Health inspection·February 16, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on February 14, 2023, at 3:44 PM, with the DON, the DON stated, residents who have an order to receive restorative nursing care involving weights/bands, have not been getting that skilled therapy for the past two weeks. The DON stated, RNA 1 had been trained and certified by Physical Therapy (PT) for restorative care treatment. These exercises are designed to maintain the resident's physical ability. During a concurrent observation and interview on February 15, 2023, at 5:04 PM, with Resident 8, observed Resident 8 in bed and able to move her arms, but not her legs. Resident 8 stated, the staff member who helped with her exercises has not been at work for a couple of weeks. Resident 8 further stated, it would be nice to have more staff to help with resident care. During an interview on February 15, 2023, at 6:21 PM, with the DON, the DON stated, she prefers to schedule RNA 1 and the Activities Certified Nursing Assistant (Activities CNA) on opposite schedules of each other (40 hours a week - 8-hour shifts). The DON acknowledged that the Activities CNA is not certified for restorative care. The DON stated, the residents who use bands and weights have not received their skilled restorative nursing care while RNA 1 has been out on leave. The DON further stated, she did not try and reach out for a registry RNA to cover for RNA 1. During a review of Resident 8's clinical record titled, Order Chronology, dated September 7, 2022, at 9:55 AM, by Medical Doctor (MD 1), indicated, Resident 8 had a physician's order to participate in the Restorative Program for AROM. During an interview on February 16, 2023, at 7:58 AM, with the DON, the DON stated, RNA 1 has not been to work from January 31, 2023, through February 16, 2023, and therefore Resident 8 has not received skilled restorative nursing care during that time frame. The DON stated, Resident 8 did not have a specific physician's order to use weights/bands, but the weights and bands were in her restorative treatment plan and had been used all through January 2023. The DON stated, the expectation was that the weights/bands would be used through the month of February 2023. During a concurrent interview and clinical record review, on February 16, 2023, at 9:40 AM, with the DON, Resident 8's clinical record titled, Restorative Nursing Program Flow Sheet, dated February 2023, was reviewed. Restorative Nursing Program Flow Sheet indicated, Resident 8's identified problem was weakness to both arms (related to MS) and osteoarthritis [wearing down of the protective tissue at the ends of bones that worsens over time causing pain and stiffness]) to the right shoulder. The treatment included AROM to both arms twice a day for at least fifteen minutes a day with two pound weights as tolerated or with a green band (resistance exercise band) from PT. When Resident 8 was in her wheelchair, staff were to encourage Resident 8 to propel herself to build strength and maintain wheelchair mobility. The DON stated, Resident 8 did not receive skilled restorative nursing care (that included weights or bands) from a RNA from January 31, 2023, through February 16, 2023. The DON acknowledged Resident 8's Restorative Nursing Program Flow Sheet, dated February 2023, was blank. 2. During a review of Resident 11's clinical record, emergency room OUTPATIENT RECORD, indicated, Resident 11, was admitted to the facility on [DATE], with a chief complaint of LTC ([Long Term Care] - need for care from a SNF). During a concurrent observation and interview on February 13, 2023, at 3:28 PM, Resident 11 was in her wheelchair with her head facing down and had difficulty raising her head when speaking. Resident 11's hands turned inward in a fist position. There were no hand rolls or splints in place. The Activity CNA stated, Resident 11 has limited ROM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 2 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 8's Minimum Data Set (MDS) Resident Assessment Validation and Entry System (an assessment tool) for Resident 11, dated, December 14, 2022, indicated: a. Section C, BIMS (brief interview for mental status) was coded as 7- cognitively impaired (a score of 0-7 suggests the patient is severely cognitively impaired). b. Section G, Functional Status, indicated, Resident 11 has impairment on both upper arms and lower legs with limited Range of Motion (ROM). Resident 11 requires extensive assistance for sell-performance locomotion on and off the unit. Resident 11 requires extensive assistance for toilet use, and total dependence on staff for bathing. Resident 11 uses a wheelchair as a mobility device. During an interview on February 14, 2023, at 8:03 AM, Resident 11 stated, the staff help her with moving her body, but resident was unable to recall the last time staff helped her with exercises involving weights. During an observation on February 14, 2023, at 8:21 AM, observed Resident 11 in her wheelchair with both hands slightly curled inwards- with the right hand having a more fist position than the left hand. There was not any staff assisting her with exercises. During an interview on December 14, 2023, at 10:00 AM, with the Director of Nurses (DON), the DON stated, RNA 1 has not been to work for a couple of weeks, due to a family issue. The DON stated, RNA 1 was the only Certified Nurse's Assistant (CNA) at the facility who has been trained to provided skilled restorative care nursing services. During an interview on February 14, 2023, at 11:18 AM, with the Minimum Data Set (MDS) Nurse (a nurse who assesses residents and collaborates with other healthcare professionals to create resident specific care plans), stated, Resident 11 is dependent on staff for her physical needs due to limited Range Of Motion (ROM) of both arms. During a concurrent interview and clinical record review on February 14, 2023, at 3:40 PM, with the DON, Resident 11's clinical record titled, Restorative Nursing Program Flow Sheet, dated February 2023, was reviewed. Restorative Nursing Program Flow Sheet indicated; Resident 11 had history of multiple falls, related to weakness and impaired mobility. Resident 11's diagnosis included hypoxic encephalopathy (brain injury caused by lack of oxygen) and cognitive (mental) impairment. The Restorative Nursing Approach was to encourage Resident 11 to use one pound weights on both legs during three rounds of leg lifts, for a total of at least 15 minutes per day. This exercise was designed to build leg strength. The DON stated, Resident 11 did not receive skilled restorative nursing care that included the use of weights from January 31, 2023, through February 16, 2023. The DON acknowledged Resident 11's Restorative Nursing Program Flow Sheet, dated February 2023 was blank. During an interview on February 14, 2023, at 3:44 PM, with the DON, the DON stated, residents who had an order to receive skilled restorative nursing care involving weights/bands, have not been getting the skilled therapy for the past two weeks. The DON stated, RNA 1 has been trained and certified by Physical Therapy (PT) for restorative care treatment. The DON stated, the PT Director came to the facility and trained RNA 1 on specific treatment exercises for the residents. These exercises are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 3 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 designed to maintain