Health inspection·June 2, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 their policy and procedure (P&P) for abuse was implemented when a licensed nurse did not report an injury of unknown origin in a timely manner for one of four sampled residents (Resident 1) in a universe of 15 residents. This failed practice had the potential for other unusual occurrences (an incident that threatens the welfare, safety, and health of the resident) to go undetected and unreported which could compromise the health and safety of residents at the facility. Residents Affected - Few Findings: During a review of a notification from the Director of Nursing (DON) to the California Department of Public Health (CDPH), dated May 20, 2023, the notification indicated, Resident 1 was a [AGE] year-old female with a history of Dementia (progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often personality change, resulting from disease of the brain), Depression (mental illness affecting how you feel, the way you think and how you act), and stroke (Blood flow to the brain is blocked resulting in injury causing effects such as emotional disturbances, ability to speak and understand, and ability to move limbs). A further review of the document indicated, the DON was notified by Licensed Vocational Nurse (LVN1) about an injury of unknown origin on May 20, 2023, at 7:15 AM. Resident 1 was assessed to have a bruise (to develop or bear discolored spot on the skin as the result of blow or fall) under her left arm that wrapped around under her breast to the front of her chest. Resident 1 stated she does not remember doing anything to cause the bruise. During an interview on May 23, 2023, at 11:38 AM, with the DON, the DON stated, Resident 1's bruising was assessed on May 18, 2023, during the day shift. The DON stated when LVN1 and Certified Nursing Assistant (CNA1) found it was fresh bruise. The DON further stated, LVN 1 did not document and did not call doctor. During an interview on May 23, 2023, at 12:03 PM, with LVN1, LVN1 stated she found the bruise on May 18, 2023. LVN1 stated, I forgot to chart it. I wrote a note to (DON) via email on May 20, 2023. I did not notify the doctor at that time. It was during med (mediaction) pass and other things happening and I did not (follow policy and procedure). Expectation is to be more aware of my charting and following protocol on change of condition. During a concurrent observation and interview on May 23, 2023, at 12:24, with Resident 1, Resident 1 had no psychosocial distress or visible injuries observed, Resident 1 stated, I don't know (how long she has been Here). I don't know (why she is here). Resident stated the staff here are ok and denied residents or staff have hurt her. Resident 1 verbalized first name, but last name verbalized was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555468 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 06/02/2023 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)