Bear Creek Nursing and Rehabilitation

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide an environment that remained as free of accident hazards as possible for 1 of 3 (100/200 hall) nurse's cart sharps container that was observed full with syringes overflowing. The facility failed to ensure nursing staff replaced the full sharps container on the100/200 hall nurses' cart with a new one at 09:21AM on 7/28/26[KA4.1]. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #2) of 4 residents reviewed for pharmacy services. The facility failed to ensure Resident #2 was not given an antibiotic that was identified as an allergy when he was administered doxycycline on 07/13/25. This failure could place the residents at risk of harm and/or serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure:- there was a sign outside of Resident #1's room indicating that the resident was on enhanced barrier precautions, which was due to the resident having an open chronic ulcer (non-pressure related) on his right heel;- LVN A, who was the Wound Care Nurse, performed hand hygiene prior to putting on gloves and between glove changes; and- LVN A wore as gown as required due to the resident being on enhanced barrier precautions; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 Residents (Resident #1, Resident #2 and Resident #3) observed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinent care on Resident #1, Resident #2, and Resident #3 on 06/27/26. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #2 and Resident #3) reviewed for accident hazards/supervision/devices 1. The Facility failed to ensure CNA A and CNA B used a gait belt when transferring Resident #2 from her wheelchair to the bed and instead lifted the resident under her arms and by her pants on 06/27/26. 2. The Facility failed to ensure CNA A and CNA B used a gait belt when transferring Resident #3 from her wheelchair to the bed and instead lifted the resident under her arms on 06/27/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents (Resident #1 and Resident #2) reviewed for incontinence care. 1. The facility failed to ensure staff provided Resident #1 timely perineal care after an incontinent episode when they failed to check and change the resident from 07:30 a.m. to 1:15 p.m. on 06/27/26. 2. The facility failed to ensure staff provided Resident #2 timely perineal care after an incontinent episode when they failed to check and change the resident from 07:45 a.m. to 1:30 p.m. on 06/27/26. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 4 residents (Resident #76) reviewed for food and nutrition. The facility failed to ensure Resident #76 received his nutritional supplement beverage (magic cup) during the lunch service on 05/06/26. This failure could lead to nutritional deficits and unintended weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #85) reviewed for dialysis. 1. The facility failed to ensure dialysis communication forms were completed for Resident #85 after returning from dialysis treatment. 2. The facility failed to ensure Resident #85 had an order to complete dialysis treatment. These failures could place residents at risk of inadequate monitoring after returning to facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 medication carts (Hall 300 nurse cart) reviewed for pharmacy services. The facility failed to ensure that one bottle of OTC Simethicone 125 mg, with an expiration date of February 2026, and Benzonatate 100 mg capsule prescribed to Resident #29, with an expiration date of 03/26/26, had been removed from the 300-hall nurse cart. This failure could place residents at risk of receiving medications that were ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #76) records reviewed for accurate documentation. RN D failed to accurately document in Resident #76's clinical record when he documented on 05/06/26 that Resident #76 received his magic cup during the lunch meal when he had not received it. This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs.

