Bear Valley Community Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Bear Valley Community Hospital D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free of significant medication errors, when the facility did not renew and administer Resident 2's scheduled Keppra (a medication used to treat and prevent seizures [which are involuntary muscle movements] for 16 medication administration opportunities, from December 3, 2022, 9:00 AM, through December 10, 2022, 4:00 PM. This failure resulted in Resident 2 sustaining a grand mal seizure (also known as a tonic-clonic seizure, characterized by intense muscle contractions and loss of consciousness), which could have jeopardized the health and safety of Resident 2. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition for 20 of 20 residents when, 1. Five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container without proper labeling or a date.2. Nine bags of tortillas with an expiration date of April 19, 2026, were found in the refrigerator (42 days expired).3. Two of two ovens were found with significant accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks. […]

• No harm, potential for more than minimal, widespreadF804May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored to conserve nutritive value (measure of a well-balanced diet) and maintain professional standards of food safety for all 21 residents admitted in the facility when: 1. There was an unlabeled bag of minced beef in the refrigerator. 2. There was an open and unlabeled bag of tortilla flour in the refrigerator. These failures had the potential to cause unsafe food consumption for all 21 vulnerable residents in the facility from possible allergenic substances in food products and consume food beyond the use date (expired date), which can negatively affect resident's health from allergic reaction or foodborne illness (illness caused by ingestion of contaminated food or beverages). 3. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary food preparation and storage practices when: 1. One dirty manual can opener was observed in the kitchen across from the ovens. 2. One oven was not kept in sanitary condition which could transfer to residents' foods during cooking. This had the potential to contaminate the food and cause foodborne illness (stomach illness acquired from ingesting contaminated food). 3. Opened and unlabeled following food packages observed in the walk in refrigerator. a. One opened and unlabeled package of smoked ham in the refrigerator. b. One opened and unlabeled package of parmesan cheese in the refrigerator. c. One opened and unlabeled package of pepperoni in the refrigerator. d. […]

• No harm, potential for more than minimal, patternF810May 8, 2025

  Based on observation, interview, and record review, the facility failed to provide special assistive devices during mealtimes for three of 21 sampled residents (Resident 3, 7 and 15) when: 1. Residents 3 and 7 were not provided with a plate guard (a clip onto the edge of a plate to prevent spilling of food) and [NAME] Anti Spill Cup (KCup-allows the cup to be easily filled, once the lid is screwed on, the liquid will not slip even if the cup is turned completely upside down) during lunch. 2. […]