Health inspection·October 5, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arm to it from slipping off the wheelchair's armrest. When the resident was asked if he had any assistive devices to support his left arm, Resident 22 stated he used to have a sling but did not know where it was or what happened to it. Resident 22 added, I've lost it a while ago, I think three or four months ago . I think laundry lost it. I asked . my CNAs to look for it, and they couldn't find it. Resident 22 stated that it was more comfortable to have a sling on to support his left arm, but nobody offered to look for it or to order a new sling. During an observation of Resident 22's room, a sign 'Sling and Splint Schedule' was noted taped to the door to resident's closet. The sign indicated, Wear L [left] arm sling during day for comfort as tolerated. Next to that sign was posted another sign with instructions for 'Sling Tips' directing nursing staff to don the sling whenever the resident wanted to wear his sling. During a concurrent observation on 10/3/23, at 11:30 a.m., Resident 22 was sitting in the dining room in his wheelchair. There was no sling to support Resident 22's left arm and from time to time the resident was noted to support his left arm with his right arm. During an interview on 10/3/23, at 12:10 p.m., Licensed Nurse (LN 1) stated she was familiar with Resident 22's care. LN 1 stated that Resident 22's left arm was flaccid (limp and weak) and added that the resident should have a sling when he is in his wheelchair to support the arm. LN 1 stated she did not notice if Resident 22 had it on earlier when she administered his medications. LN 1 stated Resident 22's left hand was contracted and he was to hold onto a soft roll to prevent his contracture from worsening. During an interview on 10/3/23, at 12:17 p.m., Certified Nursing Assistant (CNA 1) stated that Resident 22 had to wear a sling and a little spongy ball in his left hand to prevent further contracture. CNA 1 stated a sling and hand roll were stored in the resident's room in a little basket. During an observation on 10/3/23, at 12:30 p.m., Resident 22 was observed in the wheelchair in his room. Resident 22 did not have the sling to support his left arm and there was no soft roll in his left hand. Resident 22 stated, I need to support my left arm because it sometimes slips of the wheelchair. Resident 22 added that he had to hold onto a little foamy ball to prevent his fingers from curling more. During a concurrent interview on 10/3/23, at 12:47 p.m., the facility's Physical Therapist (PT) and Occupational Therapist (OT) stated that Resident 22 received therapy services at present. The OT stated that the resident had to wear the sling for his left arm. The OT explained that the resident had a foamy soft hand roll to manage his left-hand contracture and needed frequent reminders to grab and hold onto it to prevent his hand contracture from worsening. The OT stated that she had not seen Resident 22 wearing his sling lately and added, Sometimes things get misplaced. During an observation on 10/4/23, at 11:20 a.m., Resident 22 was observed sitting in wheelchair in without his sling and soft roll. During an interview on 10/4/23, at 11:28 a.m., LN 2 stated she was familiar with Resident 22 and his care. LN 2 stated the resident had a physician order to wear the sling to support his paralyzed left arm while he was in his wheelchair. LN 2 stated Resident 22 was not wearing the sling lately and was not able to explain why the physician's order was not followed and the resident had not been wearing the sling. During an interview on 10/4/23, at 2:02 p.m., the Director of Nursing (DON) stated that Resident 22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555698 If continuation sheet Page 2 of 6 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 555698 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150 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 0688 Level of Harm - Minimal harm or potential for actual harm should have had his left arm sling on every day to maintain his comfort and good body position. The DON stated the expectation for nursing staff was to follow a physician order and follow the care plan's interventions reminding the resident to keep a hand roll to prevent further contractures to his left hand. The DON added that if the sling was lost, the facility should have ordered a new sling as soon as possible and if the resident refused to wear the sling, his physician should have been notified. Residents Affected - Few 2. A review of the admission record indicated the facility admitted Resident 34 a year ago with multiple diagnoses including multiple sclerosis (a chronic disease of the central nervous system affecting person's vision, balance, mobility, and emotions). Resident 34's history indicated that the resident had multiple falls with injuries in the past related to the resident's weakness and poor balance. A review of Resident 34's MDS assessment dated [DATE] indicated the resident had no cognitive impairment. Resident 34's functional status assessment indicated that she had weakness on both lower extremities and required staff's assistance to ambulate. A review of Resident 34's 'Care Guide' (care plan) revised 7/13/23 indicated that the resident had progressive lower extremities weakness and impaired balance. The care plan indicated that to maintain her strength, balance, and safety, Resident 34 received RNA services two times a week using the exercise bike and ambulating with her walker. The care plan's goal indicated that Resident 34 will maintain her functional independence and mobility. A review of the physical therapist Discharge summary dated [DATE] indicated that Resident 34 met maximum potential and was discharged from physical therapy services on 8/18/23. The PT discharge summary indicated that the resident was referred to restorative nursing services to improve her mobility and decrease risk for falls. The discharge summary contained instructions for RNA staff to follow while ambulating and exercising Resident 34. A review of Resident 34's weekly nursing assessments dated 8/27/23, 9/4/23, 9/11/23, and 10/1/23 indicated that the resident was on RNA program. During an observation and interview on 10/2/23, at 9:19 a.m., Resident 34 was observed lying in her bed. Resident 34 stated she was dizzy and lightheaded when she attempted to stand up and walk and required staff's assistance. Resident 34 stated she had had multiple falls in the past. When Resident 34 was asked if she was on RNA program, the resident replied, Sometimes they exercise me on that bike. During a continued interview, Resident 34 stated the staff assisting her to the bathroom