Inspection Reports for
Bear Creek Healthcare LLC
322 West Collin Raye Drive, De Queen, AR 71832, AR, 71832
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan updates, physician order accuracy, and food preparation standards at Bear Creek Healthcare LLC.
Findings
The facility failed to update care plans to include interventions for incidents involving multiple residents, did not follow physician orders accurately for one resident, and did not adhere to recipes for pureed foods, compromising nutritional value and flavor.
Deficiencies (3)
Failure to update care plans to include interventions for incidents involving Residents #16, #18, and #27.
Failure to ensure physician orders were followed as written on telephone order for Resident #27.
Failure to follow recipe for pureed foods, using water instead of broth, milk, or gravy, reducing nutritional value for Residents #8, #9, #25, and #38.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 4
Incident dates: 3
Physician telephone order date: Sep 12, 2024
Physician order signature date: Oct 3, 2024
Water used for pureed food thinning: 3
Water used for pureed food thinning: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated facility lacked policies for care plans and physician orders; confirmed care plans should be updated within 24 hours; confirmed physician order discrepancies. |
| MDS Coordinator | MDS Coordinator | Confirmed care plans were not updated for incidents and interventions; explained staff communication and documentation processes. |
| RN | Registered Nurse | Acknowledged misunderstanding about responsibility for care planning incidents/accidents. |
| LPN | Licensed Practical Nurse | Confirmed telephone order for anti-anxiety medication was not clarified or reviewed. |
| Dietary Supervisor | Dietary Supervisor (DS) | Confirmed water should not be used to thin pureed foods and explained impact on nutrition and flavor. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan updates, physician order accuracy, and food preparation standards, including review of incidents, physician orders, and nutritional practices.
Findings
The facility failed to update care plans to include interventions for incidents involving multiple residents, did not follow physician orders accurately for one resident, and did not adhere to recipes for pureed foods, compromising nutritional value and flavor.
Deficiencies (3)
Failure to update care plans to include interventions for incidents involving Residents #16, #18, and #27.
Failure to ensure physician orders were followed as written on telephone order for Resident #27.
Failure to follow recipe for pureed foods, using water instead of broth, milk, or gravy, reducing nutritional value for Residents #8, #9, #25, and #38.
Report Facts
Residents affected by care plan deficiency: 3
Residents affected by physician order deficiency: 1
Residents affected by pureed food preparation deficiency: 4
Amount of water used in pureed chicken fried steak: 3
Amount of water used in pureed rolls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided statements regarding care plan policies, physician order processing, and incident reporting | |
| MDS Coordinator | Confirmed lack of care plan updates and described staff communication methods | |
| RN | Acknowledged misunderstanding about care planning responsibilities for incidents | |
| LPN | Confirmed telephone order for anti-anxiety medication was not clarified or reviewed | |
| Dietary Supervisor (DS) | Confirmed water should not be used to thin pureed foods and explained nutritional impact |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident assessments, respiratory care, food safety, infection control, and other care practices at Bear Creek Healthcare LLC.
Findings
The facility was found deficient in accurately documenting resident mental health assessments, administering oxygen at physician-ordered rates, maintaining food safety standards including hand hygiene and pest control, and performing proper infection prevention practices during peri care. These deficiencies had the potential to affect multiple residents with minimal harm noted.
Deficiencies (4)
Failure to ensure the minimum data set (MDS) accurately reflected the preadmission screening and assessment resident record (PASRR) for residents with serious mental illness or intellectual disability.
Failure to ensure oxygen was administered at the physician ordered rate to prevent respiratory complications.
Failure to procure food from approved sources and maintain proper food storage, preparation, and hygiene standards including hand washing and glove use.
Failure to provide and implement an infection prevention and control program, specifically improper hand hygiene during peri care.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 52
Residents affected: 4
Residents with oxygen orders: 6
Residents sampled for peri care: 12
Brief Mental Status Score (BIMS): 11
Brief Mental Status Score (BIMS): 10
Brief Mental Status Score (BIMS): 7
Oxygen liter flow observed: 3.5
Cold food temperature: 60
Expiration date: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed oxygen should be administered at 2 liters and described monitoring procedures |
| LPN #4 | Licensed Practical Nurse | Confirmed importance of correct oxygen rate to prevent harm |
| Director of Nursing | Director of Nursing (DON) | Confirmed nursing responsibility for oxygen rate monitoring and standard peri care practices |
| Assistant Administrator | Provided policies and confirmed absence of peri care policy | |
| Dietary Manager | Provided hand hygiene policy and commented on expired food and pest control | |
| Certified Nursing Assistant #4 | Certified Nursing Assistant (CNA) | Observed performing peri care with improper hand hygiene |
| Dietary [NAME] (DC) #1 | Dietary Cook | Observed handling food with poor hygiene practices |
| Dietary Aide #1 | Dietary Aide | Measured cold food temperatures |
| Dietary Aide #2 | Dietary Aide | Observed handling food and trays with improper hand hygiene |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, respiratory care, food safety, infection prevention, and other care standards at Bear Creek Healthcare LLC.
Findings
The facility was found deficient in accurately documenting resident assessments, administering oxygen at physician-ordered rates, maintaining food safety and hygiene standards in the kitchen, and performing proper hand hygiene during peri care. These deficiencies had the potential to affect multiple residents with minimal harm.
Deficiencies (4)
Failed to ensure the minimum data set (MDS) accurately reflected the preadmission screening and assessment resident record (PASRR) for serious mental illness or intellectual disability for Resident #24.
Failed to ensure oxygen was administered at the physician ordered rate for Resident #156, observed receiving 3.5 liters instead of 2 liters nasal cannula.