Inspectors wroteBased on interview, record review, and observation, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to ensure Resident #13, who was receiving hospice services, had a physician order for hospice care. This failure could place residents who receive hospice services at risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided with pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to have policies and processes in place to ensure the accurate dispensing and administering of medications. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of five residents reviewed for medication accuracy. The facility failed to ensure they had processes in place to ensure accurate verification and reconciliation of physician's orders and medications upon admission. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. Resident #1 was found unresponsive and was subsequently sent to the hospital. On 12/20/25 at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record review, the facility failed to make prompt efforts to resolve grievances and keep the residents' RP appropriately apprised of progress toward resolution for 1 of 6 residents (Resident #1) reviewed for grievances. The facility failed to notify Resident #1's RP the resolution of her filed grievances on [DATE]. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #1) reviewed for medication storage. The facility failed to secure all medications in a locked storage area when Resident #1's Labetalol HCl and Pantoprazole Sodium medications were found on the floor approximately 2-3 inches from resident's bed on [DATE]. This failure could place residents at risk of access to medications not approved for administration by their physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of 4 residents (Residents #33 and #99) reviewed for pharmacy services. 1. The facility failed to ensure RN C checked the current physician's orders before administering a PRN Lorazepam (a medication used to treat anxiety) medication to Resident #33 on 03/03/25, who did not have an active order of PRN Lorazepam. 2. The facility failed to ensure RN F administered the correct dosage of PRN Lorazepam (a medication used to treat anxiety) to Resident #99 on 10/31/24 and 11/14/24. These failures could place residents at risk and jeopardize their health and safety.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 4 of 20 residents (Residents #8, #9, #23, and #25) reviewed for privacy. The facility failed to ensure the rooms of Residents #8, #9, #23, and #25 were equipped with privacy curtains to assure full visual privacy. This failure could place the residents at risk of being embarrassed if they were exposed during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #5) reviewed for care plan accuracy. The facility failed to develop and implement a care plan for Resident #5, which addressed her use of an anti-depressant medication, Sertraline. This failure placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the residents environment remained free of accident hazards as possible for 4 of 20 residents (Residents #6, #8, #23, and #47) reviewed for accidents and safety. The facility failed to maintain the sharps containers, which are used to store used syringes and lancets, in a safe manner to prevent the containers from being overfilled and creating a safety hazard in the rooms of Residents #6, #8, #23, and #47. This failure could place residents at risk of exposure to bloodborne pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, for 1 of 1 resident (Resident #179) reviewed for enteral nutrition. The facility failed to follow physician orders for Resident 179's enteral feeding tube to be flushed with 55 ml of water every 1 hour. This failure could place residents who had gastrostomy tube at risk for fluid deficit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #55) reviewed for medication administration. The facility failed to ensure that MA H administered Resident #55's Lidoderm Patch 5% (Lidocaine); not a Lidocaine 4% patch. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 of 3 medication carts (Hall 100 and 200 nurse medication carts) reviewed for medication storage. The facility failed to ensure the nurses cart for 100 and 200 halls did not contain insulin, nebulizers, and inhalers that were opened and not labeled with the open date. This failure could place residents at risk of adverse medication reactions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 refrigerators reviewed for infection control. The facility failed to store specimen swabs in the specimen refrigerator, and the specimen was stored in the 100 and 200 refrigerators with medications. This failure could place the residents at risk of exposure to cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident, resident's representative, and ombudsman of the transfer or discharge and the reasons for the move, in writing and in a language and manner they understood for 1 of 2 residents (Resident #1) reviewed for discharge rights. The facility failed to ensure Resident #1 was notified in writing of the effective date of transfer, the reason for the transfer, the location to which the resident would be transferred, or the right of appeal of the transfer. The failure could affect all residents who were transferred or discharged to the hospital at risk of having their discharge rights violated.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for dialysis. The facility failed to ensure staff were trained on how to provide care and services to Resident #1 who utilized peritoneal dialysis after she was admitted to the facility. The failure could affect residents who received peritoneal dialysis treatments and could result in inadequate care of dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to extend to the resident representative the right to make decisions on behalf of the resident for one (Resident #1) of five residents reviewed for resident representative rights. The facility failed to contact Resident #1's representative/responsible party before administering her PRN medication. On 11/14/2024, Resident #1's MAR revealed LVN A administered to Resident #1 a dose of her prescribed Lorazepam (a medication used to treat seizures or decrease anxiety). LVN A failed to contact the RP prior to administering the Lorazepam as instructed in Resident #1's electronic medical record where it states in capital letters, CALL [RP] BEFORE GIVING ANY PRN MEDICATION. This failure could place residents at risk of receiving medication or treatment without consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for resident rights. The facility failed to notify the MD when Resident #1, who was a diabetic resident, had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of five residents reviewed for neglect. 1. The facility neglected to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration of his willingness to eat then a change in condition which included him becoming unresponsive. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make prompt efforts by the facility to resolve grievances the resident may have, receive and track grievances through to their conclusions; leading any necessary investigations by the facility; and the facility failed to ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for one (Resident #2) of two residents reviewed for resident rights. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 2 of 18 residents (Residents #2 and #32) of residents reviewed for safe clean homelike environment. 1. The facility failed to ensure Resident #2 had a clean privacy curtain. 2. The facility failed to ensure Residents #32's bed curtain was free from a dried brown substance. These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 7 (12/03/23, 12/23/23, 12/30/23, 12/31/23, 01/28/24, 02/04/24, or 02/11/24) of 90 days reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 7 (12/03/23, 12/23/23, 12/30/23, 12/31/23, 01/28/24, 02/04/24, or 02/11/24) of 90 days. This deficient practice could place residents at risk of no receiving specific nursing services due to staff being left without supervisory coverage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 3 (Resident #2, #20, and #26) of 3 residents and labeled in accordance with currently accepted professional principles for one (300 and 500 hall nurses' medication cart) of three medication carts reviewed for labeling and storage and temperatures were maintained within normal ranges for two of two refrigerators reviewed 100,200 halls and 300 and 500 halls. 1. The facility failed to ensure a bottle of dry eye relief was not stored or placed in a secured place for Resident #2. 2. The facility failed to ensure that Resident #26 and #20 's one bottle Saline Nasal Spray Solution, one bottle Systane Solution 0.4-0.3 % and one bottle of Dry eye relief lubricant eye drop propylene glycol 1.0% were securely stored. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 out of 2 meals (the lunch meal on 02/14/24) reviewed for food and nutrition services. The facility failed to ensure residents on a pureed diet were served pureed bread during the lunch meal on 02/14/24. This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one meal (lunch on 02/14/24) reviewed for food and nutrition services. The facility failed to deliver food at an appetizing taste and temperature for the lunch meal on 02/14/24. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and illness.

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 (Residents #45, #50, and #232 ) of 5 residents reviewed for treatment administration. 1. The facility failed to ensure staff accurately documented on Resident #45's MAR/TAR after performing wound care on Resident #45. 2. The facility failed to document wound care treatments on Resident #50's February 2024 TAR. 3. The facility failed to document wound care treatments on the Treatment Administration Record for Resident #232 indicated by blanks on Resident #232's February 2024 TAR. These failures could put residents at risk for treatment errors and errors in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary care team for 1 of 11 care plans reviewed (Resident #2). The facility failed to ensure Resident #2's care plan interventions were updated to reflect his improved condition. This failure could place residents at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community for one of three Residents (Resident #2) reviewed for meals. The facility did not provide Resident #2 with a meal or snack when going to dialysis on Mondays, Wednesdays, and Fridays. This failure could place residents who received dialysis services at risk for decreased intake, unplanned weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 4 residents (Residents #1, #2, #3, and #4) reviewed for infection control. LVN A failed to perform hand hygiene between residents while checking the vital signs of Residents #1, #2, #3 and #4 and failed to disinfect the blood pressure cuff between resident use. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had impaired cognition and was a high fall risk, was provided with adequate supervision to prevent her from eloping from the facility. On 10/16/23 Resident #1, who resided on the second floor and used a wheelchair for mobility, used the stairs to get to the bottom floor and was found outside of the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 10/16/23 and ended on 10/20/23. The facility had corrected the noncompliance before the survey began. [...]