Health inspection·March 19, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of one sampled resident (Resident 4) Percutaneous endoscopic gastrostomy (PEG- a tube placed in the stomach to provide food, water, and medications) tube placement and residual were checked before administering medications. This failure had the potential to affect the health and well being for Resident 4. Findings: During a review of Resident 4's clinical record, the history and physical (a document that contains basic information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included PEG tube. During a concurrent medication pass observation, and interview on March 13, 2024, at 8:01 AM, with Licensed Vocational Nurse (LVN 1), the LVN 1 was administering medications through the PEG tube. LVN 1 did not check Resident 4's PEG tube placement and residual before administering the medications. When asked why she did not check Resident 4's tube placement and residual, she stated knows she has to do it and they usually check it once a shift. She further stated she knows the right way is to check placement and residual every medication administration. She stated unfortunately she missed some steps. During a review of the facility's Policy and Procedure (P&P) undated, titled, Tube Feeding, indicated, .Pull the syringe back to check for residual feeding/fluid, if greater than 50 ml hold feeding, clamp the tube, close the flap. Document in EMR and notify MD. Page 1 of 13 555468 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed follow their policy and procedure for one of three sampled Residents Affected - Few residents (resident 20) when Resident 20's PRN (as needed) oxygen physician order did not include indication. This failure had the potential to cause Resident 20 to receive inadequate oxygen and place Resident 20 at higher risk of insufficient oxygenation. Findings: During a record review of the facility's face sheet (a document containing resident's demographic and medical information) of resident 20,the face sheet indicated Resident 20 was admitted with a diagnosis which included Congestive Heart failure (a chronic condition which causes low oxygen level because the heart cannot pump enough oxygen the way it should). During an observation on March 12, 2024, at 9:00 AM, in Resident 20's room, Resident 20 was observed lying in bed with a nasal cannula (NC-a medical device that provides supplemental oxygen therapy to Resident 20) set at 2 liters (unit of measurement) per minute. During a review of Resident 20's Physician Orders, dated March 13, 2024, it indicated, oxygen at 2 liters per minute via NC PRN. Further review of Resident 20's oxygen physicians order, it was noted that there was no indication for its use. During an interview on March 14, 2024, at 11:36 AM, in the nursing station with Licensed Vocational Nurse (LVN 1), LVN 1 acknowledged Resident 20 had no indication for oxygen use. LVN 1 further stated there was no documented administration and indication for oxygen use. During an interview on March 19, 2024, at 4:00 PM, in the Director of Nursing's office with the Director of Nursing (DON), DON acknowledged Resident 20's PRN order for oxygen administration does not have an indication. 555468 Page 2 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0695 Level of Harm - Minimal harm or potential for actual harm During a record review of facility's policy and procedure (P&P), undated, title,Oxygen Use in the SNF, the P&P indicated, All resident sreceiving oxygen in the Skilled Nursing Facility (SNF) shall have an order from a provider noting the L (liter)/MN (minute) Residents Affected - Few and designated as nasal cannula or mask (type) as well as continuous or PRN. Further review of the P&P, it indicated, 1.1 SpO2 [oxygen saturation - a measurement of how much oxygen is the blood carrying] monitoring shall be done on a weekly basis for all residents receiving oxygen PRN 1.2 The provider shall be notified with any SpO2 < (less than) 90% for residents receiving oxygen. [generally, indicate the need for the supplemental oxygen.] 555468 Page 3 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure a completed nurse staffing information with actual Residents Affected - Many hours worked by the licensed staff responsible for direct resident care was prominently displayed in the nursing station . This failure resulted in nurse staffing information with actual hours worked not being prominently displayed to the public in the nursing station. Finding: During an observation on March 14, 2024, at 10:00 AM, in the facility's nursing station, it was noted that the nurse staffing information was not displayed in a readily accessible area. During a review of the facility provided document titled, Nurse Staffing Information, dated March 12, 2024, through March 14, 2024, Nurse Staffing Information indicated that the actual work hours worked by the licensed staff responsible for direct resident care were not specified. During an interview on March 19, 2024, at 4:00 PM, in the Director of Nursing's office with the Director of Nursing (DON), DON acknowledged that nurse staffing information was not posted daily on a prominent place and lacked complete information . During a review of facility's undated policies and procedures (P&P) titled, Staffing Plan, The P&P indicated, Staffing guidelines reflect projected nursing workload measurement in relation to census and patient acuity. 