Bear Mountain Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bear Mountain Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 1, 2022

  Based on observations, record reviews and staff, resident, and Nurse Practitioner (NP) interviews, the facility failed to provide supervision and a safe smoking environment 1 of 3 residents reviewed for smoking (Resident #1). Resident #1 was admitted to the facility on [DATE] with a documented history of smoking with oxygen in use at another facility and was assessed as being safe to smoke unsupervised. On 10/25/22 the Director of Nursing intervened twice and removed the oxygen tank off the back of Resident #1's wheelchair as he was going out to smoke and provided education both times. No other interventions were initiated, and Resident #1 continued to smoke without supervision. […]

• Actual harm, patternF550Jan 28, 2022

  Based on record review, observations, resident and staff interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, transfers, and incontinence care resulting in residents expressing feelings of being: helpless, dirty, rank, embarrassed, angry, terrible, fed up, sad, treated like a dog, smelly, and forgotten about. This affected 5 of 5 (Residents #9, #39, #28, #13, and #360) sampled residents. Findings included: 1. Resident #9 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #9 was cognitively intact and required extensive to total assistance of 1 staff member for bathing and personal hygiene. […]

• Actual harm, patternF725Jan 28, 2022

  Based on observations, record reviews, interviews with residents and staff, the facility failed to maintain sufficient staff to assure preferred choices were honored for bathing and requests for transfer in and out of bed; failed to assure consistent showers were provided for residents dependent on staff and as a result of these failures residents expressed feeling that included being helpless and forgotten about. The facility also failed to implement, develop and/or complete baseline and comprehensive care plans and invite residents and their representative to care plan meetings. The facility failed to timely complete and/or transmit comprehensive, quarterly, and significant change Minimum Data Set assessments. […]

• Actual harm, isolatedF600Aug 10, 2023

  Based on observation, record review, resident and staff interviews, Psychiatric Physician's Assistant interview, and the Medical Director interview the facility failed to protect the rights of a resident to be free from abuse. Resident #1 was found bleeding with a laceration to her upper lip, and a bruise to her right index finger and hand. Resident #2 had struck Resident #1 with the bed adjustment remote control causing the laceration to Resident #1's lip and pulled a ring from Resident #1's right index finger. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstruction Pulmonary Disorder (COPD), panic disorder, depression, and anxiety. […]

• Actual harm, isolatedF580Dec 16, 2022

  Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician a resident's pain was not controlled after the administration of pain medication. The resident called emergency medical services and was evaluated for abdominal pain and diagnosed with acute cholecystitis (inflammation of the gallbladder) that required admission to the hospital for the surgical removal of the gallbladder for 1 of 2 residents reviewed for hospitalization s (Resident #270). The findings included: Resident #270 was admitted to the facility on [DATE] with diagnoses including a history of cervical spine trauma and quadriplegia. Resident #270 was discharged to the hospital on 11/22/22 and returned to the facility on [DATE]. […]