Bear Creek Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF755Dec 21, 2025

  Based 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. […]

• Immediate jeopardy, patternF760Dec 21, 2025

  Based 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. […]

• Immediate jeopardy, patternF580Oct 25, 2024

  Based 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. […]

• Immediate jeopardy, patternF600Oct 25, 2024

  Based 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. […]

• Immediate jeopardy, patternF684Oct 25, 2024

  Based 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. […]