555468 Page 4 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an order for Clonazepam ( a psychotropic medication that affects how the brain works and causes changes in mood, awareness, feelings and behavior) PRN (give only as needed) was renewed by the physician within 14 days for one of three sampled residents (Resident 17). This failure had the potential for Resident 17 to continue to receive PRN doses of Clonazepam, that may no longer be necessary and could cause changes in Resident 17's fatigue, mood and memory problems. Findings: During a review of Resident 17's History and Physical (H&P- a document that includes a Resident 17's medical assessment performed by a medical provider), the H&P indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses including severe deconditioning (mental and physical decline that results from physical inactivity), anxiety (feeling of fear, dread and uneasiness that can cause physical stress), and hypertension (HTN- high blood pressure). During a concurrent interview and record review on March 19, 2024, at 10:23 AM, with Pharmacist, the Interdisciplinary Care Plan (ICDP) Notes- Quarterly dated 10/18/2023 was reviewed. The ICDP Notes-Quarterly indicated, .reduce [Clonazepam] 0.5 QHS (every night at bedtime) and 0.25 in am (the morning) with 0.25 PRN (only as needed). The Pharmacist stated, Resident 17's Clonazepam dose had been decreased during a gradual dose reduction (GDR- an assessment performed by a facility to reduce the dose of antipsychotic medication a resident is taking) in October 2023. Resident 17's morning dose was cut in half from Clonazepam 0.5 mg (milligrams- units of measure) to Clonazepam 0.25 mg, and Clonazepam 0.25 mg was added with the intention to stop the PRN dose if Resident 17 tolerated this well. The Pharmacist also stated he did not know if the order had been renewed or if the attending physician had reevaluated Resident 17 for continued used of this medication. During a concurrent interview and record review on March 19, 2024, at 2:14 PM, with Physician (MD), Resident 17's Order Summary was reviewed. The Order Summary indicated, .Clonazepam 0.25 mg tab oral PRN daily start date: 10/18/2023 stop date 3/18/2024. Indication: anxiety Instructions: PRN daily at noon . The MD stated, Resident 17's Clonazepam was reduced in October 2023 as part of the GDR. The MD stated, he did not know that PRN psychotropic medications need to be renewed every 14 days and an evaluation of the patient needed to be done for the renewal of apsychotropic medication. During a review of the facility's policy and procedure (P&P) titled, Gradual Dose Reduction (GDR Psychotropic Medications, undated, indicated .All residents receiving psychotropic medications will receive the appropriate dose and duration to minimize the risk of adverse consequences. The purpose of GDR is to determine the optimal dosage of medication or whether continued use of the medication is 555468 Page 5 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0758 benefiting the residenT . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555468 Page 6 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0759 Ensure medication error rates are not 5 percent or greater. 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 medication rate was less than 5 percent when three medications out of 28 opportunities were crushed and given together through Percutaneous endoscopic gastrostomy (PEG- a tube feeding inserted through the stomach which medications, food, and water is given) for Resident 4. Residents Affected - Few This failure had the potential to affect the health and well being and cause drug interactions for Resident 4. Findings: During a review of Resident 4's History and Physical (a document that contains basic information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included PEG tube and Lennox-Gastaut syndrome (a type of seizure). During a concurrent medication observation and interview on March 13, 2024, at 8:01 AM, with Licensed Vocational Nurse (LVN 1), LVN 1 administered the following medications at the same time through the PEG tube: 1. Clobazam (a medication used for seizures) 10 mg (milligram a unit of measurement) one tablet every 12 hours 2. Phenobarbital (a medication used to treat seizures) 64.8 mg one tablet every 12 hours 3.Carbazepine (a medication used to treat seizures) 200 mg three tablet every 12 hours. LVN 1 stated she knows medication should be crushed separately and given separately but she doesn't understand the logic to it, that is why she is not doing it. During a review of Resident 4's physician's order, dated March 13, 2024, indicated, Clobazam oral tablet 10 mg every 12 hours for seizure, crush med. During a review of Resident 4's physician's order, dated March 13, 2024, indicated, Phenobarbital oral tablet 64.8 mg every 12 hours for seizures. Crush med. During a review of Resident 4's physician's order, dated March 13, 2024, indicated, Carbamazepine 200 mg 3 tablets every 12 hours for seizures. Crush Med. During a review of the facility's policy and procedure (P&P) undated, titled, Administration of Medications and Treatments, indicated, (name of the facility) shall define the role of the healthcare professional in the administration of medication to the resident; list some general safety precautions the healthcare professional observes in the preparation and administration of medication and treatments, and ensure a uniform approach in the administrating of medications to all residents. 555468 Page 7 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0759 During a review of the facility's P&P, undated, titled, Tube Feeding, indicated, Never Mix Medicines. