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Deficiency Records for Bear Mountain at West Springfield

A list of the most recent deficiencies for Bear Mountain at West Springfield. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Bear Mountain at West Springfield. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-08-27 2024-09-17 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2024-08-27 2024-09-17 N
Develop a communication plan. Fire Safety 2024-08-27 2024-09-17 N
Establish emergency prep training and testing. Fire Safety 2024-08-27 2024-09-17 N
Conduct testing and exercise requirements. Fire Safety 2024-08-27 2024-09-17 N
Provide properly protected cooking facilities. Fire Safety 2024-08-27 2024-09-17 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-08-27 2024-09-17 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-08-27 2024-09-17 N
Ensure each resident receives an accurate assessment. Health 2024-08-06 2024-09-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-08-06 2024-09-14 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-08-06 2024-09-14 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-08-06 2024-09-14 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-08-06 2024-09-14 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-08-06 2024-09-14 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2024-08-06 2024-09-14 N
Provide and implement an infection prevention and control program. Health 2024-08-06 2024-09-14 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-12-06 2024-01-19 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-12-06 2024-01-19 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-12-06 2024-01-19 Y
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2023-12-06 2024-01-19 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-12-06 2024-01-19 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-12-06 2024-01-19 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-10-12 2023-10-10 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-12 2023-10-10 Y
Assess the resident when there is a significant change in condition Health 2023-05-31 2023-07-07 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2023-05-31 2023-07-07 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-05-31 2023-07-07 N
Provide appropriate foot care. Health 2023-05-31 2023-07-07 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-05-31 2023-07-07 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2023-05-31 2023-07-07 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2023-05-31 2023-07-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-05-31 2023-07-07 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-05-31 2023-07-07 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-06-13 2023-07-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-06-13 2023-07-07 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-06-13 2023-07-07 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-06-13 2023-07-07 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-05-17 2023-05-18 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-03-08 2023-04-26 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-03-08 2023-04-26 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-03-08 2023-04-26 Y
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. Health 2023-03-08 2023-04-26 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2023-03-08 2023-04-26 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-03-08 2023-04-26 Y
Provide and implement an infection prevention and control program. Health 2023-01-18 2023-02-16 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-01-18 2023-02-11 N
Report COVID19 data to residents and families. Health 2023-01-18 2023-02-11 N
Perform COVID19 testing on residents and staff. Health 2023-01-18 2023-02-11 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-01-03 2023-01-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-03 2023-01-27 Y
Install an approved automatic sprinkler system. Fire Safety 2021-10-06 2021-11-05 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-10-06 2021-11-05 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-09-30 2021-11-04 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-09-30 2021-11-04 N
Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Health 2021-09-30 2021-11-04 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-09-30 2021-11-04 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-09-30 2021-11-04 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-09-30 2021-11-04 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2021-09-30 2021-11-04 N
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. Health 2021-09-30 2021-11-04 N
Ensure that residents are free from significant medication errors. Health 2021-09-30 2021-11-04 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-09-30 2021-11-04 N
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Health 2021-09-30 2021-11-04 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2021-09-30 2021-11-04 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-09-30 2021-11-04 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-09-30 2021-11-04 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-09-30 2021-11-04 N
Provide and implement an infection prevention and control program. Health 2021-09-30 2021-11-04 N

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