Bear Hill Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bear Hill Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 14, 2023

  Based on observation, record review and interview, the facility failed to follow the fall plan of care for 1 Resident (#124) out of a total of 36 sampled Residents. Subsequently, Resident #124 sustained a fall requiring hospitalization and was diagnosed with subdural hematoma, (bleeding that occurs within the skull but outside the actual brain tissue). Findings include: Review of the facility's Fall Prevention and Fall Committee Policy and Procedure, dated 6/7/22 indicated: *All residents who on admission, readmission or after an actual fall score at high risk for falls will have immediate interventions implemented for prevention of falls. *Any falls prevention interventions should minimize the resident's risk for falling and maintain functional independence and mobility. […]

• Actual harm, isolatedF686Oct 21, 2022

  Based on observation, record review and interview the facility failed to ensure interventions to prevent the development of a pressure ulcer were developed and implemented for 1 Resident (#82), which resulted in the development of a Stage IV pressure ulcer, out of a total sample of 29 residents. Findings include: Review of the Facility's policy, entitled 'Weekly Skin Assessment' dated as revised 6/8/22, included the following: Purpose: Early identification of alterations in skin integrity and ongoing assessment to intervene and prevent changed in resident skin condition. Policy: All residents will have a full body assessment on day of admission and weekly thereafter. […]

• No harm, potential for more than minimal, patternF684Jan 15, 2026

  Based on observation, record review, and interview, the facility failed to provide quality of care in accordance with professional standards for four Residents (#154, #40, #118, and #58) out of a total sample of 31 residents. Specifically,1. For Resident #154, the facility failed to document and assess the alteration of the skin on his/her lower extremities to determine if the areas were healing or worsening and failed to report the condition of Resident 154's lower extremities to the medical provider. 2. For Resident #40, the facility failed to implement an order for a diuretic after a significant weight gain for Resident #40, who has congestive heart failure and edema.3. For Resident #118, the facility failed to label wound dressings after changing Resident #118's dressing.4. […]

• No harm, potential for more than minimal, patternF677Dec 19, 2024

  Based on observations, record review, and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#61 and #241) out of a total sample of 30 residents. specifically 1. For Resident #61 the facility failed to provide supervision with meals. 2. For Resident #241 the facility failed to provide incontinent care or hygiene care. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, undated, indicated the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1(c). […]

• No harm, potential for more than minimal, patternF842Dec 19, 2024

  Based on record review and interview, the facility failed to accurately document in the clinical record for 4 Residents (#18, #43, #241 and #110) out of a total sample of 30 residents. Specifically: 1. for Resident #18 the facility failed to accurately document the changing of the oxygen tubing. 2. For Resident #43 the facility failed to accurately document the sex of the Resident. 3. For Resident #241 the facility failed to accurately document the Activities of Daily Living (ADL) care provided. 4. For Resident #110, the facility failed to ensure staff accurately documented the completion of wound treatments provided. […]