olopatadine Ophthalmic Solution (0.2%) was given to Resident 16 on April 19, 2023, at 6:46 AM by the LVN 1. During a concurrent interview and record review on April 20, 2023, at 11:49 AM, with the Infection Preventionist Nurse (IP Nurse), The Lippincott Manual of Nursing Practice indicated, . Instillation of Medications .2. Solution or ointment is administered using clean technique . The IP nurse stated, clean technique would include washing hands and putting on clean gloves prior to eye medication administration. During a concurrent interview and record review on April 20, 2023, at 11:52 AM, with the IP Nurse, Nursing Procedure Reference Manual (Policy) - PC, dated July 22, 2022, was reviewed. The Policy and Procedure (P&P) indicated, PURPOSE: To provide an informed method of performing general nursing 555467 Page 8 of 9 555467 04/20/2023 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few procedures. POLICY: 1. The Lippincott Manual of Nursing Practice, has been adopted as a reference for clinical/nursing procedure which are not specifically listed in the Department P&P Manual or Clinical Service Manual . The IP Nurse acknowledge the P&P was not followed. During a concurrent interview and record review on April 20, 2023, at 12:00 PM, with the Director of Nursing (DON), the P&P titled, Hand Hygiene, Employees (Policy) - IC, dated July 22, 2022, was reviewed. The P&P indicated, PURPOSE: TO ESTABLISH HAND HYGIENE GUIDELINES FOR EMPLOYEES. Policy: 1. Hand hygiene is considered the most important single procedure for preventing healthcare associated infections. All employees shall follow the following guidelines for hand hygiene. 2. Indications for hand hygiene (before or after): a. ANY patient contact, b. invasive procedures . The DON acknowledged that washing hands is the most important single procedure for preventing healthcare associated infections. 555467 Page 9 of 9