Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Valley Community Hospital D/p Snf during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was spoken to in a belittling manner by a CNA after requesting a shower at a preferred time, resulting in embarrassment in front of others. Staff interviews confirmed the CNA's unprofessional conduct and failure to respect the resident's right to self-determination and personal schedule, contrary to facility policy.
Surveyors found that staff failed to label and date refrigerated minced beef and tortilla flour, contrary to facility policy, and did not properly prepare a pureed cauliflower dish for a resident on a pureed diet, resulting in a meal that was watery and bland compared to the regular version. The Director of Nutrition Services confirmed that these actions did not meet professional standards for food safety or palatability.
Three residents with physician orders for assistive eating devices, such as plate guards and anti-spill cups, were not provided these items during meals. Two residents with conditions like hemiplegia, hemiparesis, COPD, and dementia did not receive their required devices at lunch, and another resident with dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease was not given a KCup as ordered. Staff confirmed the omissions, and facility policy requiring such support was not followed.
Two residents with significant cognitive and physical impairments were fed lunch by CNAs who stood over them rather than sitting and engaging at eye level, contrary to facility policy requiring dignified and respectful support during meals. Both CNAs acknowledged not following the expected practice, and the DON confirmed this did not meet the standard for resident dignity.
Three residents were not provided with updated informed consent forms when their psychotropic medication orders or dosages were changed. In each case, the consent documentation did not match the current physician orders, and staff confirmed that updated consents were not obtained. As a result, residents and their representatives were not informed of the risks, benefits, or their right to refuse the new or changed medications, in violation of facility policy.
A resident with multiple diagnoses, including dementia and depression, was not accurately assessed in the MDS, omitting key conditions despite being prescribed psychotropic medication. The MDS was not completed or submitted in accordance with federal and facility requirements, as confirmed by the LVN and DON, resulting in inadequate monitoring and reporting to CMS.
Two residents did not have their quarterly MDS assessments completed within the required 92-day timeframe, as confirmed by the DON during interviews and record review. One assessment was completed 52 days late, while another was not completed and was 92 days overdue, in violation of facility policy.
The facility did not transmit completed RAI/MDS assessments to CMS within required timeframes for three residents, including individuals with complex medical conditions such as schizencephaly, spastic quadriplegia, hypertension, diabetes, cerebrovascular accident, and severe disability post anoxic encephalopathy. The DON acknowledged responsibility for transmission and confirmed that facility policy requiring submission within 14 days was not followed, resulting in significant delays.
A resident with multiple diagnoses, including dementia and depression, was prescribed Abilify for behavioral and psychological symptoms. The care plan did not address the resident's dementia or the use of psychotropic medication, as confirmed by both an LVN and the DON. Facility policy requires such needs to be included in the care plan, but this was not done.
A resident with dementia, diabetes, and osteoarthritis was observed receiving oxygen therapy without the required labeling on the oxygen tubing to indicate when it was last changed. Facility policy mandates weekly changes and labeling by a licensed nurse, but this was not followed, as confirmed by both an LVN and the DON.
The facility did not ensure accurate recordkeeping for controlled medications on one medication cart, as two required signatures were missing from the shift count form for a night shift. Both a nurse and the DON confirmed that policy requires two licensed nurses to verify and sign off on narcotic counts at each shift change, but this was not done as required.
A medication refrigerator temperature log was found to be missing staff signatures for two shifts, indicating that required temperature checks were not documented as per facility policy. The DON confirmed that the policy, which requires twice-daily monitoring of medication storage temperatures, was not followed.
Two cups containing brown liquid were found on a folding table in the laundry room across from the nurse's station. EVS staff acknowledged the cups, with one stating he believed the coffee cup was allowed. The DOF confirmed that personal beverages are not permitted in the laundry room due to infection control concerns. The DON reviewed the facility's infection prevention policy and confirmed it was not followed, as drinks should only be in designated staff or break areas.
