Inspection Reports for Bear Hill Rehabilitation and Nursing Center
11 North St, Stoneham, MA 02180, United States, MA, 02180
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including care planning, activities of daily living assistance, respiratory care, and documentation accuracy at Bear Hill Healthcare and Rehabilitation Center.
Findings
The facility failed to develop adequate care plans for residents with suicidal ideation and call light accessibility issues, did not provide proper assistance with activities of daily living including incontinent care and meal supervision, failed to provide appropriate respiratory care by not changing oxygen tubing timely, and had inaccurate documentation in clinical records for multiple residents.
Deficiencies (4)
Failed to develop a care plan for suicidal ideation for Resident #43 and failed to ensure call light accessibility for Resident #241.
Failed to provide assistance with activities of daily living including supervision with meals for Resident #61 and incontinent care for Resident #241.
Failed to provide safe and appropriate respiratory care by not changing oxygen tubing and humidifier bottle weekly for Resident #18.
Failed to accurately document clinical records for Residents #18, #43, #241, and #110 including oxygen tubing changes, resident sex, ADL care provided, and wound treatment completion.
Report Facts
Residents in sample: 30
Residents affected by deficiency F0656: 2
Residents affected by deficiency F0677: 2
Residents affected by deficiency F0695: 1
Residents affected by deficiency F0842: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan development for Resident #43 and care issues for Resident #241 |
| Unit Manager #2 | Unit Manager | Observed call light on floor and acknowledged call lights should be accessible; involved in care for Resident #241 |
| CNA #1 | Certified Nurse Aide | Provided incontinent care to Resident #241 and reported staffing issues |
| CNA #2 | Certified Nurse Aide | Reported inability to provide care to Resident #241 due to lack of staff assistance |
| Unit Manager #3 | Unit Manager | Interviewed about feeding assistance for Resident #61 |
| Administrator | Administrator | Interviewed about expectations for feeding assistance for Resident #61 |
| MDS Nurse #1 | MDS Nurse | Interviewed regarding oxygen tubing change policy and documentation |
| Nurse #1 | Nurse | Documented wound treatment completion for Resident #110 but admitted treatments were not done |
| Unit Manager #1 | Unit Manager | Completed wound treatment for Resident #110 and clarified documentation discrepancy |
Inspection Report
Routine
Census: 36
Deficiencies: 14
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, infection control, medication management, and safety protocols.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and responsible parties of changes in resident conditions, failure to provide timely discharge notices, incomplete care plans, medication errors, inadequate infection control practices, and failure to ensure proper dialysis and respiratory care.
Deficiencies (14)
Failed to alert the physician of a newly developed gangrenous wound for Resident #94 and failed to notify the responsible party of a change in condition for Resident #40.
Failed to provide timely notification to residents and responsible parties before transfer or discharge for Residents #37, #98, and #127.
Failed to provide bed-hold notices upon transferring Residents #12, #37, and #98 to the hospital.
Failed to implement personalized care plans for Residents #128, #52, and #94 and failed to develop a behavior care plan for Resident #81.
Failed to ensure services met professional standards of quality including failure to follow physician's orders for fluid restriction for Residents #48 and #405 and failure to provide fortified mashed potatoes for Resident #130.
Failed to provide appropriate treatment and care according to orders for Residents #40 and #94, including failure to identify and address a gangrenous skin injury and failure to implement antibiotic treatment and monitoring for cellulitis.
Failed to follow fall prevention plan for Resident #124 resulting in a fall with subdural hematoma.
Failed to provide safe and appropriate respiratory care for Residents #98 and #134, including lack of physician orders for continuous oxygen and failure to administer oxygen as ordered.
Failed to ensure nursing staff possessed appropriate competency and skills to care for Resident #134 requiring dialysis, including inappropriate assessment of dialysis access site and lack of emergency care plan knowledge.
Failed to provide pharmaceutical services meeting resident needs, including failure to replace opened antibiotic, emergency, and insulin kits.
Medication error rate exceeded 5 percent with two medication errors observed impacting Residents #72 and #38.
Failed to ensure drugs and biologicals were labeled and stored according to professional principles, including unlocked medication and treatment carts on multiple units and presence of expired and undated medications.
Failed to provide and implement an infection prevention and control program, including failure to implement enhanced infection precautions for Residents #130 and #134, improper urinary catheter care, improper handling of clean linen, failure to disinfect multi-use medical equipment, failure to perform hand hygiene after glove use, and lack of water management risk assessment for Legionella.
Failed to develop and implement policies and procedures for flu and pneumonia vaccinations, including failure to assess Resident #130 for pneumococcal vaccine eligibility, administration, or refusal and failure to provide education on vaccine risks and benefits.
