Bear Valley Community Hospital D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition for 20 of 20 residents when, 1. Five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container without proper labeling or a date.2. Nine bags of tortillas with an expiration date of April 19, 2026, were found in the refrigerator (42 days expired).3. Two of two ovens were found with significant accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks. These failures had the potential to lead to the growth of harmful microorganisms, including bacteria, viruses, and fungi, and cause food-borne illness (occurs when you consume contaminated food or beverages) to 20 residents served by the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to post the results of the most recent survey of the facility in a place readily accessible for all 21 of 21 residents, family members, and legal representatives of residents to review. This failure had the potential to prevent residents, family members, and legal representatives from being informed about the facility's compliance with state and federal requirements, which could limit their ability to make fully informed decisions regarding the residents' care.

Inspectors wroteBased on observation and interview, the facility failed to ensure that required daily nurse staffing information for licensed and unlicensed nurses was posted in a location readily visible and accessible to all 20 of 20 residents and visitors to review. This failure resulted in residents and visitors being unable to verify whether the unit was staffed appropriately for the day.

Inspectors wroteBased on observation and interview, the facility failed to maintain the garbage storage area in a sanitary condition for 21 of 21 residents, staff, and the public when the facility's refuse (trash/garbage) was not properly disposed in the designated, covered outdoor container. This failure to properly dispose of refuse in the designated, covered outdoor container demonstrated noncompliance with established sanitation protocols, potentially increasing the risk of environmental contamination and pest infestation, and thereby compromising the health and safety of residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident was treated with respect and dignity for one resident (Resident 1) when the facility staff spoke to Resident 1 using language and tone as if one might address a child and refused Resident 1 to receive a shower at his preferred time. This failure resulted in Resident 1 feeling put down and embarrassed which could potentially affect his care from his lack of trust or doubt with the facility staff to participate in treatment plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored to conserve nutritive value (measure of a well-balanced diet) and maintain professional standards of food safety for all 21 residents admitted in the facility when: 1. There was an unlabeled bag of minced beef in the refrigerator. 2. There was an open and unlabeled bag of tortilla flour in the refrigerator. These failures had the potential to cause unsafe food consumption for all 21 vulnerable residents in the facility from possible allergenic substances in food products and consume food beyond the use date (expired date), which can negatively affect resident's health from allergic reaction or foodborne illness (illness caused by ingestion of contaminated food or beverages). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special assistive devices during mealtimes for three of 21 sampled residents (Resident 3, 7 and 15) when: 1. Residents 3 and 7 were not provided with a plate guard (a clip onto the edge of a plate to prevent spilling of food) and [NAME] Anti Spill Cup (KCup-allows the cup to be easily filled, once the lid is screwed on, the liquid will not slip even if the cup is turned completely upside down) during lunch. 2. Resident 15 was not provided with KCup as ordered. These failures had the potential to cause Resident 3, 7, and 15 to experience a decrease in food intake without appropriate assistive devices which could lead to unintentional weight loss (not having enough food to eat) and resulting in actual physical harm and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents with respect and dignity to enhance quality of life for two of two residents (Resident 12 and 15) when the Certified Nursing Assistant (CNA) were observed standing over Resident 12 and 15 during mealtime. This failure had the potential to make Resident 12 and 15 to feel devalue and disrespected which could cause Resident 12 and 15 to distrust the health care provider and would negatively impact the treatment plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or resident representatives (RP) were informed of psychotropic medication (medications that affect the mind, emotions, and behaviors) treatment for three of 12 sampled residents (Resident 2, 8, and 12) when: 1. Resident 2's informed consent (document signed by resident or representative to give permission for a proposed psychotropic medication and possible risks and benefits expected) was not updated and obtained for Resident 2's new order of Trazodone Deseryl (Trazodone-antidepressant medication) 50 milligram (MG-unit of measurement) and NF-Aripiprazole Av PAK (Aripiprazole-antipsychotic medication which is used to treatment of a wide variety of mood and psychotic disorders) 2.5 MG. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive minimum data set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessment was completed and submitted to CMS in accordance with the required federal submission timeframe for one of eight sampled residents (Resident 12). This failure resulted in inadequate monitoring of progress or decline for Resident 12 and the lack of resident specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS] every 3 months or quarterly) was completed in accordance with federal submission timeframes, for two of four residents (Residents 16 and 19) when: 1. Resident 16's quarterly RAI/MDS assessment was completed on March 18, 2025 (52 days late). 2. Resident 19's quarterly RAI/MDS assessment was not completed on March 13, 2025 (92 days late) These failures had the potential to result in a delay in determining the resources necessary to competently care for the residents during the day-to-day operations and emergencies for Residents 16 and 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly (every 3 months) Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was transmitted (submitted) to CMS in accordance with federal submission timeframes, for three of four residents (Resident 5,12, and16) reviewed for resident assessment when: 1. Resident 5's quarterly RAI/MDS assessment completed on February 14, 2025, has not been transmitted as of May 8, 2025 (69 days late). 2. Resident 16's quarterly RAI/MDS assessment dated [DATE], was transmitted on January 8, 2025 (7 days late) and quarterly MDS assessment due March 18, 2025, was not transmitted (37 days late from the due date). 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan (an individualized plan that includes residents' health problems, preferences and goals) for one of three residents (Resident 12) when Resident 12 did not have a care plan developed or implemented to address an ongoing psychotropic (mind altering) medication. This failure had the potential for Resident 12 to have unidentified medical needs, delay in treatment and lack of coordinated care related to psychotropic drugs which can negatively affect Resident 12's mental state.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe oxygen administration was provided in accordance with the facility's policy and procedure (P&P) for one of two sampled residents (Resident 8) when Resident 8's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date it was changed. This failure had the potential to result in a respiratory infection leading to a decline in Resident 8's health status.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Medication Cart 1). This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 21 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for drug storage for one of one medication refrigerator in the medication storage room when the daily medication temperature log for the refrigerator was missing two staff signatures for two shifts. This failure had the potential for medications to be less effective due to the temperature of the medications being out of range.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed for all 21 residents in the facility when two cups with brown liquid were found on the folding table/desk in the laundry room. This failure had the potential to result in spilling which can cause contamination to from uncleaned cloths and wetness can create mold and mildew to further compromised all 21 vulnerable residents in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow their policy and procedure for one of three sampled 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. This failure had the potential to affect the health and well being and cause drug interactions for Resident 4.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when Licensed 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a completed nurse staffing information with actual 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.