Health inspection·June 5, 2025

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (RAI/MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) for a change of condition was completed within 14 days as stated within their policy and procedures (P&P) and in accordance with the federal submission timeframes for one of eight sampled residents (Resident 6) when Resident 6's condition was changed from having clear speech and no impairment with movements to unable to lift right arm, speech was very weak and was having difficulty making a sentence. Residents Affected - Few This failure resulted in inadequate monitoring of Residents 6 and had the potential to delay necessary interventions leading to deterioration, increased risk of complications and poor resident prognosis. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE]. and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an interview on June 2, 2025, at 9:00 AM, with the Education Manager (EM), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and the Director of Quality and Regulation Compliance (DQRC), they stated that Resident 6 was the president of resident council (an organized group of residents in the long-term care (LTC) facility to discuss concerns and suggest improvement). During an observation on June 2, 2025, at 10:58 AM, with Resident 6, Resident 6 was unable to complete a full sentence, attempted to say her name, but was having difficulty. Resident 6 was unable to lift her right arm. During concurrent interview and record review on June 4, 2025, at 2:36 PM, with Licensed Vocational Nurse/Director of staff development (LVN/DSD), Resident 6 's Minimum Data Set quarterly assessment (MDS quarterly assessment), dated April 21, 2025, was reviewed. The MDS quarterly assessment indicated, under section B. hearing, speech and vision that Resident 6's speech was clear, under section C. cognitive [related to mental process such as thinking and reasoning] patterns the Brief Interview for Mental Status (BIMS- a measure of cognitive function in individuals, typically used in long-term care facilities with a score ranges from 0-15, a score of 0-7 suggests severe cognitive impairment, 8-12- moderate impairment, 13-15 suggests intact cognition ) was 15, under section gg. Functional Page 1 of 9 555467 555467 06/05/2025 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few abilities functional limitation of the upper extremities it indicated no impairment, and under section i. active diagnosis in the neurological there was no aphasia (loss of ability to communicate) documented. The LVN/DSD verified and confirmed that the MDS quarterly assessment is not accurate, and no change of condition has been made for Resident 6. The LVN/DSD stated that Resident 6 had shown a decline in status for about a month. The LVN/DSD further stated that it has been over 14 days since the change in Resident 6's status. During a review of Resident 6's LTC progress note, dated May 20, 2025, by the physician, the LTC progress note indicated, . Right are unable to move up or close hand and voice very weak. During an interview and record review on June 6, 2025, at 1:12 PM, with the CNO, the facility's P&P titled, Change of condition Resident (Policy)-Skilled Nursing Facility, dated January 21, 2021, was reviewed. The P&P indicated, . 8. as necessary, a significant change in status assessment MDS will be generated within fourteen (14) days of change of condition. The CNO stated the policy was not followed and should have been as per regulation. 555467 Page 2 of 9 555467 06/05/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was completed accurately for one of eight sampled residents (Resident 6) when the MDS assessment did not show Resident 6's current condition of having functional limitations to the right upper extremity and speech impairments. Residents Affected - Few This failure resulted in inaccurate documentation of assessment for Residents 6 and had the potential to cause inadequate care planning, delay of necessary interventions that can lead to deterioration, increased risk of complications and poor resident prognosis. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE] and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an interview on June 2, 2025, at 9:00 AM, with the Education Manager (EM), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and the Director of Quality and Regulation Compliance (DQRC), they stated that Resident 6 was the president of resident council (an organized group of residents in the long-term care (LTC) facility to discuss concerns and suggest improvement). During an observation on June 2, 2025, at 10:58 AM, with Resident 6, Resident 6 was unable to complete a full sentence, attempted to say her name, but was having difficulty. Resident 6 was unable to lift her right arm. During concurrent interview and record review on June 4, 2025, at 2:36 PM, with Licensed Vocational Nurse/Director of staff development (LVN/DSD), Resident 6 's Minimum Data Set quarterly assessment (MDS quarterly assessment), dated April 21, 2025, was reviewed. The MDS quarterly assessment indicated, under section B. hearing, speech and vision that Resident 6's speech was clear, under section C. cognitive [related to mental process such as thinking and reasoning] patterns the Brief Interview for Mental Status (BIMS- a measure of cognitive function in individuals, typically used in long-term care facilities with a score ranges from 0-15, a score of 0-7 suggests severe cognitive impairment, 8-12- moderate impairment, 13-15 suggests intact cognition ) was 15, under section gg. Functional abilities functional limitation of the upper extremities it indicated no impairment, and under section i. active diagnosis in the neurological there was no aphasia (loss of ability to communicate) documented. The LVN/DSD verified and confirmed that the MDS quarterly assessment is not accurate, and no change of condition has been made for Resident 