the resident's physical ability. Level of Harm - Minimal harm or potential for actual harm During an interview on February 15, 2023, at 6:21 PM, with the DON, the DON stated, she prefers to schedule RNA 1 and the Activities Certified Nursing Assistant ([CNA]- Activities CNA) on opposite schedules of each other (40 hours a week - 8 hour shifts). The DON acknowledged that the Activities CNA was not a certified for restorative care. The DON stated, the residents who use bands and weights have not received their skilled restorative nursing care while RNA 1 has been out on leave. The DON stated, she did not try and reach out for a registry RNA to cover for RNA 1. Residents Affected - Few During an interview on February 16, 2023, at 9:02 AM, with PT 1, PT 1 stated, she has worked with the residents on the Skilled Nursing Facility (SNF) side of the facility many times. PT oversees the restorative care program. PT 1 stated, she comes to the unit a few times during the training period to ensure the CNAs are doing restorative nursing care correctly. PT 1 stated, it takes about a week to certify a CNA for restorative care. PT 1 stated, PT could have covered for RNA 1 while she was out on leave if there was a physician's order placed in the computer system. PT 1 stated, PTs are employees of the hospital and not contract employees. During a concurrent interview and clinical record review, on February 16, 2023, at 9:15 AM with the DON, Resident 11's clinical record titled, Order Chronology, dated October 6, 2022, at 11:16 AM, by Physician 1, was reviewed. Order Chronology indicated, Resident 11 was ordered to participate in the restorative program with AROM to both legs with one pound weights, and PROM to both arms twice a day. The DON stated, from January 31, 2023, through February 16, 2023, Resident 11 did not receive skilled restorative nursing care that involved AROM and/or PROM that included the use of weights. During a review of Resident 11's clinical record titled, LÓNG TERM CARE PLAN, indicated, Resident 11 was at high risk for falls and had a goal of maintaining mobility, and strengthening extremities (arms and legs). The restorative program included exercising both arms with one pound ankle weights twice a day for a total of 15 minutes per day. During a concurrent interview and record review on February 16, 2023, at 10:00 AM, with the DON [FACILITY DISTRICT NAME] Job Description and Performance Review for Restorative Nursing Assistant , undated, was reviewed. Job Description and Performance Review for Restorative Nursing Assistant, indicated, Primary Purpose Under the supervision of the SNF DON and following the Physical Therapist plan of care and Scope of Service, this position will work collaboratively to deliver direct restorative nursing programs by: Providing restorative nursing care for the residents of the Skilled Nursing Unit . The DON stated, there is not another RNA to cover for RNA 1 when she is out on leave. RNA is trained by PT to do skilled exercises with the residents. During a concurrent interview and record review, on [DATE], at 10:05 AM, with the DON, facility's Policy and Procedure (P&P) titled, Restorative Nursing Program, undated , was reviewed. The P&P indicated, POLICY: Restorative Nursing care is an integrated program at [FACILITY DISTRICT NAME] to ensure that all Residents in the Skilled Nursing Facility (SNF) maintain the highest level of practicable functional mobility (highest possible level of functioning-limited by the resident's disease process and normal aging process) to enhance their overall well-being. In addition, the SNF unit's focus is to prevent of minimize physical deterioration as their medical condition permits. PROCEDURE: 1. Restorative care program is a specific approach that is organized, planned, documented, monitored and evaluated in a timely fashion. 2. The Certified Restorative Nursing Assistant provides delegated direct care services under the direction and supervision of the SNF (Skilled Nursing Facility) DON/RN (Registered Nurse) and PT Services. 3. Measurable objectives will be established with associated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 4 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interventions that will be documented in the clinical record and reflected in the residents [sic] individual care plan .3.2 The restorative aid will document the number of minutes the resident participated in the delegated program . The DON stated, the P&P was not followed when the facility did not have a RNA available to provide skilled restorative care services to Resident 8 from January 31, 2023, through February 16, 2023. The DON stated, two weeks is a long time for the residents not to be monitored by RNA 1. The DON acknowledged that portion of the policy was not followed. Event ID: Facility ID: 555468 If continuation sheet Page 5 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to complete a nutritional assessment post readmission for one of two sampled residents (Resident 4) who was newly diagnosed with Diabetes Mellitus (a disease that occurs when a person's blood sugar is too high). Residents Affected - Few This failure had the potential for not identifying the nutritional needs of Resident 4 in a timely manner which may compromise her health and well-being. Findings: During a review of Resident 4's clinical record titled History and Physical (H&P), dated January 26, 2023, at 7:21 PM, by the Medical Doctor (MD 1) indicated that Resident 4 was re-admitted from a hospital on January 25, 2023. The H&P indicated diagnoses which included cerebrovascular accident (CVA, Stroke or loss of blood flow to part of the brain), and diabetes mellitus. During an interview with Resident 4, on February 13, 2023, at 9:38 AM, Resident 4 complained about the food taste. Resident stated pudding was not sugar free and no snack are provided. During an interview on February 15, 2023, at 3:38 PM, with the Minimum Data Set nurse (MDS Nurse), MDS Nurse stated, that Resident 4 was recently placed on a diabetic diet after discharge from the hospital. MDS Nurse further-stated Resident 4 prefers to eat snacks instead of regular meals. During a concurrent interview and record review of Resident 4's Nutritional Care Dietary Consult with the Dietitian, on February 15, 2023, at 4:35 PM, the Dietitian verified that Nutritional Care Dietary Consult assessment was not done when Resident 4 was readmitted . The last assessment was completed on Jun 22, 2022. The Dietitian acknowledged that there was a delay in completing the initial evaluation of Resident 4's nutrition upon her readmission. During a review of the facility's policy and procedure (P&P) titled Comprehensive Medical Nutrition Therapy Assessment dated 2019, Chapter 8: Clinical Documentation 8-29, the P&P indicated, The RDN [Registered Dietitian nutritionist] will complete a comprehensive medical nutrition therapy (MNT) assessment for each individual that is referred or identified for assessment. The purpose of nutrition assessment is to obtain, verify and interpret data needed to identify nutrition-related problems, their causes, and significance. It is an ongoing, nonlinear dynamic process that involves data collection and continual analysis of the individual's status compared to specific criteria. procedure: 3. The RDN and/or designeee will identify nutritional risk factors and nutrition diagnosis, and recommend nutrition interventions