Bear Creek Senior Living

“Based on record review and interview the residence failed to comply with all federal and state laws andregulations relating to storage of controlled substances affecting 23 current residents in the secured environment.Findings IncludeFormer Resident #5 was admitted to the residence on 7/18/24 with a diagnosis of dementia.A disciplinary action form dated 9/2/25 read that Staff #1 left the medication cart unlocked and a resident hadaccess to the medication cart.On 9/9/25 at approximately 8:00 a.m., Staff #5 stated that she was present when Former Resident #5 was foundwith the medication. She stated that the medication belonged to Resident #2 and that the medication was fentanylpatches. She stated that all of the medication was found and accounted for and that Former Resident #5 did notuse any of the medication. On 9/9/25 at approximately 9:30 a.m., the Memory Care Care Coordinator stated that she was notified of thefentanyl patches missing on 8/28/25, a day after the incident, because she was on leave the day that it happened.She stated that she provided Staff #1 with a verbal warning and retraining. She stated that she then reached out tothe pharmacy to have the medication cart fixed or replaced in order to prevent future incidents. On 9/9/25 at approximately 10:00 a.m., Staff #1 stated that she was working the medication cart and thought sheshut and locked the medication cart before walking away. She stated that the door of the medication cart wasknown for not latching all the way, and this must be what happened because she then noticed during shift changeand narcotic count that Resident #2's fentanyl patches were not there. She stated that she knew it must be FormerResident #5 because she was known for lingering near the medication cart to take things that this was one of herbehaviors. Staff #1 stated that upon discovering the missing medication, she immediately searched FormerResident #5's room and found all of the missing medication, and it was all untampered and intact. On 9/9/25 at 1:10 p.m., the administrator stated that she expected all medication carts to be locked when notattended by a qualified medication administration person.”

“Based on observation, interview, and record review, the residence failed to update the enhanced care plan to include the necessary individualized staff approaches to address the resident's behavioral expressions, affecting one of six sample residents (#9). (Cross-reference S3060)Specifically, Resident #9 had a diagnosis of dysphagia and had a risk of choking. Resident #9 ate a styrofoam holiday decoration two weeks before the onsite visit. Subsequently, the residence failed to update the care plan to include behavioral expressions with staff approaches to address the behavior. On 12/10/24, Resident #9 ate fake plastic snow. The residence failed to completely remove the plastic snow from the resident's reach. This failure created an immediate jeopardy risk of injury or death to one of six sample residents residing in the residence. On 12/10/24, the department directed the residence to provide written evidence that the risk had been removed.1. ObservationsOn 12/10/24 at approximately 8:15 a.m., Resident # 9 was observed eating fake plastic snow from a centerpiece of the dining room table where she was sitting. Staff #2 witnessed Resident #9 eating the fake snow, removed it from her hand, and placed it back to the center of the table.On 12/10/24 at approximately 8:20 a.m., the fake snow was observed to be the size of a grain of rice.2. Record ReviewResident #9 was admitted on 9/9/24 with a diagnosis of dysphasia. An assessment and care plan, dated 9/9/24, read in part that Resident #9 had a modified diet due to esophageal concerns and was at risk for aspiration. Resident #9 required a mechanical soft diet including no rice; she required corn and peas to be pureed.An assessment and care plan, dated 12/5/24, did not address or include changes regarding the incident of Resident #9 eating the styrofoam holiday decoration two weeks prior to 12/10/24.A package, delivered to the residence on 11/23/24, contained fake sparkling plastic snowflakes. The label on the package read that the contents may pose a choking hazard. 3. InterviewsOn 12/10/24 at 10:17 a.m., the memory care director stated that Resident #9 ate a styrofoam gingerbread man from a centerpiece of the dining room table approximately two weeks prior to the onsite visit. She further stated that the gingerbread man and the snow were probably toxic, should not be ingested, and could cause her to choke.On 12/10/24 at approximately 11:30 a.m., a family member of Resident #9 confirmed that she had dysphagia and often choked on her food. He further stated that choking was one of the main reasons they decided to place her in a secure environment.On 12/10/24 at 1:05 p.m., the administrator stated that leaving plastic snow within reach of Resident #9, after she had attempted to ingest styrofoam two weeks prior and with her dysphagia diagnosis, put the resident at immediate risk of injury. Eating plastic snow put the resident at immediate risk of injury.4. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #9 at immediate jeopardy risk for potential death due to choking. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/10/24 at 2:09 p.m., the administrator submitted written evidence that read in pertinent part: "All items that are non-edible were removed from resident care dining tables, common areas, and resident rooms immediately. Resident did not eat Styrofoam gingerbread, was seen trying to put in her mouth and was removed prior to swallowing. However, the care plan was not updated for the behavior. Care plan updated as of 2:00 p.m. (on) 12/10/24.The (residence) will only use edible flowers in the dining room for centerpieces (as is our standard practice prior to the holiday décor). All residents were assessed for choking (if) eating centerpieces. (Three) other residents identified could have choked by eating non-edible items. Care plans for (residents who require) mechanical soft and pureed (diets were) reviewed for behavior. Complete room sweep will be conducted within the hour to ensure non-edible items are out of reach and in locked cabinets. All staff on schedule received immediate education on having non-edible items out of reach. The remainder of staff will be called for education by (the) end of day. (Administrator), HWD and MCD will monitor daily to ensure no non-edible items are in centerpieces or within reach of residents. Will ensure all items in resident rooms are locked securely away." However, the plan failed to identify that the resident attempted to eat the styrofoam gingerbread man or identify the behavior of eating non-food items. The plan also failed to contain the fact that Resident #9 required a mechanical soft diet, and by the residence adding edible centerpieces to the dining room tables still failed to protect the resident from the immediate risk of choking. On 12/10/24 at 3:03 p.m., the administrator submitted written evidence that read in pertinent part: "Resident attempted to eat a Styrofoam gingerbread, was seen trying to put in her mouth and was removed prior to swallowing. The (residence) will only use centerpieces and décor that does not present a choking hazard for residents in (SE)." However, the plan failed to contain how the direct-care staff would monitor the residents and the interventions the residence planned to implement. Further, the plan failed to include the assessed safety of residents having access to their hygiene products. On 12/10/24 at 4:06 p.m., the administrator submitted written evidence that read in pertinent part that the residence increased monitoring to four times daily for residents identified as a risk for attempting to place non-edible items in their mouths and document it accordingly. 5. Additionally, the residence demonstrated similar deficient practice with Resident #10.”