Failure to Honor Resident Dignity and Bathing Preferences
Penalty
Summary
Facility staff failed to treat a resident with respect and dignity when a Certified Nurse Assistant (CNA) spoke to the resident in a belittling and demeaning manner, using language and tone typically reserved for addressing a child. This incident occurred after the resident, who has a history of congestive heart failure, seizure disorder, stroke, hypothyroidism, and hypertension, requested a shower in the evening, having declined one earlier in the day. The CNA responded in a rude and unprofessional manner, scolding the resident in front of other staff and residents, which made the resident feel embarrassed and put down. Multiple interviews with facility staff, including a Registered Nurse (RN), another CNA, and the Director of Nursing (DON), confirmed that the CNA's behavior was inappropriate and did not respect the resident's right to self-determination or to choose their own bathing schedule. The facility's policy on resident rights, which emphasizes respect, dignity, and the right to choose personal schedules, was not followed in this instance. The Assistant Director of Nursing (ADON) and DON acknowledged that the resident's rights were not upheld during the incident.
Deficient Food Storage and Pureed Diet Preparation
Penalty
Summary
The facility failed to ensure proper food storage and preparation practices, as observed during a survey. In the kitchen refrigerator, a bag of minced beef was found without a label or date, and an open, unlabeled bag of tortilla flour was also present. Both the Executive Chef and the Director of Nutrition Services confirmed that these items should have been labeled and dated according to the facility's policy and procedure for food storage, which requires all food to be covered, labeled, and dated to ensure safe consumption within use-by dates. Additionally, the facility did not follow proper procedures in preparing a pureed diet for a resident with chronic obstructive pulmonary disease and dementia, who was on a physician-ordered regular diet with pureed texture. During meal preparation, kitchen staff used only hot water to puree cauliflower, rather than following the recipe that called for adding gravy, sauce, or other liquids to achieve the correct taste and consistency. The pureed cauliflower was found to be watery and bland, lacking the buttery flavor of the regular diet version, and did not meet the facility's standards for palatability and comparability to regular meals. Interviews with staff and review of facility policies confirmed that the required procedures for both food storage and meal preparation were not followed. The Director of Nutrition Services acknowledged that these failures increased the risk of foodborne illness and did not provide residents with nourishing, palatable, and attractive meals as required by facility policy.
Failure to Provide Ordered Assistive Eating Devices During Meals
Penalty
Summary
The facility failed to provide required special assistive eating devices to three residents during mealtimes, as observed and confirmed by staff. Two residents with orders for a plate guard and anti-spill cup (KCup) were not given these devices during lunch, despite their meal tickets indicating the need for them. Both residents had medical conditions such as hemiplegia, hemiparesis, COPD, and dementia, which necessitated the use of these assistive devices. A Certified Nursing Assistant (CNA) confirmed that the devices were not provided during the entire meal, and the Director of Nutrition Services acknowledged that facility policy requiring such support was not followed. Another resident with diagnoses including dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease was also not provided with a KCup as ordered, despite this being indicated on the meal ticket. The resident was observed drinking with a straw instead, and the assisting CNA confirmed the absence of the KCup. The Director of Nursing reviewed the facility's policy and confirmed that the resident should have received the KCup with meals, and that the policy was not followed by the staff involved.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Staff failed to treat two residents with respect and dignity during mealtime. Observations showed that Certified Nursing Assistants (CNAs) stood over both residents while feeding them lunch in the activity/dining room, rather than sitting and engaging with them at eye level. One resident was seated in a high back wheelchair and required assistance due to diagnoses including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia. The other resident, also in a wheelchair, had diagnoses of dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease. Both CNAs confirmed in interviews that they did not sit while feeding the residents, despite acknowledging the importance of doing so to maintain a homely environment and provide dignified care. A review of the facility's policy and procedure for assistance with feeding indicated that staff are required to support residents in a manner that maintains their dignity, independence, safety, and nutritional well-being, and to engage with residents calmly and respectfully. The Director of Nursing confirmed that the observed actions were unacceptable and not in accordance with facility policy, as staff should have been seated and engaging respectfully with the residents during mealtime.
