Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Hill Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide ordered care and documentation for several residents. One resident with chronic leg wounds had peeling, draining lower-extremity skin changes that were not fully assessed or reported to the provider. Another resident with CHF had a significant weight gain, but weekly weights were not completed as planned and the diuretic order was not implemented as expected. A resident with multiple skin tears had undated dressings, and another resident with high skin-breakdown risk did not receive weekly skin checks as ordered.
Failure to Assess Geri-Chair Use as a Potential Restraint: A resident with severe cognitive impairment, recurrent falls, agitation, and repeated attempts to self-transfer was observed multiple times seated in a reclined geri-chair and trying to climb out. The chart lacked a physician order, restraint assessment, and rehab documentation showing the geri-chair was assessed as a restraint, while staff stated it was being used for fall prevention and comfort.
Missing Individualized Activities Care Plan: A resident with intact cognition and diagnoses including adjustment disorder with mixed anxiety and depressed mood reported wanting to attend activities, but said he/she had only been to one activity since admission and was not routinely brought to programs because of room location. The resident stated a preference for music, entertainment, and group activities, yet the activity log showed only independent activities and the care plan lacked an individualized, person-centered activities plan. The ADON/Activities Director stated every resident should have an activities care plan after admission and was unaware this resident's plan had not been developed.
A resident with severe cognitive impairment and highly impaired hearing was repeatedly observed without a working hearing aid in place. Although the care plan and MD order directed staff to place bilateral hearing aids daily, the resident reported the right aid was missing and the left aid was not working even with new batteries, while staff documentation showed the aids as administered despite observations and staff confirmation that the right aid was unavailable.
Failure to Implement Wound Physician Orders for Sacral Pressure Ulcer: A resident with severe cognitive impairment, dependence for mobility, peripheral vascular disease, and multiple unstageable pressure ulcers had a sacral wound that was evaluated by the wound physician as an unstageable pressure-related injury with granulation tissue and slough. The wound physician recommended wound cleanser, Santyl, and calcium alginate with a dressing change daily and as needed, but the record did not show the new treatment was implemented. Staff interviews indicated the recommendation was expected to be approved and started the same day, but it was overlooked.
The facility failed to accurately document resident care for two residents. One resident with Alzheimer’s disease and a right humerus fracture was observed without a prescribed right arm sling even though the TAR showed it as administered, and a unit manager confirmed the order was still active. Another resident with dementia had oxygen saturation values entered as 18% and 7% despite an order for oxygen when sats were below 92%, and the progress notes did not show follow-up on those vitals.
Failure to issue SNF ABN notices after skilled services ended. Record review showed that two residents who remained in the facility after skilled services ended did not have documentation indicating that SNF ABN notices were issued, even though Notices of Medicare Non-coverage were completed. An SW stated that residents who stay after skilled services end are expected to receive a SNF ABN informing them of potential financial liability for certain services.
Two residents in an LTC facility did not receive necessary assistance with ADLs, leading to deficiencies in care. One resident with multiple sclerosis did not receive incontinence care for over two days, resulting in pain and excoriation due to dried feces. Another resident with dementia was observed eating meals alone without the required supervision or assistance, despite care plans indicating the need for such support. These lapses highlight significant failures in adhering to care plans and providing essential care.
The facility failed to accurately document medical records for four residents, leading to deficiencies in care. One resident's oxygen tubing change was inaccurately recorded, another's sex was misdocumented in psychiatry notes, and a third resident reported not receiving documented incontinent care. Additionally, wound treatments for a resident with Alzheimer's were inaccurately documented, with a nurse admitting to not having completed the treatments despite records indicating otherwise.
The facility failed to develop a care plan for a resident with suicidal ideations and did not ensure call light accessibility for another resident. A resident with severe cognitive impairment and a history of suicidal ideations lacked a care plan addressing these issues. Another resident, admitted with multiple sclerosis and other conditions, reported not receiving care due to an inaccessible call light, which was confirmed by the Unit Manager.
A facility failed to adhere to its policy of changing oxygen tubing and humidifiers every seven days for a resident with COPD, dementia, and heart disease. Observations showed that the equipment was not changed as required, despite documentation indicating otherwise. An MDS Nurse confirmed the necessity of timely changes to prevent infection.