based on each individuals medical condition, needs, desires, and goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 6 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate and sufficient staffing was available to provide nursing related services from January 31, 2023 through February 16, 2023, to substitute a Restorative Nursing Care Assistant (RNA 1) to assist two of 13 sampled residents (Resident 8 and Resident 11) with their skilled restorative nursing care program exercises (Active Range Of Motion ([AROM] the resident exclusively causes their body's movement), and/or Passive Range of Motion ([PROM] the RNA exclusively causes the resident's body movement) which included weights and/or exercise bands. This failure had the potential to cause a decline in physical mobility and function, for a medically compromised population of 13 residents who received Restorative Nursing Care, out of 15 residents. Findings: 1. During a review of Resident 8's clinical record titled, emergency room OUTPATIENT RECORD (document that contains the resident's demographic information), indicated, Resident 8 was admitted to the facility on [DATE], with a chief complaint of Multiple Sclerosis (MS - a disease that leads to muscle spasms [painful, involuntary movement of the muscles], stiffness, weakness, mobility problems, and problems with thinking, learning, and planning). During a concurrent observation and interview on January 13, 2023, at 12:00 PM, Resident 8 was in her bed and stated she was in pain (arms). During a review of Resident 8's Minimum Data Set 3.0 (MDS) Resident Assessment Validation and Entry System (as assessment tool) for Resident 8, dated, December 14, 2022, indicated: a. Section C, BIMS (brief interview for mental status) was coded as 15 (A score of 13 to 15 suggests the patient is cognitively intact). b. Section G, Functional Status, indicated, Resident 8 required extensive assistance with self-performance (ability to perform independently) locomotion (ability to move from one place to another) while off the unit, and extensive assistance with self-performance with dressing, personal hygiene, and bed mobility. Resident 8 has impairment to legs and utilized a wheelchair as a mobility device. During an interview on February 14, 2023, at 10:00 AM, with the Director of Nurses (DON), the DON stated, RNA 1 has not been to work for a couple of weeks, due to a family issue. The DON stated, RNA 1 was the only Certified Nurse's Assistant (CNA) at the facility who has been trained to provided skilled restorative care nursing services. During an interview on February 14, 2023, at 3:44 PM, with the DON, the DON stated, residents who have an order to receive restorative nursing care involving weights/bands, have not been getting that skilled therapy for the past two weeks. The DON stated, RNA 1 had been trained and certified by Physical Therapy (PT) for restorative care treatment. These exercises are designed to maintain the resident's physical ability. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 7 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on February 15, 2023, at 1:05 PM, with CNA 1, states, occasionally she will do basic restorative care, but RNA 1 was the CNA who does the trained restorative care for the residents. Restorative care involves placing hand roles in the resident's hands (to prevent contractures), having the resident sit down, and stand up, and Range Of Motion (ROM) exercises. CNA 1 stated, she does not do any of the walking of the residents but will alert the Licensed Vocational Nurse (LVN) if the task needs to be completed. CNA 1 stated, she has not done restorative care on any residents today. During an interview on February 15, 2023, at 4:06 PM, with an LVN Employee Health (LVN-EH), stated, PROM and AROM are different than Restorative Nursing Care. Restorative Nursing Care is completed by a Certified Restorative Nursing Assistant (RNA). The Physical Therapist (PT) trains the RNA on specific exercises to be completed with the resident. The LVN-EH stated, currently there is no other RNA in the facility to cover for RNA 1. The RNA oversees the Restorative Nursing Care program and writes the reviews, reports concerns to the physician and DON, and attends Intradisciplinary Team ([IDT] attended by nurses, physicians, pharmacy, administrator .) meeting. During a concurrent observation and interview on February 15, 2023, at 5:04 PM, with Resident 8, observed Resident 8 in bed and able to move her arms, but not her legs. Resident 8 stated, the staff member who helped with her exercises has not been at work for a couple of weeks. Resident 8 further stated, it would be nice to have more staff to help with resident care. Resident 8 stated, she has not been able to walk for the past 20 years. During an interview on February 15, 2023, at 6:21 PM, with the DON, the DON stated, she prefers to schedule RNA 1 and the Activities CNA on opposite schedules of each other (40 hours a week - 8-hour shifts). The DON acknowledged that the Activities CNA is not certified for restorative care. The DON stated, the residents who use bands and weights have not received their skilled restorative nursing care while RNA 1 has been out on leave. The DON further stated, she did not try and reach out for a registry RNA to cover for RNA 1. During a review of Resident 8's clinical record title, Order Chronology, dated September 7, 2022, at 9:55 AM, by Medical Doctor (MD 1), indicated, Resident 8 had a physician's order to participate in the Restorative Program for AROM. During an interview on February 16, 2023, at 7:58 AM, with the DON, the DON stated, RNA 1 has not been to work from January 31, 2023, through February 16, 2023, and therefore Resident 8 has not received skilled restorative nursing care during that time frame. The DON stated, Resident 8 did not have a specific physician's order to use weights/bands, but the weights and bands were in her restorative treatment plan and had been used all through January 2023. The DON stated, the expectation is that the weights/bands would be used through the month of February, 2023. During a concurrent interview and clinical record review, on February 16, 2023, at 9:40 AM, with the DON, Resident 8's clinical record titled, Restorative Nursing Program Flow Sheet, dated February 2023, was reviewed. Restorative Nursing Program Flow Sheet indicated, Resident 8's identified problem was weakness to both arms (related to MS) and osteoarthritis [wearing down of the protective tissue at the ends of bones that worsens over time causing pain and stiffness]) to the right shoulder. The treatment included AROM to both arms twice a day for at least fifteen minutes a day with two pound weights as tolerated or with a green band (resistance exercise band) from PT. When Resident 8 was in her wheelchair, staff were to encourage Resident 8 to propel herself to build strength and maintain wheelchair mobility. The DON stated, Resident 8 did not receive skilled restorative nursing care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 8 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (that included weights or bands) from a from January 31, 2023, through February 16, 2023. The DON acknowledged Resident 8's Restorative Nursing Program Flow Sheet, dated February 2023, was blank. 