were the only exercises she received lately. During an interview on 10/4/23, at 8:47 a.m., RNA 1 stated that Resident 34 had been on the RNA program for a long time. RNA 1 explained that Resident 34's RNA program included ambulating and exercising on the bike twice a week. RNA 1 stated that the residents, including Resident 34 have not been receiving RNA services for weeks because she had been working the floor as certified nursing assistant (CNA). RNA 1 explained that she was the only RNA in the entire facility trained to provide RNA services and added, When I'm working as CNA, residents don't get their exercises. RNA 1 stated she had not offered RNA services to Resident 34 in three weeks. A review of the RNA Program report provided by the RNA 1 indicated that Resident 34 was offered RNA exercises four times in the month of August 2023, instead of eight times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555698 If continuation sheet Page 3 of 6 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 555698 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the RNA program report indicated that Resident 34 was offered RNA exercises one time in the month of September 2023 instead of eight times. There was no documented evidence that Resident 34 was offered RNA services from 10/1 through 10/4/23. During an interview with DON on 10/4/23, at 2:15 p.m., the DON stated that the facility had issues with providing their residents with RNA services and acknowledged that residents' care plans were not followed consistently. The DON stated that the facility had one trained RNA and she was pulled from the RNA program to take over CNAs assignments frequently. The DON stated RNA program was important for Resident 34 to help her stay safe and to prevent worsening of the resident's mobility and added, It's our goal that residents don't lose their ability to walk. A review of the facility's policy and procedure titled, Restorative Care Program, with the revision date of 4/21, indicated the purpose of the policy was To maintain [residents] quality of life. The policy further indicated that the facility offered a Restorative Nursing program to any resident .who is identified as needing the services .to improve and/or maintain joint ROM [Range of Motion], normal body alignment and overall functional strength, mobility .to increase resident self-esteem .to minimize the effects of disability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555698 If continuation sheet Page 4 of 6 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 555698 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150 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 - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to respond in a timely manner to a medication irregularity for one of 16 sampled residents (Resident 8), when the facility did not follow up on a Pharmacy Consultant (PC) recommendation to discontinue nitrofurantoin (antibiotic, a medication to treat infections) for 56 days. This failure placed Resident 8 at an increased risk for developing adverse drug consequences (unwanted, uncomfortable, or dangerous effects) from the prolonged use of an antibiotic medication. Findings: A review of the admission record indicated the facility admitted Resident 8 earlier this year with multiple diagnoses which included chronic pain and a history of urinary tract infections (UTI-an infection of the urinary track which includes the kidney, bladder, or urethra). A review of the physician order dated 2/4/23 indicated, Nitrofurantoin . 50 MG [milligram, unit of measurement] .Give 1 capsule by mouth one time a day for UTI prophylactic (a medication used to prevent disease). A review of the clinical record for Resident 8 contained a pharmacy consultant (PC) report titled, Consultation Report, dated 8/8/23. The PC report indicated a recommendation to discontinue nitrofurantoin and initiate another medication while monitoring for signs and symptoms of UTI. The PC documented, Rationale for Recommendation: The potential for developing pulmonary fibrosis [a serious lung disease that occurs when lung tissues becomes damaged and scarred resulting in difficulty to breathe], hepatotoxicity [liver damage], C difficile infection [inflammation of the colon resulting in diarrhea and pain], and peripheral neuropathy [a condition peripheral nerves become damaged resulting in pain, numbness, and weakness in the hands and feet] increases with duration of use. The section of the report with the information of the physician's response to the pharmacist's recommendation, signature, and the date was blank. A review of Resident 8's clinical records indicated there was no documented evidence the facility acted upon the recommendation to discontinue nitrofurantoin and order another antibiotic recommended by PC. A review of Resident 8's medication administration records (MARs) for August 2023 and September 2023 indicated that the resident continued to receive nitrofurantoin 50 mg every morning after the PC wrote the recommendation to discontinue the medication. A review of Resident 8's MARs from October 1 through October 4, 2023 indicated Resident 8 continued receiving nitrofurantoin 50 mg every morning. During a concurrent interview and record review on 10/3/23, at 11:40 a.m., the facility's Infection Preventionist (IP) confirmed that the facility did not act upon a pharmacist recommendation dated 8/8/23 to discontinue nitrofurantoin. The IP added, We had no DON for three (3) months, and it was missed. A review of the facility's policy titled, Medication Regimen Review, with a revision date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555698 If continuation sheet Page 5 of 6 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 555698 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150 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 - Some 8/17/23, indicated, The Consultant Pharmacist will conduct MRRs [medication regiment reviews] and will make recommendations based on the information available in the residents' health record .Facility should encourage Physician/Prescriber .and the Director of Nursing to act upon the recommendations contained in the MRR .Facility should encourage Physician/Prescriber to either accept and act upon the recommendations .or reject .recommendations .and provide an explanation as to why the recommendation was rejected. During an interview on 10/4/23, at 2:05 p.m., the DON stated that the facility should have acted upon the pharmacy consultant's recommendation to discontinue nitrofurantoin within 72 hours after receiving the report and added, We missed it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555698 If continuation sheet Page 6 of 6