Failures in skin care, wound documentation, weight monitoring, and ordered treatment implementation
Penalty
Summary
The facility failed to provide quality of care for a resident with multiple sclerosis, severe protein calorie malnutrition, and chronic venous hypertension with ulcers of the lower extremities by not documenting and assessing changes to the skin on both lower legs and by not reporting the condition to the medical provider. The resident had moderate cognitive impairment and required substantial to maximal assistance with daily care. During observation, the resident’s lower legs had partial dry and crusted areas of skin that were peeling and draining fluid, with dried fluid stains on the sheets and areas of old skin that were moist and yellow/blackish in color. The record showed a high risk for skin breakdown and a history of chronic leg wounds, but the treatment record did not include a wound assessment for the left shin and the medical record did not show that the provider was notified of the change in the leg wounds during the period reviewed. The facility also failed to implement an order for a diuretic after a significant weight gain for a resident with congestive heart failure and edema. The resident’s record showed intact cognition and a care plan that called for weekly weight monitoring related to fluid volume issues. The weight record showed an increase from 126.3 pounds to 133 pounds and then to 137.6 pounds, but the record did not show that weights were being completed weekly as planned. After the weight gain was noted, the record did not show that an additional Lasix order was initiated as expected from the documented change in condition. The facility further failed to label wound dressings after dressing changes for a resident with severe cognitive impairment and multiple skin tears, including on the left arm, left hand, left shoulder, and head laceration. Surveyors observed bandages on the resident’s forehead and hands on multiple occasions, and the bandages were undated. In addition, the facility failed to complete weekly skin checks for another resident with severe cognitive impairment and high risk for skin breakdown. The resident’s care plan and physician orders required weekly skin evaluations, but the scheduled skin evaluations were completed only two times out of seven scheduled checks during the review period.
Failure to Assess Geri-Chair Use as a Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of a geri-chair as a potential physical restraint for Resident #118. The facility’s restraint policy stated restraints are to be used only for resident safety and well-being, after other alternatives have failed, and only after a pre-restraint assessment, physician order, and consent. The policy also required documentation of the reason for restraint use, the type of restraint, the time period, and care provided while the restraint was in use. Resident #118 was admitted in November 2025 with diagnoses including unspecified symptoms and signs involving cognitive functions and awareness, depression, and sepsis. The most recent MDS showed severe cognitive impairment, need for assistance with bathing, dressing, toileting, ambulation, and transfers, and did not indicate any restraints. The resident’s fall care plan identified high fall risk related to decreased mobility, recurrent falls, poor safety awareness, weakness, restlessness, agitation, and constant attempts to self-transfer, and listed a geri-chair and sitting at the nurses’ station in a geri-chair as interventions. Survey observations on multiple dates showed Resident #118 seated in a reclined geri-chair behind or near the nursing station and in the room, agitated and repeatedly trying to get up by thrusting forward and throwing legs over the side of the chair. The medical record did not contain a physician order for the geri-chair, a restraint assessment, or rehab documentation showing assessment of the geri-chair as a restraint. Nursing notes stated the geri-chair was provided for fall prevention and working positively, and staff interviews confirmed the resident had been using the geri-chair since returning from the hospital to prevent falls. The DON stated the resident was switched to the geri-chair for comfort and to keep him/her from falling, and the Regional Nurse Consultant stated a restraint assessment should have been completed before use of the geri-chair.
Missing Individualized Activities Care Plan
Penalty
Summary
Failure to develop an individualized activities care plan for Resident #40 was identified during record review and interview. Resident #40 was admitted in November 2025 with diagnoses including adjustment disorder with mixed anxiety and depressed mood, and the MDS dated [DATE] showed a BIMS score of 15 out of 15, indicating intact cognition. During interview, the resident stated a desire to attend activities but reported having only attended one activity since admission, said no one comes to get him/her for activities because he/she is at the end of the hall, and stated that he/she loves music, entertainment, and group activities. An observation later that day found the resident sitting in a wheelchair in the room and stating that no activities had been done that day. Review of the January 2026 activities attendance log showed the resident participated in independent activities for the entire month, and review of the care plan showed no individualized, person-centered activities care plan had been developed. The Activities Director stated that every resident should have an activities care plan after admission and was unaware that this resident's care plan had not been developed.