2. During a review of Resident 11's clinical record, emergency room OUTPATIENT RECORD, indicated, Resident 11, was admitted to the facility on [DATE], with a chief complaint of LTC (Long Term Care- need for care from a Skilled Nursing Facility [SNF]). During a concurrent observation and interview on February 13, 2023, at 3:28 PM, Resident 11 was in her wheelchair with her head facing down and had difficulty raising her head when speaking. Resident 11's hands turned inward in a fist position. There were no hand rolls or splints in place. The Activity CNA stated, Resident 11 has limited ROM. During a review of Resident 8's Minimum Data Set (MDS - Minimum Data Set, an assessment tool) Resident Assessment Validation and Entry System for Resident 11, dated, December 14, 2022, indicated: a. Section C, BIMS (brief interview for mental status) was coded as 7- which indicates, Resident 11 is cognitively impaired. (A score of 0-7 suggests the patient is severely cognitively impaired). b. Section G, Functional Status, indicated, Resident 11 has impairment on both upper arms and lower legs with limited Range of Motion (ROM). Resident 11 requires extensive assistance for sell-performance locomotion on and off the unit. Resident 11 requires extensive assistance for toilet use, and total dependence on staff for bathing. Resident 11 uses a wheelchair as a mobility device. c. Section O, Special Treatments, Procedures, and Programs, indicated, Resident 11 received PROM and AROM activities three times a day for more than 15 minutes per day. During an interview on February 14, 2023, at 8:03 AM, Resident 11 stated, the staff help her with moving her body, but resident was unable to recall the last time staff helped her with exercises involving weights. During an observation on February 14, 2023, at 8:21 AM, observed Resident 11 in her wheelchair with both hands slightly curled inwards- with the right hand having a more fist position. There was not any staff assisting her with exercises. During an interview on December 14, 2023, at 10:00 AM, with the Director of Nurses (DON), the DON stated, RNA 1 has not been to work for a couple of weeks, due to a family issue. The DON stated, RNA 1 is the only Certified Nurse's Assistant (CNA) at the facility who has been trained to provided skilled restorative care nursing services. During an interview on February 14, 2023, at 11:18 AM, with the Minimum Data Set Nurse ([MDS Nurse]nurse who assesses residents and collaborates with other healthcare professionals to create resident specific care plans), stated, Resident 11 was dependent on staff for her physical needs due to limited Range Of Motion (ROM) of both arms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 9 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and clinical record review on February 14, 2023, at 3:40 PM, with the DON, Resident 11's clinical record titled, Restorative Nursing Program Flow Sheet, dated February 2023, was reviewed. Restorative Nursing Program Flow Sheet indicated; Resident 11 had a history of multiple falls, related to weakness and impaired mobility. Resident 11's diagnosis included hypoxic encephalopathy (brain injury caused by lack of oxygen) and cognitive (mental) impairment. The Restorative Nursing Approach was to encourage Resident 11 to use one pound weights on both legs during three rounds of leg lifts, for a total of at least 15 minutes per day. This exercise was designed to build leg strength. The DON stated, Resident 11 did not receive skilled restorative nursing care that included the use of weights from January 31, 2023, through February 16, 2023. The DON acknowledged Resident 11's Restorative Nursing Program Flow Sheet, dated February 2023 was blank. During an interview on February 15, 2023, at 6:21 PM, with the DON, the DON stated, she prefers to schedule RNA 1 and the Activities Certified Nursing Assistant ([CNA]- Activities CNA) on opposite schedules of each other (40 hours a week - 8 hour shifts). The DON acknowledged that the Activities CNA was not a certified for restorative care. The DON stated, the residents who use bands and weights have not received their skilled restorative nursing care while RNA 1 has been out on leave. The DON stated, she did not try and reach out for a registry RNA to cover for RNA 1. During an interview on February 16, 2023, at 9:02 AM, with PT 1, stated, she has worked with the Residents on the SNF side of the facility many times. PT oversees the restorative care program. PT 1 stated, she comes to the unit a few times during the training period to ensure the CNAs are doing restorative nursing care correctly. PT 1 stated, it takes about a week to certify a CNA for restorative care. PT 1 stated, PT could have covered for RNA 1 while she was out on leave if the physician would have put an order in the computer system. PT 1 stated, PTs are employees of the hospital and not contract employees. During a concurrent interview and clinical record review, on February 16, 2023, at 9:15 AM with the DON, Resident 11's clinical record titled, [FACILITY DISTRICT NAME] Order Chronology, October 6, 2022, at 11:16 AM, by Physician 1, was reviewed. [FACILITY DISTRICT NAME] Order Chronology indicated, Resident 11 was ordered to participate in the restorative program with AROM to both legs with one pound weights, and PROM to both arms twice a day. The DON stated, from January 31, 2023, through February 16, 2023, Resident 11 did not receive skilled restorative nursing care that involved AROM and/or PROM that included the use of weights. During a review of Resident 11's clinical record titled, LÓNG TERM CARE PLAN, indicated, Resident 11 was at high risk for falls and had a goal of maintaining mobility, and strengthening extremities (arms and legs). The restorative program included exercising both arms with one pound ankle weights twice a day for a total of 15 minutes per day. During a review of facility's document NAME Staffing Guide dated from february 3, 2023 through February 16, 2023, was reviewed. Facilty's staffing guide indicated, RNA 1 was out from the facility and there was no documented evidence of a replacement for restorative care. During a concurrent interview and record review on February 16, 2023, at 10:00 AM, with the DON [FACILITY DISTRICT NAME] titled Job Description and Performance Review for Restorative Nursing Assistant , undated, was reviewed. Job Description and Performance Review for Restorative Nursing Assistant, indicated, Primary Purpose : Under the supervision of the SNF DON and following the Physical Therapist plan of care and Scope of Service, this position will work collaboratively to deliver direct restorative nursing programs by: Providing restorative nursing care for the residents of the Skilled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 10 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Nursing Unit . The DON stated, there was no other RNA to cover for RNA 1 when she was out on leave. RNA was trained by PT to do skilled exercises with the residents. During a concurrent interview and record review on [DATE], at 10:05 AM, with the DON, faciltiy's Policy and Procedure (P&P) titled, Restorative Nursing Program, undated, was reviewed. The P&P indicated, POLICY: Restorative Nursing care is an integrated program at [FACILITY DISTRICT NAME] to ensure that all Residents in the Skilled Nursing Facility (SNF) maintain the highest level of practicable functional mobility (highest possible level of functioning-limited by the resident's disease process and normal aging process) to enhance their overall well-being. In addition, the SNF unit's focus is to prevent of minimize physical deterioration as their medical condition permits. PROCEDURE: 1. Restorative care program is a specific approach that is organized, planned, documented, monitored and evaluated in a timely fashion. 