“Based on observation and interview, the residence failed to ensure the administrator completed 40 hours of training as required, affecting 116 current residents.On 12/11/24, documentation of the administrator's 40-hours of administrator training was requested but not provided.On 12/11/24 at 8:15 a.m., the administrator stated that she had not completed the required 40-hour administrator training. She added that she had a waiver for the training since she was a nursing home administrator. However, she stated she was unable to provide the waiver. She stated that nursing facilities and assisted living residences had different regulatory requirements. On 12/11/24 at 8:17 a.m., the regional nurse stated that the waiver that the administrator spoke of did not waive the required training.”

“Based on observation, interview, and record review, the residence failed to investigate an allegation of abuse in accordance with the residence's written policy, affecting 116 current residents. (Cross-reference S640)Findings include:1. Residence PolicyThe residence's Resident Abuse Prevention policy, dated 8/8/17, read in part that the residence investigated all allegations of abuse and that the residence followed up on each allegation with documented interventions to prevent reoccurrence and assure the protection of all residents. 2. Record ReviewDocumentation of an investigation of abuse, dated 10/5/23, read that an external service provider (ESP) for Resident #2 noticed a bruise on the resident's inner thigh. When the resident was asked how it occurred, she stated, "The large black lady was rough with me." The residence completed an abuse investigation. The resident later reported that she was not sure who the staff member was, could not elaborate on the "rough treatment," was not fearful, and was only able to identify the staff member as being African-American. Therefore, the residence determined that the resident sustained a bruise while transferring and put interventions in place to address that risk; however, the residence determined that since no staff was identified, there was no staff suspended. The residence failed to provide any additional investigations for October 2023.Former Resident #13 was admitted on 1/27/23 with a diagnosis of chronic pain. A task sheet, dated 10/16/23-10/17/23, read in part that Staff #1 assisted Former Resident #13 with dressing assistance and toileting/incontinence care during the overnight shift.A report from law enforcement (LE), dated 10/18/23, read in part that LE was investigating a crime against at-risk adults - assault in the third degree. On 10/17/23 at 3:27 p.m., LE arrived at the residence and met with Former Resident #13. The resident reported that on 10/16/23 at approximately 12:00 a.m., a current female staff pulled his undergarment up so hard that his testicles were outside of the undergarment through the leg holes. He added he believed the staff member did this intentionally to cause pain, which it did. The resident identified his pain level to be seven on a scale from one to 10. He added that there was no reason for the staff member to pull the undergarment up so harshly as he was not falling or unsteady on his feet. The resident identified the staff member as a black woman with dark skin and identified her as a regular staff member who had worked at the residence and was familiar to him. LE spoke with the health and wellness director (HWD). The HWD reported that the resident was developing memory issues. She added that the resident had reported the allegation to her earlier in the day; however, the details were slightly different. The HWD stated that two staff members worked at the residence at approximately 12:00 a.m. on 10/16/24, and one of them (Staff #1) met the description provided by the resident. She added that Staff #1 was familiar to the resident. LE spoke with Staff #1 briefly; however, due to Staff #1's accent and language barrier, LE did not obtain a complete statement. Staff #1 stated to LE that she worked on 10/16/23 at approximately 12:00 a.m. and that Former Resident #13 was angry with staff regarding a shower. Staff #1 stated that the resident was in a foul mood, so she left the resident's door open all night so that staff could check on him. ESP notes, dated 10/26/24, read that Former Resident #13 felt more empowered regarding voicing concerns since he reported the abuse allegation to LE and that an adult protective services (APS) caseworker was assigned. 