Failure to Ensure Hearing Aid Use and Function
Penalty
Summary
The facility failed to assist Resident #145 with access to hearing services by not ensuring the resident’s left hearing aid was working and available for use. Resident #145 was readmitted in September 2024 and had diagnoses including Parkinson’s disease, chronic ischemic heart disease, and unspecified dementia. The most recent MDS showed severe cognitive impairment, highly impaired hearing, and that hearing aids or another hearing appliance were used. The care plan and physician’s orders directed staff to place bilateral hearing aids in the morning, remove them at bedtime, and use size 13 batteries. During observations on 1/13/26 and 1/14/26, Resident #145 was repeatedly found without the left hearing aid in place and had difficulty communicating. The resident stated the right hearing aid had recently gone missing and was awaiting replacement, and that the left hearing aid was not working even with new batteries. The resident showed a container with one hearing aid and scattered batteries and said the batteries did not work. Social Worker #1 later confirmed the right hearing aid had been lost, found in laundry, and was out for repair, and that she had provided batteries for the left hearing aid without knowing the resident was not wearing it or that it was not working. The TAR documented bilateral hearing aids as administered on multiple days, which conflicted with the observations and with staff statements that the right hearing aid was unavailable and the resident reported the left hearing aid batteries were not working.
Failure to Implement Wound Physician Orders for Sacral Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to implement the wound physician’s recommended treatment for a resident’s sacral pressure ulcer. The resident was admitted with peripheral vascular disease, an acquired absence of the right leg below the knee, severe cognitive impairment, dependence for mobility, and three unstageable pressure ulcers, including the sacrum. The resident’s care plan directed treatment as ordered, use of a low air loss mattress, and monitoring and documentation of the wound’s location, size, treatment, and any abnormalities or signs of infection. The active physician orders included daily cleansing of the sacrum with normal saline, application of calcium alginate, and coverage with bordered foam. The wound physician evaluated the sacral wound and documented that it was an open wound with granulation tissue and slough obscuring the wound bed, consistent with an unstageable pressure-related injury. The wound physician recommended cleansing with wound cleanser and applying Santyl and calcium alginate to the base of the wound, secured with a dressing and changed daily and as needed. The medical record did not show that these new treatment orders were implemented. The nurse practitioner progress note did not indicate awareness of the wound physician’s recommendation, and staff interviews confirmed the recommendation was expected to be approved and put into place the same day but was overlooked.
Inaccurate Documentation of Sling Use and Oxygen Saturation
Penalty
Summary
The facility failed to accurately document resident-identifiable information in the electronic medical record for two residents. For one resident with Alzheimer’s disease and a displaced fracture of the upper end of the right humerus, the physician’s order required a right arm sling to be in place at all times, with removal allowed only for hygiene, ADLs, and skin assessment every shift. However, the resident was observed multiple times without the sling, and the Treatment Administration Record documented the sling as administered on dates when it was not being worn. A nurse stated the resident had not been using the sling for a while, and a unit manager reviewed the order and confirmed it remained active and that staff should not have documented the sling as provided when it was not. For another resident with dementia and hypertension, the MDS indicated severe cognitive impairment and that the resident received oxygen therapy. The physician’s order required 2 L of oxygen when oxygen saturation was less than 92%, but the recorded oxygen saturation values were documented as 18% and 7%. The progress notes did not show any follow-up or review of these out-of-parameter vitals. The DON stated that staff should be entering vitals correctly and that this was an issue she had identified.
Failure to Issue SNF ABN Notices After Skilled Services Ended
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) notices for 2 applicable residents out of a sample of 3 residents after skilled services ended. Record review showed that two Notices of Medicare Non-coverage were issued for the residents who remained in the facility after skilled services ended on 11/28/25 and 1/9/26, but those notices failed to indicate that SNF ABN notices were issued. During an interview on 1/14/26 at 10:04 A.M., Social Worker #1 stated that residents who remain in the facility after skilled services end are expected to receive a SNF ABN notice informing them of potential financial liability for certain services.