6. The LVN/DSD stated that Resident 6 had shown a decline in status for about a month. The LVN/DSD further stated that it has been over 14 days since the change in Resident 6's status. During a review of Resident 6's LTC progress note, dated May 20, 2025, by the physician, the LTC progress note indicated, . Right are unable to move up or close hand and voice very weak. During a review of the Speech language pathologist [SLP] Speech evaluation (SLP speech evaluation), 555467 Page 3 of 9 555467 06/05/2025 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated May 24, 2025, the SLP speech evaluation indicated, [Resident 6's last name] struggled to hold a conversation. She demonstrated word-finding difficulties during spontaneous speech . under the indication for speech therapy it indicated, impaired motor speech, impaired spoken language expression. During a review of the SNF [skilled nursing facility] interdisciplinary resident care conference (SNF interdisciplinary care), dated April 22, 2025, the SNF interdisciplinary care indicated, Resident 6 had new onset right sided weakness. During a concurrent interview and record review on June 6, 2025, at 1:12 PM, with the CNO, the facility's policy & procedures (P&P) titled change of condition resident (Policy)- skilled nursing facility, dated January 21, 2021, was reviewed. The P&P indicated, . 8. as necessary, a significant change in status assessment MDS will be generated within fourteen (14) days of change of condition. The CNO stated Resident 6's assessment was not accurate, and a change of condition should have been done according to the facility's policy. 555467 Page 4 of 9 555467 06/05/2025 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record reviews, the facility failed to establish a comprehensive care plan (an individualized plan that includes residents' health problems, preferences and goals) consistent with the resident's medical needs for one of four residents (Resident 6) when the facility staff did not update Resident 6's care plan after identifying a change of condition. This failure resulted in inadequate response to Resident 6's changing needs, and had the potential increased risk of harm, delayed treatment, and reduced quality of life. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE] and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an observation on June 2, 2025, at 10:58 AM, with Resident 6, Resident 6 was unable to complete a full sentence, attempted to say her name, but was having difficulty. Resident 6 was unable to lift her right arm. During concurrent interview and record review on June 4, 2025, at 2:36 PM, with the Licensed Vocational Nurse/Director of staff development (LVN/DSD), Resident 6 's Minimum Data Set (MDS-a standardized, comprehensive assessment that collects information about a resident's functional, medical, psychosocial, and cognitive status.) quarterly assessment (MDS quarterly assessment), dated April 21, 2025, was reviewed. The MDS quarterly assessment indicated, under section B. hearing, speech and vision that Resident 6's speech was clear, under section C. cognitive [related to mental process such as thinking and reasoning] patterns the Brief Interview for Mental Status (BIMS- a measure of cognitive function in individuals, typically used in long-term care facilities with a score ranges from 0-15, a score of 0-7 suggests severe cognitive impairment, 8-12- moderate impairment, 13-15 suggests intact cognition ) was 15, under section gg. Functional abilities functional limitation of the upper extremities it indicated no impairment, and under section i. active diagnosis in the neurological there was no aphasia (loss of ability to communicate) documented. The LVN/DSD verified and confirmed that the MDS quarterly assessment is not accurate, and no change of condition has been made for Resident 6. The LVN/DSD stated that Resident 6 had shown a decline in status for about a month. The LVN/DSD further stated that it has been over 14 days since the change in Resident 6's status. During an interview on June 5, 2025, at 11:28 AM, with LVN 3, LVN 3 stated that anytime a resident gets speech therapy added to the facility's electronic health record (EHR) system, nursing staff will get a pop up to that asks if the nursing staff want to incorporate it into the resident's care plan. LVN 3 further stated that the nurse can also manually put it into the resident's chart if the care plan needs to be updated. During a review of Resident 6's LTC [long-term care] progress note, dated May 20, 2025, by the physician, the LTC progress note indicated, . Right are unable to move up or close hand and voice very weak. 555467 Page 5 of 9 555467 06/05/2025 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on June 6, 2025, at 1:18 PM, with the Chief Nursing Office (CNO), Resident 6's care plan, undated, was reviewed. The care plan indicated that the last time it was reviewed was May 18, 2025. The CNO stated she did not see that the care plan was reviewed after Resident 6's change of condition. During a concurrent interview and record review on June 6, 2025, at 1:20 PM, with the CNO, the facility's policy and procedure (P&P) titled Change of Condition Resident (Policy)- Skilled Nursing Facility [SNF], dated January 21, 2021, was reviewed. The P&P indicated, . 