2. The Certified Restorative Nursing Assistant provides delegated direct care services under the direction and supervision of the SNF (Skilled Nursing Facility) DON (Director of Nursing/RN (Registered Nurse) and PT Services. 3. Measurable objectives will be established with associated interventions that will be documented in the clinical record and reflected in the residents [sic] individual care plan .3.2 The restorative aid will document the number of minutes the resident participated in the delegated program . The DON stated, the P&P was not followed when the facility did not have a RNA available to provide skilled restorative care services to Resident 8and Resident 11, from January 31, 2023, through February 16, 2023. The DON stated, two weeks is a long time for the residents not to be monitored by the RNA. The DON acknowledged that portion of the policy was not followed. Event ID: Facility ID: 555468 If continuation sheet Page 11 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the stop date for Resident 2's scheduled Keppra (a medication used to treat and prevent seizures, which are involuntary muscle movements), medication during medication regimen review for one out of three sampled residents (Resident 2). This failure resulted in Resident 2 not receiving 16 consecutive scheduled Keppra medication administrations and which may have contributed Resident 2's seizure on december 11, 2022 Findings: During a review of the Coding Summary, (a document that contains a resident's demographic and medical information), for Resident 2, the Coding Summary indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage that leads to complete paralysis of half of the body) and hemiparesis (a weakness of one side of the body caused by brain damage) following other cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue), and other epilepsy (group of disorders marked by problems in the normal functioning of the brain, causing seizures). During a concurrent observation and interview on February 13, 2023, at 9:43 AM, in Resident 2's room, Resident 2 was observed lying in bed with a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and glasses on. Resident 2 stated, this one, this one, and this one is good, but that one is not. Resident 2 was asked, who were this one and that one, and Resident 2 was unable to identify who they were. Resident 2 was unable to focus with the interview questions. During a concurrent interview and record review, on February 15, 2023, at 2:32 PM, with the Director of Nursing (DON), the DON stated, Resident 2 was the only resident listed on the facility's undated document titled Patients Receiving Seizure Medications, in the facility. During a review of Resident 2's medication administration record (MAR), 5 Day MAR - Final, dated from November 28, 2022, to December 12, 2022, the MAR indicated, Resident 2's Keppra medication order was 1,000 mg (milligrams, unit of measurement) to be given by mouth twice a day, in the morning and evening. with a start date of December 3, 2021, and a stop date of December 3, 2022. The MAR indicated, Resident 2's Keppra medication order was discontinued on December 3, 2022, at 7:54 AM. Resident 2's MAR indicated, there were 16 consecutive ordered Keppra medication administrations not given to Resident 2, between December 3, 2022, and December 11, 2022. During a review of Resident 2's Order Chronology dated February 15, 2023, the Order Chronology indicated Resident 2 had a new order for Keppra medication, dated December 11, 2022, at 8:33 AM. During a review of Resident 2's Long Term Care Plan, dated February 14, 2023, the Long Term Care Plan indicated, Resident 2 has a potential for alteration in health maintenance related to diagnosis of epilepsy/seizure problem. The Long Term Care Plan further indicated, Resident 2 did not receive her Keppra as ordered due to a system error for renewal of medication. Resident 2 had a seizure on December 11, 2022, no injuries noted as a result of the seizure, MD 1 was notified and Keppra was reordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 12 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on February 14, 2023, at 3:30 PM, with Registered Nurse Supervisor (RN 1), stated, the system in place to prevent missed medication administration was the monthly medication regimen review with the pharmacist (RPH) and RN. RN 1 stated, at the time of the occurrence, the electronic health record (EHR) system would send a report to the printer at the nurses' station, notifying the nurses of medications that had a stop date that would soon occur. The printed page would then be placed on the nurses' station desk, where the medication nurse would determine the next action, which may include faxing the pharmacy if a refill is needed. RN 1 stated, she was unable to verify where the report, indicating Resident 2's Keppra medication stop date had been placed. During a review of the facility's policy and procedure (P&P) titled, Pharmacy Medication Review, undated, the P&P indicated, The pharmacist directly reports any potential irregularities to nursing and the physician. During an interview on February 15, 2023, at 3:47 PM, with the RPH, the RPH stated, monthly medication regimen review (an evaluation of the medication regimen of a resident) is completed by the RPH. The RPH stated, the stop dates for medications were not looked at prior to Resident 2's medication error. The RPH stated, order recapitulations (recap(s) - a report completed by the medical doctor with their decision to continue or discontinue an order) are forwarded to the medical doctor (MD 1). The RPH stated, the recap process had stopped due to staff not completing the recap process at the time of Resident 2's medication error. The RPH stated, stop date for Resident 2's Keppra medication order been noted, he would have referenced his concerns to the DON and/or the interdisciplinary team (a group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a resident). During a review of Resident 2's, Pharmacist Monthly Medication Review/Consultation, dated December 2022, the Pharmacist Monthly Medication Review/Consultation indicated Resident 2 had a seizure condition and Resident 2's indicated medication to treat the seizure condition was Keppra medication. The Pharmacist Monthly Medication Review/Consultation further indicated in the discussion notes with nursing, that Resident 2 had a seizure this month and appeared to be related to Resident 2 not receiving their Keppra. During an interview on February 15, 2023, at 5:08 PM, with the Director of Nursing (DON), the DON stated, they noticed on the day of Resident 2's seizure that the EHR system was automatically discontinuing medications based on the stop dates in the EHR system. The DON stated, MD 1 was able to review the orders in the EHR system and choose whether to continue or discontinue any orders, including medication orders. The DON stated, the report with all orders was printed and included all medications and the medication stop dates. During a review of the facilty's policy and procedure (P&P) titled, Physician's Orders - SNF, undated, the P&P indicated, Procedure: 1.All SNF residents nursing and medication orders shall be renewed on a monthly basis. 