Failure to Provide Necessary ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, leading to deficiencies in care. Resident #241, who was admitted with multiple sclerosis, malnutrition, and other conditions, did not receive incontinence care or morning and evening hygiene care from the 7:00 A.M. to 3:00 P.M. shift on 12/15/24 until 11:20 A.M. on 12/17/24. The resident reported that staff did not provide care despite requests, and the call light was found on the floor, inaccessible to the resident. Observations confirmed that the resident had not received care, and when care was finally provided, the resident experienced pain due to dried feces, resulting in red and excoriated genitalia. Documentation indicated that care tasks were left blank, and there was no record of the resident refusing care. Resident #61, admitted with cerebral infarction, altered mental status, and dementia, was observed multiple times eating meals alone in their room without supervision or assistance, despite care plans indicating the need for supervision and assistance with eating. The resident was seen struggling to reach utensils and had food on their cheek, indicating difficulty with self-feeding. Staff interviews revealed a misunderstanding of the resident's needs, with the Unit Manager stating that the resident could eat independently, contrary to the care plan requirements. These deficiencies highlight a failure to adhere to care plans and provide necessary assistance, resulting in unmet needs for residents requiring help with ADLs. The lack of supervision and assistance with meals for Resident #61 and the failure to provide timely incontinence care for Resident #241 demonstrate significant lapses in care delivery, as documented by the surveyor's observations and resident interviews.
Documentation Failures in Resident Medical Records
Penalty
Summary
The facility failed to accurately document medical records for four residents, leading to deficiencies in care. For one resident with chronic obstructive pulmonary disease and dementia, the facility did not accurately document the changing of oxygen tubing as per the physician's orders. The tubing was observed to be dated incorrectly, and the Treatment Administration Record inaccurately indicated that the tubing had been changed, which was not the case according to the observations made by the surveyor. Another resident's medical record inaccurately documented their sex in psychiatry notes over several months. This discrepancy was noted in the records dated October, November, and December, indicating a failure to maintain accurate resident-identifiable information. Additionally, a resident with multiple sclerosis and dysphagia reported not receiving incontinent care as documented. The facility's records inaccurately showed that care was provided, but the resident stated otherwise, highlighting a significant gap between documented care and actual care provided. For a resident with Alzheimer's Disease and diabetes, the facility failed to ensure accurate documentation of wound treatments. The Treatment Administration Record showed that a nurse documented the completion of wound care, which was not performed by him but by another staff member. This discrepancy was confirmed through interviews, where the nurse admitted to not having completed the treatments yet, despite the records indicating otherwise. These documentation failures reflect a lack of adherence to the facility's policy on accurate and complete medical record-keeping.
Failure to Develop Care Plan and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to develop a care plan for a resident with a history of suicidal ideations. Resident #43, who was admitted with diagnoses including suicidal ideation, depression with psychotic features, and dementia, did not have a care plan addressing these issues. The Minimum Data Set assessment indicated severe cognitive impairment, and a psychiatry note confirmed the need for continued monitoring of suicidal symptoms. However, the care plan lacked any focus, goals, or interventions related to the resident's suicidal ideations, as confirmed by the Director of Nursing. Additionally, the facility failed to ensure that a call light was accessible for Resident #241, who was admitted with multiple sclerosis, malnutrition, and an ulcer of the right lower extremity. The resident reported not receiving incontinence care or morning and evening care for an extended period, as the call light was found on the floor, making it inaccessible. The Unit Manager confirmed that call lights should always be accessible to residents, highlighting a lapse in ensuring the resident's ability to request assistance.
Failure to Change Oxygen Tubing and Humidifier Timely
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident with chronic obstructive pulmonary disease, dementia, and heart disease. The facility's policy required that humidifiers, nasal cannulas, masks, and tubing be changed every seven days. However, observations revealed that the oxygen tubing and humidifier bottle for the resident were dated 12/9/24, indicating they had not been changed as per the policy. The Treatment Administration Record documented that the tubing was changed on 12/15/24, but this was inconsistent with the observed dates. An interview with an MDS Nurse confirmed that the tubing and humidification bottle should be changed every seven days to prevent infection.
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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 Stoneham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Wakefield | 1.5 mi | ★★★★★ | 13 | 0 |
| Greenwood Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Woburn Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Melrose Healthcare | 3.3 mi | ★★★★★ | 0 | 0 |
| Willow Brook Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 30 | 0 |
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