Report Facts
Residents sampled: 36
Medication error rate: 7.41
Fluid restriction: 2000
Fluid restriction: 2000
Fall risk evaluation date: Oct 20, 2023
Fall care plan revision date: Oct 20, 2023
Dialysis pick up time: 05:15
Dialysis days per week: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Named in relation to failure to notify physician and family of Resident #94's gangrenous wound |
| Nurse #2 | Nurse | Named in relation to failure to notify physician and family of Resident #94's gangrenous wound |
| Nurse #5 | Nurse | Named in relation to unlocked medication cart and infection control observations |
| Nurse #6 | Nurse | Named in relation to Resident #40 antibiotic treatment and infection control |
| Nurse #8 | Nurse | Named in relation to dialysis care and medication omission |
| Nurse #9 | Nurse | Named in relation to medication error and oxygen administration |
| Nurse #11 | Nurse | Named in relation to infection control and incomplete orientation |
| Nurse Practitioner #1 | Nurse Practitioner | Named in relation to Resident #94's gangrenous wound assessment |
| Nurse Practitioner #3 | Nurse Practitioner | Named in relation to Resident #40 antibiotic treatment |
| Director of Nursing | Director of Nursing | Named in relation to multiple findings including wound care, antibiotic treatment, medication management, dialysis care, and infection control |
| Unit Manager #1 | Unit Manager | Named in relation to medication cart observations and Resident #128 and #52 care |
| Unit Manager #2 | Unit Manager | Named in relation to dialysis care and infection control |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in relation to Resident #128 fall mats |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in relation to Resident #128 fall mats |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in relation to infection control breach |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Named in relation to Resident #40 condition and linen handling |
| Social Worker #1 | Social Worker | Named in relation to Resident #81 behavior care plan |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Named in relation to infection control practices and vaccination policy |
| Staff Developer | Staff Developer | Named in relation to dialysis care education |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 21, 2022
Visit Reason
The inspection was a routine survey of Bear Hill Healthcare and Rehabilitation Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to investigate potential abuse, failure to develop and implement appropriate care plans, failure to provide adequate supervision and assistance with activities of daily living, failure to maintain accurate medical records, failure to implement physician orders, failure to prevent falls, failure to provide appropriate pressure ulcer care, failure to ensure safe respiratory care, failure to ensure food served at appropriate temperatures, and failure to properly manage psychotropic medications.
Deficiencies (14)
Failed to accommodate the physical environment needs of a resident with vision impairment.
Failed to investigate potential incidents of abuse for two residents.
Failed to develop and implement complete care plans for multiple residents including air mattress use, prosthesis care, and notification of low blood sugar.
Failed to ensure one staff member did not present falsified behavior sheets to justify antipsychotic medication use.
Failed to implement a physician's order for blood pressure medication resulting in missed doses.
Failed to provide assistance with activities of daily living including feeding supervision and nail care.
Failed to identify alterations in skin and failed to obtain physician order to treat a skin tear.
Failed to provide appropriate pressure ulcer care and prevent development of a Stage IV pressure ulcer.
Failed to provide appropriate care to maintain or improve range of motion related to a hand splint order.
Failed to ensure interventions to prevent falls including use of bed and chair alarms were implemented.
Failed to implement a physician's order for oxygen therapy at the prescribed liter flow.
Failed to develop and implement a plan of care related to the indications of use of an antipsychotic medication.
Failed to ensure meals were served at palatable and appetizing temperatures.
Failed to maintain accurate medical records related to medication administration.
Report Facts
Residents sampled: 29
Fall incidents: 5
Blood pressure readings: 5
Oxygen saturation: 84
Oxygen saturation: 90
Skin evaluation dates: 6
Stage IV pressure ulcer size: 4.2
Stage IV pressure ulcer size: 5.5
Stage IV pressure ulcer size: 1
Fall risk score: 16
Fall risk score: 13
Fall risk score: 10
Fall risk score: 12
Temperature: 124
Temperature: 120
Temperature: 122
Temperature: 50
Temperature: 48
Temperature: 95
Temperature: 110
Temperature: 100
Temperature: 55
Temperature: 60
Temperature: 108
Temperature: 130
Temperature: 110
Temperature: 60
Temperature: 58
Temperature: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #2 | Unit Manager | Named in falsified behavior sheets finding and interview regarding antipsychotic medication monitoring |
| Unit Manager #1 | Unit Manager | Interviewed regarding resident room safety pads and blood pressure patch |
| Certified Nursing Assistant #11 | CNA | Interviewed regarding resident room safety pads |
| Unit Manager #1 | Unit Manager | Interviewed regarding failure to investigate bruises |
| Nurse #2 | Nurse | Interviewed regarding air mattress care and ace wrap order |
| Nurse #1 | Nurse | Interviewed regarding air mattress care and skin evaluation |
| Director of Nursing | DON | Interviewed regarding bruise investigations, low blood sugar notification, pressure ulcer care, fall prevention, and antipsychotic medication plan of care |
| Administrator | Administrator | Interviewed regarding falsified behavior sheets and antipsychotic medication monitoring |
| Certified Nursing Assistant #7 | CNA | Interviewed regarding nail care |
| Nurse #3 | Nurse | Observed oxygen therapy and adjusted oxygen flow for Resident #9 |
| Food Service Director | Food Service Director | Interviewed regarding meal temperatures |
| Certified Nursing Assistant #12 | CNA | Interviewed regarding hand splint use |
| Rehabilitation Services Staff #1 | Rehabilitation Staff | Interviewed regarding hand splint use |
| Nurse #5 | Nurse | Interviewed regarding skin evaluation and hand splint use |
| Certified Nursing Assistant #10 | CNA | Interviewed regarding fall prevention and sensor alarm use |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding fall prevention and chair alarm use |
| Nurse #6 | Nurse | Interviewed regarding bed alarm functionality |
| Nurse #1 | Nurse | Interviewed regarding fall prevention and sensor alarm use |
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