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? |
---|---|---|---|---|
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 |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-12 | 2021-08-27 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-12 | 2021-08-27 | Y |
Respond appropriately to all alleged violations. | Health | 2021-07-12 | 2021-08-27 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-16 | 2019-10-18 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-16 | 2019-10-18 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-16 | 2019-10-18 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-09 | 2019-10-11 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-09 | 2019-10-11 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-09 | 2019-10-11 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-09 | 2019-10-11 | N |
Provide activities to meet all resident's needs. | Health | 2019-08-09 | 2019-10-11 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-09 | 2019-10-11 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-09 | 2019-10-11 | 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 | 2019-08-09 | 2019-10-11 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-08-09 | 2019-10-11 | N |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-08-09 | 2019-10-11 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-09 | 2019-10-11 | 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 | 2019-08-09 | 2019-10-11 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-08-09 | 2019-10-11 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-08-09 | 2019-10-11 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-09 | 2019-10-11 | N |