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555468 Page 8 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 follow proper maintenance and sanitation practices when several dish drying racks were found to have black stains on both the inner and outer part of the racks and some dish drying racks had cracks with jagged edges. This failure had the potential to result in food borne illness in a medically vulnerable population of 18 residents. Findings: During a concurrent observation and interview with the Director of Nutrition Services (DNS) and Food and Nutrition Services (FNS) in the kitchen, on March 11, 2024, at 10:08 AM, several dish drying racks were observed with black stain in the inner part and outer part of the rack. Some had a crack with a jagged edge on it. The FNS washed one dish drying rack with soap and water and the black stain came off. She stated the black stain is not dirt it is residue from heat and hot water. She confirmed one dish drying rack had black stain. When asked how often they clean the racks the DNS stated, We will replace the old dish racks. There are seven old racks. She confirmed the dish drying racks had jagged edges on them. 555468 Page 9 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain infection control practices when Licensed Residents Affected - Few Vocational Nurse (LVN 1) did not perform hand hygiene when preparing medications for two out of five sampled residents (Resident 20 and 5). This failure had the potential to put the health of sampled Residents 20 and 5 at risk of contracting infectious diseases caused by bacteria, viruses, fungi, or parasites. Findings: 1. During a review of facility's (undated) admission record for Resident 20, the admission record indicated Resident 20 was admitted on January 30, 2024, with a diagnosis of Congestive Heart Failure (a chronic condition that affects the heart to pump blood). During an observation for Resident 20's medication administration, on March 14, 2024, at 8:49 AM, in front of Resident 20's room, LVN 1 did not perform hand sanitization process after touching her personal cell phone while preparing Resident 20's medication. During an interview on March 14, 2024, at 8:52 AM, in the nurse's station with LVN 1, the LVN 1 acknowledged touching her personal cellphone while preparing medication of Resident 20, but did not perform hand sanitation process afterwards. 2.During a review of facility's (undated) admission record for Resident 5, the admission record indicated Resident 5 was admitted on February 2, 2023, with a diagnosis that included Diabetes (a long-term condition that affects the body's ability to control blood sugar levels use it for energy). During an observation for Resident 5's medication administration, on March 13, 2024, at 12:56 PM, in front of Resident 5's room, with LVN 1, the LVN 1 did not perform hand sanitation process prior to going into the resident 20's room and performed the medication 555468 Page 10 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0880 administration. Level of Harm - Minimal harm or potential for actual harm During an interview on March 13, 2024, at 12:59 PM, in the nurse's station with LVN 1, the LVN 1 stated that she did not perform Residents Affected - Few hand sanitation process prior to entering resident 5's room since she had medications in her hands. During a review of facility's (undated) policy and procedure (P&P) titled, Infection Prevention - SNF The P& P indicated, .Principles of Standard Precautions are adhered to in caring for all residents . 555468 Page 11 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure for one of five sampled residents (Resident 18) was offered a pneumococcal vaccine (a vaccine which helps to prevent a lung infection) upon admission to the facility on August 1, 2023. Residents Affected - Few This failure had the potential to affect the health and well- being for Resident 18 by not being offer the pneumococcal vaccine to help prevent a lung infection. Findings: During a review of Resident 18's clinical record, Resident 18's History and Physical, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and seizure disorder. During a concurrent interview, and record review, with the Infection Preventionist (IP), on March 14, 2024, at 10:46 AM, a review of Resident 18's immunization records was conducted. There was no documented evidence a pneumococcal vaccine was offered . The IP stated, [I] don't know if pneumococcal and COVID was offered during admission. A review of the document provided by the IP only indicated the Influenza vaccine had been declined. 555468 Page 12 of 13 555468 03/19/2024 Bear Valley Community Hospital 41870 Garstin Rd Big Bear Lake, CA 92315

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure for one of five sampled residents (Resident 18) was offered a COVID vaccine (a vaccine which helps to prevent a lung infection) upon admission to the facility on August 1, 2023. This failure had the potential to affect the health and well being for Resident 18 by not being offer the COVID vaccine to help prevent a lung infection. Findings: During a review of Resident 18's clinical record, Resident 18's History and Physical, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and seizure disorder. During a concurrent interview, and record review, with the Infection Preventionist (IP), on March 14, 2024, at 10:46 AM, a review of Resident 18's immunization records was conducted. There was no documented evidence a COVID vaccine was offered . The IP stated, [I] don't know if pneumococcal and COVID was offered during admission. A review of the document provided by the IP only indicated the Influenza vaccine had been declined. 555468 Page 13 of 13