Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Creek Healthcare Llc during CMS and state inspections, most recent first.
A resident with dementia, anxiety, depression, and on hospice had a Durable Power of Attorney, Living Will, and signed DNR order all specifying no CPR, and the face sheet reflected no CPR; however, physician orders, a MD progress note, and the MAR repeatedly listed the resident as full code from admission onward. Nursing staff and leadership (including a RN, LPN, ADON, DON, and the Administrator) acknowledged that while the advance directives and resuscitate/DNR form showed DNR status, the active orders and MAR still indicated full code, even though staff commonly rely on these documents to determine code status, contrary to facility policy requiring alignment of the care plan and physician orders with the resident’s documented treatment preferences.
A facility failed to update care plans for three residents after incidents occurred, including a bruise, a fall, an infection, and a skin tear. The DON confirmed the absence of a policy for care plan revisions, and a misunderstanding between the RN and MDS Coordinator led to the failure to update care plans within the expected timeframe.
The facility failed to follow recipes for pureed foods, using water instead of recommended liquids like broth or gravy, which diminished the nutritional value for residents on pureed diets. Both the staff member and the Dietary Supervisor confirmed the error, acknowledging that water should not have been used.
A resident with anxiety disorder was prescribed an anti-anxiety medication with a telephone order for twice daily administration. However, the facility's records showed a different dosage of three times a day, which was not clarified. The DON confirmed the absence of a policy for processing physician's orders, and an LPN acknowledged the need for clarification. This led to a failure in accurately following the physician's orders.
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency, posing a choking hazard for residents on pureed diets. The Dietary Supervisor confirmed the inadequacy of the pureed chicken and sausage served during two observed meals.
The facility failed to follow proper food storage, handling, and hygiene practices, and did not maintain a pest-free kitchen. Opened bottles of soy sauce and lime juice were not refrigerated, expired salad dressings were found, and cold food items were not kept at the required temperature. Dietary staff did not wash hands or change gloves after handling dirty objects, and live roaches were observed in the kitchen.
The facility failed to accurately document a resident's serious mental illness in the MDS, despite having a Level II PASRR evaluation. This discrepancy was identified during a survey, where the MDS nurse initially denied but later confirmed the presence of a Level II PASRR. The facility lacked a specific MDS policy, affecting the care of six residents with similar evaluations.
The facility failed to administer oxygen at the physician-ordered rate for a resident with COPD, who was observed receiving 3.5 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by an LPN and the DON, highlighting a failure to adhere to the facility's oxygen administration policy.
A facility failed to ensure proper hand hygiene during peri care for a resident with severe cognitive impairment. A CNA used the same hand to pull out clean wipes and perform peri care without changing gloves or performing hand hygiene, then continued to handle the resident's draw sheet, clean brief, and applied lotion without proper hand hygiene. The facility lacks a specific peri care policy.
Inconsistent Documentation of DNR Status in Medical Record
Penalty
Summary
The facility failed to ensure that one resident’s medical record accurately and consistently reflected the resident’s advance directive specifying no Cardiopulmonary Resuscitation (CPR). The resident had non-Alzheimer’s dementia, anxiety, depression, moderate impairment in decision-making, and was receiving hospice services. Documentation in the record included a Durable Power of Attorney for Health Care, a Living Will Declaration, and a Resuscitate/Do Not Resuscitate order, all indicating that CPR and chest compressions were to be withheld and that the resident was a Do Not Resuscitate (DNR). The resident’s face sheet also indicated an advance directive for no CPR. Despite these documents, multiple parts of the electronic health record and physician documentation identified the resident as a full code. Physician’s orders from admission onward, including after the resident was admitted to hospice, contained orders indicating full code status. A MD progress note also documented the resident as a full code, and the Medication Administration Record (MAR) for the reviewed period listed the resident as full code. These entries conflicted with the existing DNR orders and advance directive documents in the record. Interviews with nursing staff and leadership confirmed awareness of the discrepancy between the resident’s documented advance directives and the active physician orders and MAR entries. A RN, an LPN, the ADON, the DON, and the Administrator each acknowledged that the resident’s advance directives and resuscitate/do not resuscitate order indicated DNR status, while the current physician orders and MAR showed full code. Staff stated that code status is typically verified using the medical record, MAR, and face sheet, and they recognized that the inconsistency meant staff could rely on incorrect information about whether to initiate CPR. Facility policy required that advanced directives be respected, that the plan of care be consistent with documented treatment preferences, and that the physician be notified so appropriate orders could be documented in the medical record and care plan, which did not occur in this case.