CENTERTON, AR - Federal inspectors cited Apple Creek Health and Rehab for immediate jeopardy violations following a complaint investigation that revealed multiple safety protocol failures resulting in resident injuries and placing vulnerable patients at serious risk.
Mechanical Lift Accident Causes Multiple Injuries
The most serious incident involved Resident #62, who experienced multiple skin tears after falling from a mechanical patient lift on December 3, 2024. The 74-year-old resident, who had diagnoses including cachexia, pulmonary hypertension, and chronic obstructive pulmonary disease, was completely dependent on staff for transfers and positioning.
According to the facility's incident report, two certified nursing assistants were using the mechanical lift to weigh the resident when they failed to secure one of the lift sling loops. This critical oversight caused the resident to slide out of the lift, resulting in three minor skin tear injuries.
The resident's cognitive impairment, documented with a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment, made them particularly vulnerable to such accidents. The facility's own care plan specified that this resident required limited assistance for transfers and was at risk for falls.
Unauthorized Transfer Results in Fall
In a separate incident on November 12, 2024, Resident #81 experienced a fall when two CNAs attempted to transfer them without using the required mechanical lift. The resident, who had been diagnosed with metabolic encephalopathy, muscle weakness, and diabetes, was dependent on staff for bed mobility and transfers.
"At the time they fell, the two CNAs knew she didn't like to be transferred with the mechanical lift, so they attempted to transfer without it, after becoming weak she had fallen on her knees," Resident #81 told inspectors during the investigation.
The resident's care plan explicitly required a mechanical lift with assistance of two staff for all transfers. This deviation from established protocols directly contributed to the fall and injury.
Gait Belt Safety Protocols Ignored
Inspectors documented another serious safety violation involving Resident #148, who fell during an assisted bathroom transfer when staff failed to use a required gait belt. The incident occurred on November 13, 2024, when a CNA attempted to assist the cognitively intact resident without following established safety protocols.
According to witness statements, the resident specifically told nursing staff about the importance of using safety equipment. "CNA #5 is so big and strong, I always remind him that I am old and slow because he will just pick me up," the resident explained to investigators.
The facility's own policy mandated that gait belts be utilized for any resident transfers or ambulation requiring assistance. The resident's care plan specifically required one-person assistance with a gait belt for all transfers.
Critical Safety Equipment Requirements
Mechanical lifts and gait belts serve essential safety functions in nursing home care. Mechanical lifts distribute a resident's weight evenly and provide controlled movement for individuals who cannot bear their own weight or have limited mobility. When sling loops are not properly secured, the entire safety system fails, creating an immediate fall risk.
Gait belts provide caregivers with a secure grip point during transfers and ambulation, allowing for better control and support of residents with mobility limitations. These devices are particularly crucial for residents with balance issues, weakness, or cognitive impairment who may not be able to communicate their needs clearly during transfers.
Dysphagia Care Protocol Violations
Inspectors also identified dangerous lapses in dysphagia care protocols. Resident #300, who had been diagnosed with oropharyngeal dysphagia and ordered a pureed diet with no straws, was repeatedly provided drinks with straws despite clear medical contraindications.
Multiple observations over three days documented straws in the resident's beverages. On January 6, 2024, straws were observed in drinks on the resident's bedside table. Follow-up observations on January 7 and 8 showed continued violations, with all three cups containing straws despite the medical prohibition.
Dysphagia, or difficulty swallowing, significantly increases choking risk. Straws can alter the flow rate and direction of liquids, making swallowing more difficult for affected patients. Speech-language pathologists assess swallowing function and recommend specific modifications to reduce aspiration risk, making adherence to these protocols critical for patient safety.
Staff Knowledge and Training Gaps
CNAs interviewed during the investigation acknowledged understanding the importance of following care plans but demonstrated gaps in consistent implementation. One CNA confirmed that residents with dysphagia should not receive straws due to choking hazards, yet the violations continued despite this knowledge.
The facility had provided relevant training, including in-services on transferring with gait belts, abuse and neglect prevention, and the importance of following care plans. However, the documented violations suggest implementation failures despite adequate educational opportunities.
Regulatory Standards and Expectations
Federal regulations require nursing homes to provide care that maintains or improves each resident's quality of life, health, and safety. Facilities must develop individualized care plans based on comprehensive assessments and ensure staff follow these plans consistently.
The immediate jeopardy designation indicates that the facility's actions created a situation where serious injury, harm, impairment, or death was likely to occur without immediate intervention. This classification triggers enhanced oversight and requires immediate corrective measures.
Facility Response and Oversight
The inspection report documented that facility administrators conducted their own investigations into reported incidents and provided additional staff education following violations. In-services were conducted on November 13, 2024, emphasizing the importance of following care plans and proper transfer techniques.
The facility's policy documentation showed awareness of safety requirements, including detailed procedures for gait belt use and transfer protocols. However, the gap between written policies and actual practice created dangerous conditions for vulnerable residents.
This case highlights the critical importance of consistent protocol adherence in nursing home settings, where residents' safety depends entirely on staff following established care procedures designed to prevent foreseeable accidents and injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Apple Creek Health and Rehab, LLC from 2025-01-09 including all violations, facility responses, and corrective action plans.
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