7.The following shift is to verify orders for completion and accuracy. 8. All skilled nursing charts will be checked for new orders every 24 hours during the night shift by a licensed staff memeber for accuracy and completion of orders . During a concurrent interview and record review on February 16, 2023, at 10:47 AM, with the DON, the DON was asked if the facility's policy and procedure (P&P) titled, Physician's Orders - SNF, undated, which indicated, All SNF residents nursing and medication orders shall be renewed on a monthly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 13 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 basis, was followed by the facility. The DON stated, this was a system error and was not completed for Resident 2. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 14 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - 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 three sampled residents (Resident 2) was free of significant medication errors, when the facility did not renew and administer Resident 2's scheduled Keppra (a medication used to treat and prevent seizures [which are involuntary muscle movements] for 16 medication administration opportunities, from December 3, 2022, 9:00 AM, through December 10, 2022, 4:00 PM. Residents Affected - Few This failure resulted in Resident 2 sustaining a grand mal seizure (also known as a tonic-clonic seizure, characterized by intense muscle contractions and loss of consciousness), which could have jeopardized the health and safety of Resident 2. Findings: During a review of Resident 2's Coding Summary, (a document that contains a resident's demographic and medical information), ,dated February 2, 2023, the Coding Summary indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage that leads to complete paralysis of half of the body) and hemiparesis (a weakness of one side of the body caused by brain damage) following other cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue) and other epilepsy (group of disorders marked by problems in the normal functioning of the brain, causing seizures) . During a concurrent observation and interview on February 13, 2023, at 9:43 AM, in Resident 2's room, Resident 2 was observed lying in bed with a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and glasses on. Resident 2 stated, this one, this one, and this one is good, but that one is not. Resident 2 was asked, who were this one and that one, and Resident 2 was unable to identify who they were. Resident 2 was unable to focus with the interview questions. During a telephone interview on February 13, 2023, at 2:20 PM, received by the surveyor from a family member (FM 1) of Resident 2, FM1 stated Resident 2's seizure medication fell off the system and Resident 2 was without seizure medication for eight to nine days and had a grand mal seizure. FM 1 stated, they were called about Resident 2's seizure and told that the facility would investigate the occurrence. During a review of Resident 2's medication administration record (MAR), 5 Day MAR - Final, dated from November 28, 2022, to December 12, 2022, the MAR indicated, Resident 2's Keppra medication order was 1,000 mg (mg-milligrams, unit of measurement) to be given by mouth twice a day, with start date of December 3, 2021, and stop date of December 3, 2022. The MAR indicated, the Keppra medication order was discontinued on December 3, 2022, at 7:54 AM. During a review of Resident 2's Order Chronology (Physician Orders), dated February 15, 2023, the Physician Orders indicated, Resident 2 's physician order for Keppra, oral tablet, 1,000 mg, one tablet taken by mouth twice a day, start date was from December 11, 2022, at 8:33 AM. During a review of Resident 2's 5 Day MAR - Final (MAR), dated from November 28, 2022, to December 2, 2022, the MAR indicated, Resident 2's Keppra medication order was last administered on December 2, 2022, at 4:09 PM. The MAR dated from December 3, 2022, to December 7, 2022, indicated, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 15 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Actual harm Residents Affected - Few 2's Keppra medication order was discontinued on December 3, 2022, at 7:54 AM. The MAR, dated from December 8, 2022, to December 12, 2022, indicated, Resident 2's Keppra medication order was next administered on December 11, 2022, at 9:10 AM. Resident 2's MAR indicated, 16 consecutive scheduled Keppra medication administrations were not given to Resident 2, between December 3, 2022, to December 10, 2022. During a review of Resident 2's Long Term Care Plan (Care Plan- specific interventions to provide effective and person-centered care to meet the resident's needs), dated February 14, 2023, the Long Term Care Plan indicated, Resident 2 has a potential for alteration in health maintenance related to diagnosis of epilepsy/seizure problem. The Long Term Care Plan indicated Resident 2 did not receive her Keppra as ordered due to a system error for renewal of medication Resident 2 had a seizure on December 11, 2022, no injuries noted as a result of the seizure, MD was notified and Keppra was reordered. During an interview on February 14, 2023, at 8:20 AM, with Minimum Data Set Nurse (MDS Nurse - a nurse who assesses residents and collaborates with other healthcare professionals to create resident specific care plans), MDS Nurse stated, Resident 2 was not given multiple scheduled Keppra medication administrations during a COVID-19 (a highly contagious respiratory disease) outbreak in the facility. MDS Nurse stated, Resident 2 was noticed by the night nurse on December 11, 2022, at 5:52 AM, to be having a seizure and at that time it was noticed that Resident 2 had not been receiving their Keppra medication. MDS Nurse stated, the Keppra for Resident 2 had been removed by the electronic health record (EHR) system automatically. MDS Nurse stated, the facility completed an investigation and notified family when Resident 2 had the seizure. MDS Nurse stated, Resident 2's seizure had occurred during the night shift, early morning of December 11, 2022. During an interview on February 14, 2023, at 3:30 PM, with Registered Nurse 1 (RN1), RN 1 stated, the system in place to prevent missed medication was the monthly review with the pharmacist and RN 1. RN 1 stated, at the time of the occurrence, the electronic health record system would send a report to the printer at the nurses' station notifying the nurses of medications that had a stop date that would soon occur. The printed page would then be placed on the nurses' station desk where the medication nurse would determine the next action which may include faxing the pharmacy if a refill is needed. RN 1 stated, they are unable to verify where the report indicating Resident 2's Keppra medication stop date had been placed. During a concurrent interview and record review on February 15, 2023, at 2:32 PM, with the Director of Nursing (DON), the DON stated, Resident 2 was the only resident listed on the facility's undated document titled Patients Receiving Seizure Medications in the facility. During a review of Resident 2's Patient Progress Notes, dated December 11, 2022, at 5:52 AM, indicated, Resident 2 had a witnessed grand mal seizure, lasting approximately one and half minutes. The Patient Progress Notes