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to ensure that care plans were updated to include interventions for incidents involving three residents. The Director of Nursing (DON) confirmed that the facility did not have a policy for care plan revisions. Resident #16, who was cognitively intact, experienced two incidents: a bruise on the toe and a fall from the bed. Despite these incidents, the care plan was not updated to include interventions to prevent recurrence. Similarly, Resident #18, who had severe cognitive impairment, developed an infection on the right forefinger, but the care plan was not updated to include the infection or the prescribed treatment. Resident #27, who was severely impaired for daily decision-making, suffered a skin tear while using a wheelchair. The care plan did not include the incident or the intervention for a larger, safer chair requested from hospice. The MDS Coordinator confirmed that the care plans for these residents were not updated with the necessary interventions following the incidents. The DON stated that incidents and infections were reviewed in morning meetings, and the RN was responsible for updating the care plans, which was not done. Interviews with the MDS Coordinator and RN revealed a misunderstanding regarding the responsibility for updating care plans. The RN believed that the MDS Coordinator would handle the updates, while the MDS Coordinator expected the RN to do so. This miscommunication resulted in the failure to update care plans within the expected 24-hour timeframe after incidents occurred, as confirmed by the DON.
Improper Pureeing Technique Reduces Nutritional Value
Penalty
Summary
The facility failed to adhere to the prescribed recipes for pureed foods, which resulted in a deficiency in maintaining the nutritional value for four residents on pureed diets. During an observation, it was noted that the staff member responsible for preparing pureed meals used water to thin the food mixtures, specifically for chicken fried steak and rolls. The recipes explicitly stated that water should not be used as it diminishes the nutritional content and flavor of the food. Instead, alternatives such as broth, milk, gravy, or sauce were recommended to enhance both nutrition and taste. Upon review, both the staff member and the Dietary Supervisor acknowledged the error, confirming that water should not have been used. The Dietary Supervisor reiterated that using water reduces the nutritional value and flavor of the meals, which could have been preserved by using the recommended liquids. This oversight affected the dietary intake of the residents receiving pureed foods, potentially impacting their nutritional status.
Failure to Follow Physician Orders for Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that physician orders were followed as written for a resident with anxiety disorder, muscle spasm, and bipolar disorder. The resident was prescribed an anti-anxiety medication, with a telephone order indicating a dosage of 0.5 mg to be administered twice a day. However, the physician's orders for October showed a different dosage of 0.5 mg three times a day, which was not consistent with the original telephone order. This discrepancy was not clarified, leading to a failure in accurately following the physician's orders. The Director of Nursing (DON) confirmed that the facility did not have a policy for processing physician's orders, and the Licensed Practical Nurse (LPN) acknowledged that the order should have been clarified when the twice-a-day dosage was crossed out on the Medication Administration Record (MAR). The process described by the DON involved writing the order, faxing it to the pharmacy, and entering it into the electronic system, but it was not followed correctly, resulting in the inconsistency. The lack of a clear policy and failure to clarify the order contributed to the deficiency.
Improperly Blended Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During an observation on 6/03/24 at 12:05 PM, residents on pureed diets were served pureed chicken that was gritty and not smooth. The Dietary Supervisor confirmed that the pureed chicken was gritty and could be a choking hazard. Similarly, on 06/05/24 at 7:40 AM, pureed sausage served to residents for breakfast was also gritty and had water in it. The Dietary Supervisor acknowledged that the pureed sausage was not properly blended and needed more consistency.