2. InterviewsOn 12/10/24 at approximately 2:30 p.m., Resident #6 stated that Staff #1 did not listen to her about the care that she needed. She stated that Staff #1 did what she wanted to do rather than listening to what Resident #6 needed and that Staff #1 treated Resident #6 as though she was not smart. Resident #6 stated that she felt that Staff #1 was there for herself rather than to help Resident #6. On 12/10/24 at 3:32 p.m., the ESP for Former Resident #12 stated that the resident reported an abuse allegation to her in October 2023. The ESP stated that the resident reported a black female staff member who worked at night intentionally pulled his incontinence product up so far that it caused him pain in his genital area. The ESP stated she reported the allegation to the HWD; however, she was not aware of any action from the residence regarding the concern. On 12/10/24 and 12/11/24, during the onsite visit, Confidential Staff #9-#13 were interviewed. The staff members stated that Staff #1 had a history of being rude and confrontational to the residents or failing to treat them with dignity, such as directing residents to "sit their butts down." The staff members stated that Staff #1 failed to listen to residents' care concerns or requests, resulting in residents' discomfort. The staff members said that when Staff #1 did not like a resident, she intentionally did things that the resident did not like, such as turning a resident's fan on and off when the resident did not want the fan adjusted or removing a dinner plate before a resident was done eating the meal. They stated when questioned by staff, Staff #1 replied, "it is my word against his." The staff members stated that Staff #1 changed residents' clothing and undergarments even when the resident refused or did not need to be changed and had a history of being rough when providing hands-on care. The staff members stated that the physical description provided by Resident #2 and Former Resident #13 met the physical description of Staff #1. Further, Confidential Staff #12 stated that Staff #1 did not like Former Resident #13, and the resident often expressed anger toward the staff member. They added that in October 2023, Staff #1 was the only black female staff member who worked during evening or overnight shifts. On 12/11/24 at 12:08 p.m., the administrator stated that the residence did not investigate an allegation of abuse lodged by Former Resident #13, as she was not aware of the allegation. She stated she did not know that LE visited the residence on 10/18/23 and interviewed the resident, the HWD, and Staff #1. The administrator stated that Staff #1 met the physical description provided by Resident #2 and Former Resident #13. She stated that the residence should have investigated the allegation of abuse. On 12/11/24 at 12:15 p.m., the HWD stated she did not recall Former Resident #13 alleging a staff member abused him. She added she did not remember LE interviewing her at the residence on 10/18/23 regarding the allegations. The HWD stated that the residence should have investigated the allegation of abuse. On 12/11/24 at 2:33 p.m., the regional nurse stated she "did not have a good feeling about Staff #1. She felt that Staff #1 "used her language barrier to justify her behavior."3. ObservationOn 12/11/24 at approximately 2:30 p.m., the memory care director (MCD) walked in the hallway with Staff #1. Staff #1 asked the MCD, "What is wrong now?" The MCD stated that the administrator wanted to talk with her in her office. Staff #1 raised her voice and again asked what this was about; she looked angry.”

“Based on observation, interview, and record review, the residence failed to ensure each staff member received orientation and training prior to providing any care services to a resident for one sample staff (#1), affecting 116 current residents. (Cross-reference S1410)Findings include: On 12/11/24 at 2:00 p.m., Staff #1 arrived at the residence to work in the secure environment (SE).A personnel file for Staff #1 read that the residence hired her on 6/1/19. The file contained no documentation that the staff member completed an orientation, including all required topics such as reporting requirements, occurrence reporting procedures, or resident rights.The November 2024 staff schedule read that Staff #1 worked at the residence in the assisted living area on 11/1-11/5,11/7-11/12, 11/14-11/19, 11/21-11/26, and 11/28-12/1/24. The December 2024 schedule read that Staff #1 was scheduled to work in the SE on 12/11/24. On 12/11/24 at 2:03 p.m., the administrator stated that the residence had documented training on a few topics; however, they were not the required topics for orientation. She added that Staff #1 had worked at the residence for four or five years, providing care to the residents.”

“Based on observation and interview, the residence failed to make available, either directly or indirectly, a physically safe environment, affecting 25 current residents in the secure environment (SE). Findings include:The residence's undated Orientation and Policy training document read that all staff were trained to maintain a safe, healthy environment.On 12/11/24, the actuator on the screen door that led from the SE to the outdoor smoking area was loose and sticking out of the door approximately one foot above the ground. This presented a hazard to residents who would go outdoors.On 12/11/24 at 3:56 p.m., Staff #10 stated that the actuator for the screen door broke some time in the summer of 2024. Additionally, Staff #10 mentioned that several residents utilized the outdoor space and expressed concern that the broken actuator could potentially cause an injury and was a hazard.”