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Deficiency Records for Bear Mountain Health and Rehabilitation
A list of the most recent deficiencies for Bear Mountain Health and Rehabilitation. 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 Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-25 | 2024-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-25 | 2024-05-22 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-04-25 | 2024-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-25 | 2024-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-25 | 2024-05-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-03-07 | 2024-03-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-07 | 2024-03-27 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-07 | 2024-03-27 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-07 | 2024-03-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-07 | 2024-03-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-27 | 2023-08-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-27 | 2023-08-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-10 | 2023-08-04 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-25 | 2023-03-20 | 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 | 2022-12-16 | 2023-01-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-16 | 2023-01-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-16 | 2023-01-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-16 | 2023-01-09 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-12-16 | 2023-01-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-16 | 2023-01-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-12-16 | 2023-01-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2023-01-09 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-16 | 2023-01-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-16 | 2023-01-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-16 | 2023-01-09 | Y |
| 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 | 2022-12-16 | 2023-01-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-16 | 2023-01-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-16 | 2023-01-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-16 | 2023-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-01 | 2022-12-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-01 | 2022-12-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-01 | 2022-12-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-05 | 2022-05-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-05 | 2022-05-20 | Y |
| 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 | 2022-05-05 | 2022-05-20 | Y |
| 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 | 2022-01-28 | 2022-05-20 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-05 | 2022-05-13 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-28 | 2022-05-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-28 | 2022-05-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-28 | 2022-05-05 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-28 | 2022-05-05 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-01-28 | 2022-05-05 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-28 | 2022-05-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-01-28 | 2022-05-05 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-28 | 2022-05-05 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-01-28 | 2022-05-05 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-28 | 2022-05-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-28 | 2022-05-05 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-28 | 2022-05-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-28 | 2022-05-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-28 | 2022-05-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-28 | 2022-05-05 | Y |
| Post nurse staffing information every day. | Health | 2022-01-28 | 2022-05-05 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-28 | 2022-05-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-28 | 2022-05-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-28 | 2022-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-05-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-28 | 2022-05-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-28 | 2022-05-05 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-22 | 2022-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-22 | 2022-03-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-22 | 2022-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-22 | 2022-03-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-28 | 2022-02-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-28 | 2022-02-28 | Y |
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