Bear Creek Nursing Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow physician orders for three residents (#1, #8, and #12) out three residents sampled. Findings Included:Review of Resident #1's admission record revealed an initial admission date of 09/24/2022. Resident #1 was admitted to the facility with diagnoses to include; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, unspecified convulsions, need for assistance with personal care, personal history of other venous thrombosis and embolism, and unspecified dementia, unspecified severity, with other behavioral disturbance. A review of Resident #1's Treatment Administration Record (TAR) for June 2026 revealed the following:Start Date: 01/20/2024: Vital Signs.every day shift was blank for 6/13/2026. Start Date: [...]

Inspectors wroteBased on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II assessment upon a new qualifying mental health diagnosis and/or ensure the accuracy of the PASRR Level I assessment for 9 residents (#11, #17, #24, #34, #49, #56, #67, #81, #245) of 32 sampled residents

Inspectors wroteReview of the admission Record, dated 02/08/2024, showed Resident #88 was admitted on [DATE] with diagnoses to included but not limited to Traumatic Subdural Hemorrhage without loss of consciousness, subsequent encounter, chronic obstructive pulmonary disease, unspecified, unspecified lack of coordination, nicotine dependence, cigarettes, uncomplicated. Review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Section I Health Conditions, showed Yes were answered to question number 1 to indicate Resident #88 is a current tobacco user. Review of the care plan created and initiated on 02/09/2024 and revised on 03/07/2024 showed Resident #88 is a smoker and is at risk for smoking related injury/incident. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow-up on pharmacy recommendations for five residents (#3, #10, #30, #49 and #56) of five residents sampled for unnecessary medications. 1) Review of the admission record for Resident #49 revealed an admission date of 6/13/2023 and a current admission date of 3/8/2024. Review of the Consultant Pharmacist's medication regime review, dated 1/1/2024 and 1/15/2024 for Resident #49 revealed the following: 1. Clonazepam tablet dispersible 0.125 Milligram (MG) give 1 tablet by mouth two times a day for anxiety. Request attempt for dose reduction to verify that resident is on lowest possible dose. 2. Mirtazapine tablet 7.5 mg give one tablet by mouth at bedtime for depression, evaluate for trial dose reduction? 3. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for three residents (#11, #34, and #245) out of twenty-one sampled residents. Finding Include: 1) A review of the admission Record, dated 03/13/2024, showed Resident # 11 was admitted on [DATE] with diagnoses to include chronic kidney disease, stage 3 unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, generalized anxiety disorder, and major depressive disorder, recurrent, mild. A review of Resident #11's Minimum Data Set (MDS), dated [DATE], revealed the following: -Section C-Cognitive Function: 0 was coded to indicate Resident #11 was not able to complete a Brief Interview for Mental Status (BIMS) -Section I-Active Diagnoses: no documentation to show Resident # 11 had depression. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to timely revise and effectively implement individualized care plans for three residents (#81, # 49 and #3) of thirty-three sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure skin assessment were accurate for two residents (#63 and #72) out of 21 residents sampled.

Inspectors wroteBased on record review and interview, the facility failed to ensure there were no discrepancies between the narcotic records and the residents' medical records for three (Residents #3, #4, #5) of three residents who had physician's orders for and received narcotics to relieve their pain.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#1) out of seven residents with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. The facility failed to properly secure an exit gate, or implement proper methods to prevent elopement, on 10/9/2023 and 10/15/2023. The facility nursing staff neglected to ensure the safety of Resident # 1. Resident # 1 was able to exit the facility unsupervised on 10/9/2023 and 10/15/2023. On 10/9/2023, Resident # 1 self-propelled out a fire exit door leading to a smoking patio and exited the facility unwitnessed through a gate leading into a parking lot next to a busy highway. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide supervision and services to prevent unwitnessed exits from the facility, on two occasions, for one (Resident # 1) of seven residents at high-risk of elopement. This failure created a situation which resulted in the likelihood for serious injury, harm and/or death to Resident # 1, and resulted in the determination of Immediate Jeopardy on 10/09/2023. The findings of Immediate Jeopardy were determined to be removed on 10/27/2023, and the scope and severity was reduced to a D after verification of removal of Immediate Jeopardy. Resident # 1 is a [AGE] year-old male who was moderately cognitively impaired, at risk for falls related to unsteadiness on his feet, was known to staff to have a history of wandering and expressed a desire to leave the facility. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to submit an immediate and a 5-day report for one (#1) out of seven residents sampled who eloped on two occasions (10/09/2023 and 10/15/2023). Findings Included: Review of Resident Information Record dated 10/26/2023 showed Resident # 1 was originally admitted to the facility on [DATE], with diagnosis that include Muscle Weakness (Generalized), Unsteadiness on Feet, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate impairment. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to complete a thorough investigation and take corrective actions to prevent one (#1) out of seven residents reviewed from eloping on two occasions (10/09/2023 and 10/15/2023). Findings Included: Review of Resident Information Record dated 10/26/2023 showed Resident # 1 was originally admitted to the facility on [DATE], with diagnosis that include Muscle Weakness (Generalized), Unsteadiness on Feet, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate impairment. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to electronically transmit the periodic Minimum Data Set (MDS) assessments within 14 days after the facility completed the MDS assessment for three residents (#2, #4, and #5) out of four sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed provide treatment and care in accordance with professional standards of practice by 1) not assessing one resident (#32) for new skin conditions after a shower, and 2) having one resident's (#135) skin tear treated by a Certified Nursing Assistant (CNA) for a nurse for a sample of two residents observed with skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was below 5.00%. A total of thirty-two medications were observed, and two medications were verified for one resident (#5) of five residents observed. The medication errors constituted a medication error rate of 6.25 percent.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one Resident #32's bed frame was inspected to ensure safety and use of a correctly fitted mattress for the bed frame of a total of 94 residents audited in the facility.

Inspectors wroteBased on medical record review, observation and staff interviews, the facility failed to ensure that the Quarterly Minimum Data Set Assessment (MDS) accurately reflected the resident's status for suctioning for one resident (#28) of one resident with a tracheotomy in the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement the care plan related to checking the placement of a wander/elopement alarm for one resident (Resident #27) out of the sampled thirty-five residents.

Inspectors wroteBased on interviews and review of the medical record, the facility failed to ensure that one dependent resident (#20) out of 35 residents sampled, received the necessary services for meal set up and assistance as needed. Resident #20 was unable to carry out meal activities by herself.

Inspectors wroteBased on observation, record review, and interviews the facility failed to provide wound care in accordance with professional standards of practice for one resident (#280) out of two residents sampled for pressure injuries as evidence by a skin tear dressing applied on September 7, 2020 and not addressed until 10/2/2020.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to maintain professional standards for food service safety as evidenced by: 1. The facility failed to ensure food and snack items were dated and labeled properly in one nutrition room (Light House Way) out of 2 nutrition rooms sampled, 2. The facility failed to ensure hydration carts were maintained in a clean and sanitary manner for one hydration cart (Light House Way) out of three sampled.