Bear Creek Healthcare LLC

In the surveyor’s words

From the most serious findings on record at Bear Creek Healthcare LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF607Oct 20, 2022

  Based on record review and interview, the facility failed to ensure the facility abuse policies and procedures were implemented, as evidenced by failure to ensure an injury of unknown origin and an unwitnessed fall resulting in a fracture for 1 (Resident #16) was immediately reported to the Administrator, thoroughly investigated, evidence gathered, and findings reported to the state agency to rule out the possibility of abuse and or neglect. The failed practice resulted in Immediate Jeopardy (IJ). On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of the IJ. […]

• Immediate jeopardy, patternF609Oct 20, 2022

  Based on record review and interview, the facility failed to ensure that an injury of unknown origin was investigated and reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 1 Resident #16 of 5 residents sampled (Residents #16, #30, #33, #36 and #255) of residents who were reviewed for abuse/neglect. This failed practice resulted in Immediate Jeopardy for Resident #16 and had the potential to affect all 50 residents who resided in the facility according to the Resident Census and Condition of Residents Form dated 10/17/22. On 10/19/22 at 1:50 pm, the facility Owner and the DON notified of IJ (Immediate Jeopardy). […]

• Immediate jeopardy, patternF610Oct 20, 2022

  Based on observation, record review, and interview, the facility failed to ensure their abuse policies and procedures were implemented, as evidenced by failure to immediately report an injury of unknown origin and an unwitnessed fall resulting in a fracture to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law and failure to ensure an investigation was immediately initiated to determine if abuse or neglect occurred for 1 of 1 (Resident #16) the sampled case mix. This failed practice resulted in Immediate Jeopardy (IJ) for 1 (Resident #16) and the potential to affect 50 residents who were living in the facility according to the list provided by the Director of Nursing (DON) on 10/17/22. […]

• No harm, potential for more than minimal, widespreadF812Dec 21, 2023

  Based on observations, interview and record review, the facility failed to ensure foods in the stand-up freezer and chest freezer were properly dated, sealed, and stored in 1 of 1 facility kitchen. This failed practice had the potential to affect 53 residents who received their meals from the kitchen as identified by the Resident List Report provided by Infection Preventionist on 12/17/2023 at 10:54 AM. The findings are: 1. a. On 12/17/2023 at 9:37 AM, an initial kitchen tour was conducted. In the back room was a three-door refrigerator, a stand-alone two-door freezer and two chest freezers. On 12/17/23 at 9:47 AM, in the left door on the bottom shelf of the stand-alone two-door freezer, was 1 resealable bag with 7 fried pork steaks in it with no date on the bag. b. […]

• No harm, potential for more than minimal, widespreadF812Nov 24, 2021

  Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered and sealed, expired food items were discarded by the expiration or use by dates; dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items; pureed food was prepared using the same freshly cooked food served to other residents; and the kitchen was free of pests, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 33 residents who received meals from the kitchen (total census: 33), as documented on a list provided by the Dietary Supervisor on [DATE] at 9:40 AM. The findings are: 1. […]