Inspection visit
Inspection
Citations
26 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Dpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0500GeneralS&S Dpotential for harm
Meet other general requirements that are deficient.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0886GeneralS&S Bno actual harm
Perform COVID19 testing on residents and staff.
- 0781GeneralS&S Cno actual harm
Have restrictions on the use of portable space heaters.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F660 - Quality of life
Plan the resident's discharge to meet the resident's goals and needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
- 0281GeneralS&S Dpotential for harm
Install proper backup exit lighting.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the December 16, 2022 survey of Bear Mountain Health and Rehabilitation?
This was a inspection survey of Bear Mountain Health and Rehabilitation on December 16, 2022. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Bear Mountain Health and Rehabilitation on December 16, 2022?
Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.