Failure to Update Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to ensure that residents or their representatives were properly informed and provided updated informed consent for changes in psychotropic medication orders. For three residents, documentation showed that either the consent forms did not reflect new medication orders or dosage changes, or the consent forms did not match the current physician orders. Specifically, one resident had new orders for Trazodone and Aripiprazole, but the consent on file was for different dosages and was not updated. Another resident had new orders for Escitalopram and Risperidone, but the consents on file reflected previous dosages and were not updated to match the current orders. Additionally, a third resident had a consent form for Abilify at a lower dosage than what was currently ordered by the physician, and the consent did not match the physician's order. In each case, staff interviews confirmed that updated consents reflecting the current medication regimens could not be found. The facility's own policy required that informed consent be updated with any change in psychotropic medications, but this was not followed. As a result, the residents and their representatives were not informed of the risks, benefits, adverse reactions, or their right to refuse the administration of the new or changed psychotropic medications. This failure violated the residents' rights to be fully informed about their care and treatment, as required by facility policy and regulatory standards.
Failure to Accurately Complete and Submit MDS Assessment
Penalty
Summary
The facility failed to complete and submit a comprehensive Minimum Data Set (MDS) assessment for a resident within the required federal timeframe. Upon review, it was found that the resident, who had diagnoses including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia, was admitted with these conditions documented in the admission record. However, the MDS assessment did not accurately reflect the resident's current diagnoses, specifically omitting depression and dementia, despite the resident being prescribed a psychotropic medication for behavioral and psychological symptoms of dementia. Interviews with the LVN responsible for MDS completion and the Director of Nursing confirmed that the assessment was not completed accurately or in accordance with facility policy and federal requirements. The facility's policy required timely and accurate completion and electronic submission of the MDS, but this process was not followed. As a result, the resident's progress or decline was not adequately monitored, and accurate, resident-specific information was not submitted to CMS for payment and quality measure monitoring.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed within the required federal submission timeframes for two residents. For one resident with a history of hypertension, type 2 diabetes mellitus, and cerebrovascular accident, the quarterly MDS assessment was completed 52 days late. For another resident diagnosed with dementia, the quarterly MDS assessment was not completed and was 92 days overdue. These lapses were identified through interviews and record reviews with the Director of Nursing (DON), who acknowledged responsibility for completing the MDS assessments and confirmed the assessments were not completed within the required 92-day interval as outlined in the facility's policy and procedure. The facility's policy, which requires quarterly reviews to be conducted within 92 days of the previous assessment, was not followed in these cases. The DON confirmed during interviews that the policy was not adhered to and recognized the importance of timely assessments for accurate reimbursement and care planning. The findings were based on direct review of medical records and interviews with the DON, who admitted the assessments were late or not completed as required.
Failure to Timely Transmit Resident MDS Assessments
Penalty
Summary
The facility failed to ensure timely transmission of the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, three residents' assessments were not submitted within the federally mandated timeframes. For one resident with schizencephaly and spastic quadriplegia, the quarterly MDS assessment completed in February was not transmitted as of May, resulting in a delay of 69 days. Another resident with hypertension, type 2 diabetes mellitus, and a history of cerebrovascular accident had a quarterly assessment transmitted 7 days late and another assessment 37 days late. A third resident, who had severe disability post anoxic encephalopathy, had a comprehensive assessment due in March that was not transmitted, resulting in an 81-day delay. Interviews with the Director of Nursing (DON) confirmed that it was her responsibility to transmit the completed MDS assessments and that the facility's policy required submission within 14 days of completion. Record reviews and interviews revealed that these policies were not followed, and the DON acknowledged the lapses. The facility's own policy, reviewed during the survey, reiterated the requirement for timely electronic transmission of completed MDS assessments to the CMS QIES-ASAP system, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed a psychotropic medication. The resident was admitted with multiple diagnoses, including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia. A physician's order was in place for Abilify to address behavioral and psychological symptoms of dementia. However, upon review of the resident's care plan, there was no documented evidence that addressed the resident's dementia or the use of psychotropic medication. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan did not include the resident's dementia diagnosis or the associated psychotropic medication. The facility's policy requires that all medical, nursing, and psychological needs identified in the comprehensive assessment, including the use of psychotropic medications, be addressed in the care plan. Staff acknowledged that the care plan was not developed or updated as required by facility policy.