Failed to ensure food safety practices including proper storage of seasonings, hand hygiene by dietary staff, removal of expired food, maintaining cold food temperatures at or below 41°F, and pest control in the kitchen.
Failed to ensure proper hand hygiene was performed during peri care for Resident #11, risking cross contamination and infection.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 52
Residents affected: 4
Temperature: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed oxygen should be administered at 2 liters and described monitoring procedures |
| LPN #4 | Licensed Practical Nurse | Confirmed importance of correct oxygen rate to prevent harm |
| Director of Nursing | Director of Nursing (DON) | Confirmed nursing responsibility for monitoring oxygen rates and standard care practices for peri care |
| CNA #4 | Certified Nursing Assistant | Observed performing peri care without proper hand hygiene |
| Dietary Manager | Dietary Manager | Provided hand hygiene policy and commented on expired food and pest control |
| Dietary Supervisor | Dietary Supervisor | Responded to questions about food items and pest control |
| Dietary [NAME] (DC) #1 | Dietary Cook | Observed handling food without washing hands and contaminating food items |
| Dietary Aide (DA) #1 | Dietary Aide | Checked cold food temperatures |
| DA #2 | Dietary Aide | Observed handling clean equipment improperly without hand hygiene |
| Assistant Administrator | Assistant Administrator | Provided policies and confirmed absence of peri care policy |
| MDS nurse | MDS Nurse | Reviewed Resident #24's chart and confirmed PASRR coding errors |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Dec 21, 2023
Visit Reason
The inspection was conducted based on complaints and observations related to resident care, medication administration, discharge planning, infection control, and facility safety.
Complaint Details
The visit was complaint-related, triggered by concerns about resident dignity during feeding, medication administration errors, discharge planning deficiencies, infection control lapses, and call light malfunctions. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified feeding practices, improper medication administration and self-administration procedures, inadequate discharge planning and documentation, poor personal hygiene care, medication errors exceeding acceptable rates, improper medication storage, food storage and labeling issues, infection control lapses including hand hygiene and Legionella water management, and malfunctioning call light systems.
Deficiencies (10)
Failure to ensure staff did not stand over residents while assisting with eating and meal trays were improperly handled affecting dignity.
Failure to ensure interdisciplinary team assessment and care planning for resident self-administration of medication.
Failure to maintain privacy when flushing PEG tube for a resident.
Failure to conduct discharge planning and provide discharge summary for a discharged resident.
Failure to provide necessary personal hygiene care for a resident dependent on staff.
Medication error rate exceeded 5% due to improper administration and documentation of medications.
Failure to ensure medication (Biotene mouthwash) was not left at bedside for self-administration without proper assessment and safeguards.
Failure to ensure foods in freezers were properly dated, sealed, and stored, risking food safety for residents.
Failure to ensure residents washed hands after placing hands in trash can and lack of Legionella water management program.
Failure to ensure call lights were in good working order for a resident, risking inability to summon help.
Report Facts
Medication error rate: 5.13
Residents affected: 53
Residents affected: 54
Residents sampled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding feeding practices, medication administration, discharge planning, infection control, and call light system. | |
| Licensed Practical Nurse (LPN) #2 | Observed and interviewed regarding medication administration errors and self-administration. | |
| Certified Nursing Assistant (CNA) #5 | Observed and interviewed regarding resident hygiene and feeding practices. | |
| Certified Nursing Assistant (CNA) #6 | Observed regarding food handling and infection control practices. | |
| Dietary Manager (DM) | Interviewed regarding food storage and labeling practices. | |
| Maintenance Supervisor | Interviewed regarding Legionella policy and water management. | |
| Social Worker | Interviewed regarding discharge planning documentation. |
Inspection Report
Routine
Deficiencies: 10
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, discharge planning, personal care, infection control, food safety, and call light functionality in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during feeding, improper medication administration and documentation, inadequate discharge planning, insufficient personal hygiene assistance, unsafe medication storage, food storage and labeling issues, lack of infection control practices especially in the locked unit, and non-functional call light systems for residents.
Deficiencies (10)
Failed to ensure staff did not stand over residents while assisting with eating and meal trays were improperly handled, affecting resident dignity.
Failed to ensure interdisciplinary team assessment and care planning for resident self-administration of liquid mouthwash medication.
Failed to maintain privacy during PEG tube flushing for a resident.
Failed to conduct discharge planning and provide discharge summary documentation for a discharged resident.
Failed to provide necessary personal hygiene care, resulting in dirty and jagged fingernails for a resident.
Failed to maintain medication error rate below 5%, including improper administration of blood pressure medication against parameters.
Failed to ensure medication (Biotene mouthwash) was not left at bedside for self-administration without proper care planning and safety assessment.
Failed to ensure foods in freezers were properly dated, sealed, and stored, and improper handling of food serving by staff.
Failed to ensure residents in the locked unit washed hands after placing hands in open trash can and lacked a water management plan for Legionella.
Failed to ensure call lights were in good working order for a resident, compromising resident safety and ability to summon help.
Report Facts
Medication error rate: 5.13
Residents affected by food storage issue: 53
Residents affected by infection control issue: 54
Residents sampled for call light issue: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding feeding practices, medication administration, discharge planning, infection control, and call light issues. |
| Licensed Practical Nurse #2 | LPN | Observed administering medication and interviewed regarding medication administration and self-administration practices. |
| Certified Nursing Assistant #5 | CNA | Observed feeding residents and interviewed regarding personal hygiene care. |
| Certified Nursing Assistant #6 | CNA | Observed handling food serving and interviewed regarding infection control practices. |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food storage and labeling practices. |
| Maintenance Supervisor | Maintenance Supervisor (MS) | Interviewed regarding Legionella policy and water management. |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding call light system and resident safety. |
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