indicated, Resident 2 suddenly raised up left arm, became stiff and started shaking mildly and was unresponsive throughout the seizure and confused following the seizure. During an interview on February 15, 2023, at 3:47 PM, with the Pharmacist (RPH), the RPH stated, the monthly medication regimen review (MRR - an evaluation of the medication regimen of a resident) is completed by the RPH. The RPH stated, the stop dates for medications were not looked at prior to Resident 2's medication error. The RPH stated, order recapitulations (a report completed by the medical doctor with their decision to continue or discontinue an order) are forwarded to the medical doctor (MD 1). The RPH stated, the recap process had stopped due to staff not completing the recap (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 16 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Actual harm process at the time of Resident 2's medication error. The RPH stated, the stop date for Resident 2's Keppra been noted he would have referenced his concerns to the Director of Nursing (DON) and/or the interdisciplinary team (a group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a resident). Residents Affected - Few During an interview on February 15, 2023, at 5:08 PM, with the Director of Nursing (DON), the DON stated, they noticed on the day of Resident 2's seizure that the EHR system was automatically discontinuing medications based on the stop dates in the EHR system. The DON stated, MD 1 was able to review the orders in the EHR system and choose whether to continue or discontinue any orders, including medication orders. The DON stated the report with all orders was printed and included all medications and the medication stop dates. The DON was asked if the stop date had been noticed prior to Resident 2's seizure, would Resident 2's seizure been avoidable? The DON replied, Resident 2 had a history of refusing medications before and did not know if Resident 2's missed Keppra medication administrations had caused Resident 2 to sustain their grand mal seizure. During a review of Resident 2's Pharmacist Monthly Medication Review/Consultation, dated December 2022, the document indicated, Resident 2 had seizure condition and Resident 2's indicated medication to treat the seizure condition was Keppra. The document further indicated in the discussion notes with nursing, Resident 2 had a seizure this month and appeared to be related to Resident 2 not receiving their Keppra. During a review of the facility's policy and procedure (P&P) titled, Physician's Orders - SNF, undated, the P&P indicated, Procedure: 1.All SNF residents nursing and medication orders shall be renewed on a monthly basis. 7.The following shift is to verify orders for completion and accuracy. 8. All skilled nursing charts will be checked for new orders every 24 hours during the night shift by a licensed staff member for accuracy and completion of orders . During a concurrent interview and record review on February 16, 2023, at 10:47 AM, with the DON, the DON was asked if the facility's policy and procedure (P&P) titled, Physician's Orders - SNF, undated, was followed in reference to item 1(one), which indicated, All SNF residents nursing and medication orders shall be renewed on a monthly basis. The DON stated, this was a system error and was not completed for Resident 2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 17 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary food preparation and storage practices when: Residents Affected - Many 1. One dirty manual can opener was observed in the kitchen across from the ovens. 2. One oven was not kept in sanitary condition which could transfer to residents' foods during cooking. This had the potential to contaminate the food and cause foodborne illness (stomach illness acquired from ingesting contaminated food). 3. Opened and unlabeled following food packages observed in the walk in refrigerator. a. One opened and unlabeled package of smoked ham in the refrigerator. b. One opened and unlabeled package of parmesan cheese in the refrigerator. c. One opened and unlabeled package of pepperoni in the refrigerator. d. One opened and unlabeled package of sausage in the refrigerator. 4. One dirty trash can and trash roller in the kitchen. 5. One dirty serving tray located in the serving line. These failed practices had the potential for the growth of harmful bacteria that could lead to food borne illnesses for a medically compromised population of 15 residents who received food from the kitchen . Findings: 1. During a concurrent observation and interview on February 13, 2023, at 9:35 AM, with the Certified Dietary Manger (CDM), one large, mounted manual can opener (located in the kitchen across from the ovens), had a red, caked on substance on the exterior portion of the can opener. The CDM stated, the can opener appeared to have old sauce on it and the can opener should be cleaned daily or after each use. During a concurrent interview and policy and procedure review (P&P), on February 13, 2023, at 3:37 PM, with the Registered Dietitian (RD), facility's Policy & Procedure Manual (P&P) Cleaning Instructions: Can Opener, dated 2019, was reviewed. The P&P indicated, Policy: The can opener will be cleaned after each use . The RD stated, the P&P was not followed because the can opener obviously was not cleaned after use. 2. During a concurrent observation and interview, on February 13, 2023, at 9:40 AM, with the CDM, one oven (there were two ovens next to each other- the oven on the right) had dried food spatter on the inside of the bottom oven and on the inside of the oven door. The CDM stated, the oven should be cleaner than its current state. Ovens are cleaned every Saturday and as needed. The CDM stated, there is not a cleaning log that employees check off when the cleaning task has been completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 18 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent interview and facility guideline review, on February 13, 2023, at 3:32 PM, with the Registered Dietitian (RD), FNS Cleaning Schedule, undated, was reviewed. FNS Cleaning Schedule indicated, ovens are cleaned weekly (Saturday) or when food has spilled. The RD stated, the ovens are supposed to be cleaned on Saturday and as needed with any spills. The facility was unable to provide a cleaning schedule or a cleaning task log. The RD stated, the cleanings schedule was not followed when the oven spill was not immediately cleaned. During a concurrent interview and record review, on February 13, 2023, at 3:33 PM, with the RD, facility's Policy & Procedure (P&P) Cleaning Instructions: Ovens, dated 2019, was reviewed. The P&P indicated, Policy: Ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). Spills and food particles will be removed after each use . 7. Wipe off any loosened grease and particles from inside the open and the oven door . The RD stated, the oven should not have splatter on the inside of the door and the cleaning policy was not followed. 