Bear Creek Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 27, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 27, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF684Jul 25, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF644Mar 14, 2024

  Based 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 Findings included: 1. Review of the Admission Face Sheet revealed Resident #17 was admitted on [DATE] and readmitted on [DATE], a diagnoses including diabetes and major depressive disorder as of 11/07/2022, single episode without psychotic features as of 09/27/2023, generalized anxiety disorder as of 11/07/2022, hypertension, and legally blind. […]

• No harm, potential for more than minimal, patternF689Mar 14, 2024

  Based on interviews, observations, and record review, the facility failed to provide adequate supervision to 1.) prevent falls for three residents (#81, #49 and #35) out of thirty-three sampled residents; and 2.) ensure safety related to smoking for one resident (#88) out of five residents sampled. Findings include: On 3/11/24 at 09:30 a.m. an observation was made of Resident #81 in her bed next to a window with eyes closed, lights out and food tray at bedside. An observation was made on the 3/11/24 at 10:30 a.m., of Resident #81 remaining in hospital gown, eyes closed and breakfast tray removed. On 3/12/24 at 08:10 a.m. […]