Failure to Label and Change Oxygen Tubing per Facility Policy
Penalty
Summary
A deficiency occurred when a resident receiving oxygen therapy did not have their oxygen tubing labeled to indicate the date it was last changed, as required by facility policy. During an observation, the resident was found in bed with oxygen running at three liters per minute, and the tubing lacked any label or date. A Licensed Vocational Nurse confirmed that the tubing was supposed to be changed weekly and labeled accordingly, but this had not been done. Further review of the facility's policy and procedure for oxygen use confirmed that both the humidifier bottle and oxygen tubing should be changed every Sunday night by a licensed nurse, with a label attached noting the date, time, and nurse's initials. The Director of Nursing acknowledged that the staff did not follow this policy. The resident involved had a medical history including dementia, diabetes, and osteoarthritis, and was admitted with these diagnoses.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of two medication carts, specifically Medication Cart 1. Review of the Controlled Medication Shift Count (CMSC) form revealed two missing signatures for the night shift, indicating that the required verification and documentation by two licensed nurses at shift change did not occur on those occasions. This was confirmed by a nurse and the DON, who both acknowledged that the facility's policy requires two licensed nurses to conduct and sign off on narcotic counts at each shift change, and that this procedure was not followed as documented.
Medication Refrigerator Temperature Log Incomplete
Penalty
Summary
The facility failed to adhere to its policy and procedure for drug storage by not ensuring that the daily medication refrigerator temperature log was properly completed. During an observation in the medication storage room, it was found that the temperature log for the medication refrigerator was missing staff signatures for two shifts, specifically on two separate dates. The Director of Nursing confirmed that the required temperature checks were not documented as per the facility's policy, which mandates that all refrigerators used for medication storage be monitored twice daily. This lapse meant there was no proof that staff had monitored the refrigerator's temperature as required.
Improper Storage of Personal Beverages in Laundry Room Breaches Infection Control Policy
Penalty
Summary
Surveyors observed two cups containing brown liquid, one with a sippy lid and one clear, left on a folding table in the laundry room across from the nurse's station in Unit B. Both the Environment Service (EVS) staff and an EVS trainee acknowledged the presence of these cups during the observation. The EVS staff member stated he had been informed that the coffee cup was allowed in the area. However, the Director of Facilities (DOF) later confirmed that personal drinks or beverages are not permitted in the laundry room, citing infection control concerns. A review of the facility's infection prevention policy, confirmed by the Director of Nursing (DON), indicated that the policy was not followed in this instance. The policy requires the maintenance of a safe environment to prevent the spread of infection, and specifically prohibits drinks in care areas outside of designated staff personal or break areas. The DON acknowledged that the presence of drinks in the laundry care area was a violation of this policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Big Bear Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountains Community Hosp Dp/snf | 16.1 mi | ★★★★★ | 0 | 0 |
| Cedar Mountain Post Acute | 17.1 mi | ★★★★★ | 17 | 0 |
| University Post Acute | 17.7 mi | ★★★★★ | 9 | 0 |
| Oak Glen Post Acute | 18.4 mi | ★★★★★ | 1 | 0 |
| Creekside Post Acute | 18.4 mi | ★★★★★ | 2 | 0 |
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