Food Storage, Handling, and Pest Control Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage, handling, and hygiene practices, as well as maintaining a pest-free kitchen environment. Observations revealed that opened bottles of soy sauce and lime juice were not refrigerated as per manufacturer specifications. Expired Italian salad dressings were found in the dining area, and cold food items such as tuna salad were not maintained at the required temperature of 41 degrees Fahrenheit or below. Additionally, dietary staff were observed not washing their hands or changing gloves after handling dirty objects and before handling clean equipment or food items, leading to potential contamination of food served to residents. Specifically, a dietary cook handled dirty dishes and then clean dishes without washing her hands, and another dietary aide handled various items and then clean glasses without changing gloves or washing hands. The facility also failed to maintain a pest-free kitchen environment. Pest control records indicated the presence of German roaches, and live roaches were observed falling from a recipe book. These deficiencies were observed during meal preparation and service, affecting the quality and safety of food provided to 52 residents. The facility's policy on handwashing was not followed, contributing to the risk of contamination and potential health hazards for the residents.
Inaccurate MDS Documentation for Resident with Level II PASRR
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the preadmission screening and assessment resident record (PASRR) for a resident with a serious mental illness and/or intellectual disability. Specifically, Resident #24, who had diagnoses of Vascular Dementia, Parkinson's, and altered mental status, was not correctly documented in section A1500 of the MDS. The resident's annual MDS indicated no mental health diagnoses, despite having a Level II PASRR evaluation that identified a serious mental illness. This discrepancy was observed during a survey, where the MDS nurse initially denied the presence of a Level II PASRR for Resident #24 but later confirmed it upon review. The MDS nurse acknowledged the importance of accurate MDS coding for ensuring appropriate care and referenced the Resident Assessment Instrument (RAI) manual for guidance. The surveyor's review revealed that the facility did not have a specific MDS policy in place. The Assistant Administrator and the MDS nurse were asked to provide documentation from the RAI manual concerning section A1500, which was eventually provided. The failure to accurately document the resident's mental health status in the MDS had the potential to affect six residents with a Level II PASRR. This deficiency highlights a significant lapse in the facility's assessment and documentation processes, which are crucial for delivering appropriate care to residents with serious mental illnesses or intellectual disabilities.
Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-ordered rate for Resident #156, who has a diagnosis of chronic obstructive pulmonary disease (COPD). The physician's order specified that oxygen should be administered at 2 liters per minute via nasal cannula as needed for shortness of breath. However, observations on multiple occasions revealed that the resident was receiving 3.5 liters per minute. This discrepancy was confirmed by Licensed Practical Nurse (LPN) #3, who acknowledged that the oxygen should have been set at 2 liters per minute as per the physician's order. The Director of Nursing (DON) also confirmed that nursing staff are responsible for checking the oxygen rate with every medication pass and whenever walking down the hall. The deficiency was further highlighted when the Assistant Administrator provided the facility's oxygen administration policy, which clearly stated that the flow meter should be set to the rate ordered by the physician and checked at regular intervals. Despite this policy, the resident's oxygen was not set correctly, and the staff failed to monitor and adjust the oxygen rate as required. This failure had the potential to affect other residents with oxygen orders, as the facility did not adhere to its own procedures for ensuring safe and appropriate respiratory care.
Failure to Ensure Proper Hand Hygiene During Peri Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during peri care for Resident #11, who has severe cognitive impairment and requires total assistance with all activities of daily living. On 06/03/2024, a surveyor observed a CNA using the same hand to pull out clean wipes and perform peri care without changing gloves or performing hand hygiene. The CNA then continued to handle the resident's draw sheet, clean brief, and applied lotion without proper hand hygiene, only washing hands at the sink after completing the care. The CNA admitted to not following proper hand hygiene procedures during an interview. The facility's policy on hand hygiene, provided by the Dietary Manager, states that hands should be washed after touching anything that may contaminate them. The Director of Nursing confirmed that it is not standard practice to go back and forth from clean to dirty without performing hand hygiene. Additionally, the Assistant Administrator confirmed that the facility does not have a specific peri care policy. This deficiency had the potential to affect other residents requiring peri care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near De Queen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dierks Health And Rehab Of Dierks | 19 mi | ★★★★★ | 0 | 0 |
| Broken Bow Health And Rehab | 23.1 mi | ★★★★★ | 7 | 1 |
| Little River Nursing & Rehab | 28.5 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Nashville Rehab And Nursing Center | 28.5 mi | ★★★★★ | 1 | 0 |
| The Springs Of Mine Creek | 29 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.