7. A care plan will be developed by the SNF Licensed Nurse receiving the orders, addressing the change of condition, goals of treatment and interventions . The CNO stated the policy was not followed and it is important to update the care plan for resident safety and overall care. 555467 Page 6 of 9 555467 06/05/2025 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 9) was free from significant medication error, when a furosemide (a medication commonly called as water pill that used to eliminate water and salt from the body) was held for a systolic blood pressure (the top number in a blood pressure reading and represents the pressure in the arteries when the heart beats) less than 100 without a hold order. Residents Affected - Few This failure resulted in lack of appropriate documentation and had the potential to cause adverse health outcomes by not achieving the effective purpose of the medication and miscommunication amongst the following nursing staff. Findings: During a review of Resident 9's History and Physical (H&P- a formal assessment document by the physician), dated April 30, 2025, the H&P indicated, Resident 9 was admitted on [DATE], with diagnoses of benign prostatic hyperplasia (BPH-refers to a non-cancerous enlargement of the prostate gland, hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream), and cerebral palsy (is a group of lifelong movement disorders that occur due to brain damage before, during, or shortly after birth). During a concurrent medication administration observation and interview on June 3, 2025, at 9:03 AM, with Licensed Vocational Nurse (LVN 1), in front of the dining area, a furosemide medication was held for Resident 9. LVN 1 stated, Resident 9's furosemide would be held today because the parameter is to hold for systolic blood pressure < less than 100. During a concurrent interview and record review on June 3, 2025, at 2:24 PM, with LVN 1, Resident 9's medications orders, initiated on May 6, 2025, was reviewed. The medication orders indicated, furosemide (Lasix) 20 mg [milligram-unit of dosing medication] PO [by mouth] DAILY tablet and had a clinical indication for fluid retention. The order did not have any hold parameters. LVN 1 verified and stated that the current order for furosemide did not have any hold parameters. LVN 1 stated that the previous order furosemide order initiated on April 20, 2024, fell off on May 6, 2025, and that when the order was renewed, whoever put in the order did not put the hold parameters as the previous order . LVN 1 stated, it is important to have appropriate hold parameters in the orders, so that any nurse that takes over the resident's care know what to do. During a follow-up telephone interview on June 5, 2025, at 10:55 AM, with LVN 1, LVN 1 stated that furosemide order was not followed when it was held without any hold parameters. LVN 1 further stated she contacted the pharmacist to fix the order after it was brought up to her attention. During a concurrent interview and record review on June 5, 2025, at 1:14 PM, with the Chief Nursing Officer (CNO) the facility's policy and procedure (P&P) titled, medication errors and adverse reactions (policy), dated June 30, 2023, was reviewed. The P&P indicated, .Policy: All medications prescribed for and/or administered to patients and residents of the [Facility Name] shall be handled in a safe and effective manner, and properly recorded into the patient/resident's medical record. Deviations from this policy resulting in medication errors . may be related to: prescribing, order communication . Categories: Order communication, Types: Written order not entered into E-MAR [Electronic medical administration recordplace on the electronic health record where staff can record the 555467 Page 7 of 9 555467 06/05/2025 Mountains Community Hosp Dp/Snf 29101 Hospital Road Lake Arrowhead, CA 92352

F 0760 Level of Harm - Minimal harm or potential for actual harm administration of medication], and Examples: written order not entered into E-MAR different from written or telephone order . The CNO agreed that according to the policy it is a medication error related to renewal of a written order into E-MAR. The CNO stated it was a system error and should have not happened. Residents Affected - Few 555467 Page 8 of 9 555467 06/05/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control guidelines for a universe of 19 residents when expired medical supplies were found in procedure cart and medical supply room and were readily available for use. Residents Affected - Many This failure had the potential to cause unsafe care provided to the facility's 19 residents with beyond the use date (expired) supplies, which could potentially cause infection, injuries, and/ or death. Findings: During a concurrent observation and interview on [DATE], at 6:10 AM, in the facility's treatment cart and medical supply room, with the Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN 2). The medical supplies were observed as follows: 1. 41 safety intravenous (IV) catheters (a thin, flexible tube inserted into vein to deliver fluids, medications or blood products directly into the blood stream) Size 24 gauge (size of catheter) with an expiration date of [DATE] (3 days expired). 2. Nine IV extension set (flexible tube used to extend the length of existing IV lines) with an expiration date of [DATE] (4 days expired). The DSD and LVN 2 verified and confirmed that 41 safety IV catheters and nine IV extension sets have been expired and should have been discarded. During a concurrent interview and record review on [DATE], at 10:10 AM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Infection Prevention and Control, dated [DATE], was reviewed. The P&P indicated, . 4. The Infection Prevention and Control Plan Policy objectives read in number one through eight: 1) Decrease the risk of infection to patients and personnel. 2) Monitor for occurrence of infection and implement appropriate control measures. 3) Identify and correct problems relating to infection prevention practices. 4) Limit unprotected exposures to pathogens throughout the hospital. 5) Minimize the risk associated with procedures, medical devices and medical equipment. 6). Maintain compliance with state and federal regulations relating to infection prevention . The CNO stated medical supplies should have been checked regularly and expired items should have been discarded, as using expired medical supplies can cause infections and injuries. The CNO further stated the facility did not follow the infection prevention and control policy. 555467 Page 9 of 9