Cycle 1
Health 2024-10-17 · Fire 2024-10-17
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
De Queen, AR
Bear Creek Healthcare LLC
4-star overall rating with 4-star inspections with 3 recent health deficiencies
322 West Collin Raye Drive, De Queen, AR
(870) 642-3562
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
4.71
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,351
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 61.91% · Performance 73.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
6.64
Baseline 3.92 hours · Performance 4.97 hours · Measure score 6.64 · Achievement 6.64 · Improvement 5.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 6.37% |
| Discharge to community | 31.81% |
50.57%
18.8 pts worse
|
Worse than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 18.72% |
| Medicare spending per beneficiary | 1.55 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 27 · Denominator 28 |
| Falls with major injury | 3.57% |
0.77%
2.8 pts worse
|
Numerator 1 · Denominator 28 |
| Discharge self-care score | 52.38% |
53.69%
1.3 pts worse
|
Numerator 11 · Denominator 21 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 9 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 4.54% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.32% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 76 |
| Staff flu vaccination coverage | 98.89% |
42%
56.9 pts better
|
Numerator 89 · Denominator 90 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 9 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.2 |
2.2
3 pts worse
|
1.8
3.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 4.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
94.9%
3.9 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 85.1% · Q3 95.7% · Q4 93.8% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
96.1%
2.1 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
3.9%
4.6 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 6.4% · Q3 10.6% · Q4 8.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
1.4%
1.5 pts worse
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 4.7% · Q4 4.4% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
4.9%
0.1 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.1% · Q3 2.7% · Q4 5.6% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
21.8%
1 pts worse
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 26.5% · Q3 18.9% · Q4 23.7% · 4Q avg 22.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
12.5%
1.7 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 25.0% · Q3 3.7% · Q4 0.0% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.5% |
11.4%
5.9 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
10.4%
0.3 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.1% · Q3 19.4% · Q4 8.6% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.1%
About the same
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.8% |
14.6%
6.8 pts better
|
19.8%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 11.1% · Q3 9.8% · Q4 4.2% · 4Q avg 7.8% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.6%
2.1 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.4% · Q3 2.5% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.7% |
81.8%
20.1 pts worse
|
81.7%
20 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 55.6% · Q3 69.7% · Q4 71.4% · 4Q avg 61.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
13.8%
4.9 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.3% |
77.9%
18.6 pts worse
|
79.7%
20.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
25.2%
4.5 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 22.7% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-12-21 · Fire 2023-12-21
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-06-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-06-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-06
F · Potential for more than minimal harm
2023-12-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-01-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-06-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-18
F · Potential for more than minimal harm
2023-12-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-19
Penalties and ownership
What sits behind the stars
Ownership
Parsons, Cathy
5% Or Greater Direct Ownership Interest · Individual
Parsons, Cathy
W-2 Managing Employee · Individual
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