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)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
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: 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
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. |
Viewing
Loading inspection reports...
