A list of the most recent deficiencies for Bear Valley Community Hospital. 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 implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-02 | 2023-06-20 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-14 | 2023-04-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-03-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-03-28 | 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 | 2023-02-16 | 2023-03-28 | 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 | 2023-02-16 | 2023-03-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-16 | 2023-03-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-03-28 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-16 | 2023-03-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-26 | 2023-02-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-26 | 2023-02-14 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-08-01 | 2022-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-06-15 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2019-12-13 | 2020-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-13 | 2020-01-07 | 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 | 2019-11-21 | 2019-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-21 | 2019-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-19 | 2019-03-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-19 | 2019-03-14 | 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 | 2018-11-28 | 2019-01-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-28 | 2019-01-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-28 | 2019-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-28 | 2019-01-16 | N |
| Keep all essential equipment working safely. | Health | 2018-11-28 | 2019-01-16 | N |
