Bear Creek Nursing And Rehabilitation

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #1 passed away. She stated she was in route to the facility to visit Resident #1 and submit the grievance when she go the call she had passed away. She stated as of [DATE REDACTED] she had still not received a call from the facility about her filed grievances. In an interview with the DON on [DATE REDACTED] at 2:11 PM, she stated the SW received all grievances. She revealed the SW received the grievance form from Resident #1's RP on [DATE REDACTED]. She also revealed she received Resident #1's RP, filed grievances and started investigating. The DON stated shortly after she started her investigation, she had to go out for surgery and handed it off the ADON. She stated she did not know how far the ADON had gotten into the grievance process. The DON stated as of [DATE REDACTED] she had not followed up with a resolution call to Resident #1's RP.

She stated she had completed the investigations into the filed concerns in the grievance. The DON stated it was the responsibility of the DON or ADON to investigate any concern that dealt with the nursing side. She stated she, ADON or SW were responsible for providing an update of progress to a resident, a resident's RP or family member. She stated she thought the call to Resident #1's RP was completed by ADON or SW while she was on leave. In an interview on [DATE REDACTED] at 2:45 PM, the SW stated she attempted to contact Resident #1's RP to discuss the grievance. SW stated she did not document the attempt to contact. The SW also stated she did not remember if she left a message on the Resident #1's RP voicemail. She stated

she did not know what days she attempted to contact the resident's RP, but she felt it was the same day

she saw the grievance. She stated as of [DATE REDACTED] she had not updated Resident #1's RP about resolution of

the grievances she filed. In an interview on [DATE REDACTED] at 4:06 PM, the ADON stated she had not investigated

the concerns in the grievance submitted by Resident #1's RP. She stated she knew the DON had started investigating but was not aware of how far she had gotten. She stated she had not received the task of completing the grievance from the DON. She stated she was not aware that she had to keep Resident #1's RP apprised of the resolution. She stated she thought it was the DON or SW that would contact resident's RP. The DON stated they had failed to keep Resident #1's RP apprise of the findings and resolutions of investigation regarding her grievance. Record review of the facility's policy, implemented and revised on [DATE REDACTED], titled Resident Rights, reflected in part the following: 9. Grievances. The resident has the right to: a.

Voice grievances to the facility or other agency or entity that hears grievances without discriminationor reprisal. Such grievances include those with respect to care and treatment which has been furnishedas well as that which has not been furnished; and the behavior of staff and of other residents; andother concerns regarding their LTC facility stay.b. The resident has the right to and the facility must make prompt efforts by

the facility to resolve

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bear Creek Nursing and Rehabilitation

3729 Ira E Woods Avenue Grapevine, TX 76051

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to get the medications. Resident #1's friend stated shortly after LVN B went into Resident #1's room and retrieved the medications. Resident #1's friend also stated that LVN B told her she would check the computer to find out which pills it was. Resident #1's friend stated LVN B came back into the room and informed her it was Resident #1's Protonix (treat conditions that cause too much stomach acid) and Labetalol HCl (lower high blood pressure). She stated the LVN told her one was for Resident #1's stomach and the other for the resident's blood pressure. She stated the LVN stated the resident record showed she had taken two medications in the morning and did not want to give it to her if she had already taken them.

Resident #1's friend stated LVN B stated she would document the medications on the floor in the system.

Resident #1's friend stated she did not know how long it had been on the floor and was concerned.

Interview with LVN B, she stated she had worked for agency. She stated she worked with Resident #1 on [DATE REDACTED] on 2nd shift. She stated she worked from 2:00pm-10:00pm. LVN B stated Resident #1's friend came out and got her from the nurse's station. She stated it was shortly after she got on shift that day. She stated

she and Resident #1's friend went back to the resident's room where two pills lay on the tray table. LVN B stated she picked up the two pills and took them to the nurse's station to investigate. She stated she found that it was Resident #1's Protonix and Labetalol HCI. LVN B stated she went back to Resident #1's room and informed resident's friend of her findings. She stated it was two pills that Resident #1 took in the morning. LVN B revealed it had shown on the MARs the medications were given to the resident, so she did not want to double her more pills. LVN B stated she checked Resident #1's blood pressure which was good.

The LVN stated she told resident's friend she would give her the evening medications. LVN B stated she reported it to the DON or the ADON but she was not aware of who it was as she spoke to the person over

the phone. She stated she was told to document it on the 24-hour log report. She stated she documented

the incident in the 24-hour report and later administered Resident #1's evening medications. In an interview with DON on [DATE REDACTED] at 2:11 PM, she stated she was made aware that Resident #1's friend told one of her nurse's she had found two pills on the resident's floor. She stated she started an investigation to investigate how the pills got on the floor. She stated her belief was maybe the nurse tried to throw the pills in the trash.

The DON stated her staff was not aware of any medication being on Resident #1's floor until it was brought to their attention by the resident's friend. In an interview with ADON on [DATE REDACTED] at 4:06 PM, she stated Resident #1's friend told one of the nurse's she had found some medication at the resident's bedside. She stated she spoke with the nurse and told her to document and assess the resident. Record review of 24-hour report book did not have any documentation 24-hour report of Resident #1's medications on the floor. Record review of the facility's policy, implemented and revised on [DATE REDACTED], titled Destruction of Unused Drugs, reflected in part the following: Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements).

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If continuation sheet