The resident's representative was driving to the facility to visit and submit additional grievances when she received the call that Resident #1 had passed away. As of the inspection date, she still had not received any response about her filed complaints.
Three different administrators pointed fingers at each other about who was supposed to handle the grievance response.
The Director of Nursing told inspectors she received the grievance and started investigating, but then had to leave for surgery. She said she handed the case off to the Assistant Director of Nursing but never followed up on whether the family had been contacted.
"She stated as of [the inspection date] she had not followed up with a resolution call to Resident #1's RP," inspectors wrote.
The DON admitted she had completed her investigation into the family's concerns but failed to communicate any findings back to the grieving family member.
When inspectors interviewed the Assistant Director of Nursing, she said she never received the task of completing the grievance from the DON. She claimed she didn't know the DON had started investigating and wasn't aware she needed to keep the family updated.
"She stated she thought it was the DON or SW that would contact resident's RP," according to the inspection report.
The social worker told inspectors she attempted to contact the family member to discuss the grievance, but couldn't remember what days she tried calling. She didn't document her attempt to contact the family and couldn't recall if she left a voicemail message.
"She stated as of [the inspection date] she had not updated Resident #1's RP about resolution of the grievances she filed," inspectors found.
The social worker said she thought she tried calling on the same day she saw the grievance, but provided no documentation of any outreach efforts.
All three staff members acknowledged their roles in the communication breakdown. The DON told inspectors that either she, the ADON, or the social worker were responsible for providing progress updates to residents and family members about grievance investigations.
The facility's own policy, implemented and revised earlier this year, explicitly states that residents have the right to voice grievances about care, treatment, staff behavior, and other concerns regarding their stay. The policy requires the facility to make "prompt efforts" to resolve such complaints.
But none of the administrators could explain why the family never received a single phone call about their concerns.
The DON admitted to inspectors that "they had failed to keep Resident #1's RP apprise of the findings and resolutions of investigation regarding her grievance."
The breakdown occurred despite clear facility policies outlining grievance procedures. The policy states residents have the right to voice complaints "without discrimination or reprisal" about care that has been furnished, care that hasn't been provided, staff behavior, and other facility concerns.
Federal inspectors cited the facility for failing to ensure residents can voice grievances and receive prompt resolution efforts, as required by federal regulations governing nursing home operations.
The violation received a "minimal harm" rating, affecting few residents. But for the family member who filed the grievances, the failure meant never receiving answers about their loved one's care before it was too late to matter.
The resident's representative had been concerned enough about the quality of care to file formal grievances with facility management. She was prepared to file additional complaints on the day she learned of the resident's death.
Instead of receiving the prompt response promised by facility policy, she encountered a system where three different administrators each assumed someone else would handle the family's concerns.
The inspection found that Bear Creek Nursing's grievance process broke down at multiple points, leaving a grieving family member without answers about the care their loved one received in their final days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bear Creek Nursing and Rehabilitation from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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