3. During an initial tour of the kitchen on February 13, 2023, at 9:45 AM, with the CDM, the following opened and unlabeled food products were observed in the walk in refrigerator. a. One package of opened and unlabeled smoked ham was found in the walk in refrigerator. b. One package of opened and unlabeled parmesan cheese was found in the walk in refrigerator. c. One package of opened and unlabeled pepperoni was found in the walk in refrigerator. d. One package of opened and unlabeled sausage was found in the walk in refrigerator. During an interview with the CDM on February 13, 2023, at 9:56 AM, the CDM acknowledged the opened and unlabeled food products observed in the walk in refrigerator and stated opened packages of food products stored in the refrigerator should have an open date and an use by date (use by- final day that the product will be at its optimum freshness). During a concurrent interview and P&P review on February 13, 2023, at 3:53 PM, with the RD, [FACILITY DISTRICT NAME] Nutrition and Dietary Services Storage and Labeling Policy, undated, was reviewed. The P&P indicated, Policy: All food and non-food items purchased by [FACILITY NAME] or the Food and Nutrition Services (FNS) department shall be properly stored and labeled . 2. Storage Practices: . 2.3.1.1 The name of the food, opened and use-by-dates will be placed on these items . 5. Perishable Storage: . 5.10 All food items in refrigerators are properly labeled, dated per this policy and in approved containers . 5.16.2 Cured meats such as bacon, franks, and sandwich meats will be used within 7 days of opening or freezer wrapped, dated and labeled and frozen for later use . The RD stated, the policy was not followed when the opened food item was not properly labeled. 4. During a concurrent observation and interview on February 13, 2023, at 9:57 AM, with the CDM, there was caked on dry splatter on the outside of one trash can and one trash roller system (one of two) was observed in the kitchen. The CDM stated, the trash can, and rollers should be cleaned every two weeks and they should not look dirty. During a concurrent interview and facility guideline review on February 13, 2023, at 3:40 PM, with the RD, FNS Cleaning Schedule, undated, was reviewed. FNS Cleaning Schedule indicated, trash cans should be cleaned daily and with a weekly spray wash. The RD stated, the outside of the trash can, and roller system was very dirty and should have been cleaned daily. The RD stated, it was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 19 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 acceptable to see the trash can and rollers that dirty. The cleaning schedule was not followed. Level of Harm - Minimal harm or potential for actual harm 5.During a concurrent observation and interview on February 13, 2023, at 10:10 AM, with the CDM, one of ten serving trays on the serving tray line, was observed to have a caked on red substance on the left upper corner of the serving tray, and bread like crumbs over the serving tray. The CDM stated, the dirty tray should not have been in the line of clean trays that were ready to use. Residents Affected - Many During a concurrent interview and record review on February 13, 2023, at 3:44 PM, with the RD, facility's P&P, Cleaning Dishes/Dish Machine, undated, was rereviewed. The P&P indicated, Policy: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use . 8. During the unloading process, visually inspect all items for cleanliness . 10. Inspect for cleanliness and dryness and put dished away if clean . The RD stated, the trays are cleaned the same way the dishes are cleaned, and the P&P tiled, Cleaning Dishes/Dish Machine is also used for the cleaning of food trays. The RD stated, the serving tray was not cleaned properly and the P&P was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 20 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 sampled residents (Resident 2) had access to the call light while in bed in resident rooms. Residents Affected - Few This failure had the potential to result in Resident 2's inability to call for staff assistance when needed. Findings: During a review of the Coding Summary, (a document that contains a resident's demographic and medical information), for Resident 2, the Coding Summary indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage that leads to complete paralysis of half of the body) and hemiparesis (a weakness of one side of the body caused by brain damage) following other cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue) and other epilepsy (group of disorders marked by problems in the normal functioning of the brain, causing seizures). During a concurrent observation and interview on February 13, 2023, at 9:43 AM, in Resident 2's room, Resident 2 was observed lying in bed with a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and glasses on. Resident 2 was observed with right hand in fist. Resident 2 was able to use left hand and arm to grab her water tumbler and tablet. Resident 2 stated, this one, this one, and this one is good, but that one is not. Resident 2 was asked, who were this one and that one, and Resident 2 was unable to identify who they were. Resident 2 was unable to focus with the interview questions. During an observation on February 13, 2023, at 9:50 AM, in Resident 2's room, Resident 2 was observed lying in bed and the call light was laying on the right side of Resident 2's head on the bed. During a telephone interview on February 13, 2023, at 2:20 PM, (call received by the surveyor from a family member (FM 1) of Resident 2, FM 1 stated, Resident 2 has waited for 15 to 20 minutes for the call light to be answered by the facility. FM 1 stated, concern for Resident 2's call light being placed on Resident 2's flaccid (limp or weak muscular tone) right side. During a review of Resident 2's Order Chronology, dated February 15, 2023, the Order Chronology indicated, an order to have the call light in reach of Resident 2, dated April 27, 2022. During a review of Resident 2's Long Term Care Plan (Care Plan- specific interventions to provide effective and person-centered care to meet the resident's needs), dated February 14, 2023, the Care Plan indicated, Resident 2, under the section self-care deficit problem, related to right sided hemiplegia/hemiparasites, intervention number 13, was to ensure call light was always within reach for Resident 2. The Care Plan further indicated, for Resident 2, under the section risk for falls due to history of falls, impaired mobility, and poor safety awareness that intervention number seven (7) was to always have Resident 2's call light within reach. During a subsequent observation on February 14, 2023, at 8:18 AM, in Resident 2's room, the call light was observed draped over the bedrail on the right side of Resident 2. Resident 2 was asked if she could reach the call light. Resident 2 stated, no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555468 If continuation sheet Page 21 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent observation and interview, on February 14, 2023, at 3:01 PM, with Minimum Data Set (MDS Nurse - a nurse who assesses residents and collaborates with other healthcare professionals to create resident specific care plans), in Resident 2's room, Resident 2 was asked to locate her call light. Resident 2 stated, she could not locate the call light. MDS Nurse was observed looking for Resident 2's call light. MDS Nurse located the call light draped over the oxygen device on the wall, along with Resident 2's television remote, and bed controller. MDS Nurse acknowledged that Resident 2's call light was not within reach . MDS Nurse further stated, the call light should be always placed within reach of Resident 2. Event ID: Facility ID: 555468 If continuation sheet Page 22 of 22