Apple Creek Health And Rehab, Llc

F-F689 at a lower severity:

2. A review of Resident # 62's diagnosis list indicated diagnoses of cachexia (wasting syndrome), pulmonary hypertension, anemia and chronic obstructive pulmonary disease.

The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/04/2024 documented Resident #62 had a brief interview of mental status (BIMS) of 11, indicating a moderately impaired cognitive status, and was dependent on staff for toileting, bathing, turning, positioning, and transfers and was non-ambulatory. The MDS revealed one fall with a minor injury.

Resident #62's care plan with a revision date of 06/11/2023 documented the resident required limited assistance of one staff to move between surfaces and was at risk for falls.

An OLTC Incident and Accident Report (I&A), dated 12/03/2024, indicated Resident #62 had sustained a fall from a mechanical patient lift on 12/03/2024 at 3:04 PM when two certified nursing assistants (CNAs), when using the mechanical lift to weight the resident had failed to secure one of the lift sling loops to the mechanical lift, allowing resident to slide out. This fall resulted in 3 minor skin tear injuries

On 01/07/2024 at 4:16 PM, Certified Nursing Assistant (CNA) #5 related how she and another CNA were using a mechanical patient lift to weigh Resident #62, and when they elevated resident and moved lift to get

an accurate weight, one of the loops that secures lift pad was not secured and the resident slid out of lift pad.

3. A review of Resident #81's diagnosis list revealed diagnoses of metabolic encephalopathy, muscle weakness, and type 2 diabetes.

A quarterly MDS with an ARD of 11/05/2024 indicated Resident #81 had a BIMS of 07, and resident was dependent on staff for bed mobility and transfers.

Resident #81's care plan with a revision date of 07/08/2024 indicated the resident required a mechanical lift with assistance of two staff for transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 045465 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045465 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Apple Creek Health and Rehab, LLC 1570 W Centerton Blvd Centerton, AR 72719

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 0689 On 11/12/2024. a facility incident reported to the office of long-term care indicated Resident #81 had sustained a fall when two CNAs attempted to transfer resident without use of a mechanical lift. Resident Level of Harm - Immediate #81's closet care plan, included in the reportable, indicated resident required a mechanical lift with jeopardy to resident health or assistance of two staff for transfers. safety

On 01/07/2024 at 8:51 AM, Resident #81 said at the time they fell , the two CNAs knew she didn't like to be Residents Affected - Few transferred with the mechanical lift, so they attempted to transfer without it, after becoming weak she had fallen on her knees.

4. A review of the Order Summary indicated Resident #148 had diagnoses that included multiple falls, other abnormalities of gait and mobility, age related osteoporosis, and interstitial pulmonary disease.

A review of a facility policy titled, Gait Belts, Use of, dated 05/01/2016 revealed, Policy: Gait Belts will be utilized for any resident transfers (sit to stand; stand to sit; sit to sit) or for resident ambulation that requires assistance.

The discharge MDS with an ARD of 12/06/2024, revealed Resident #148 had a BIMS score of 15, indicating

the resident was cognitively intact. Section GG is coded 04 (Supervision or touching assistance) for transfers. Section J reveals Resident #148 had one fall with no injury since admission/entry or reentry.

Review of Resident #148's Care Plan, revised on 12/09/2024, revealed the resident had an activity of daily living performance deficit. A revision dated 12/09/2024 on the care plan revealed the resident is a high fall risk, and the resident had an actual fall with no injury on 11/13/2024 with an intervention of staff education.

Review of a Morse Scale and Care Plan Tasks assessment done on 11/13/2024 revealed that Resident #148 scored a 40, which is a moderate fall risk.

Review of a Nsg-Incident and Accident Note done by Administrator on 11/15/2024 revealed, Family Member reported that resident had a fall onto their bed while ambulating back from the bathroom. Family Member stated it was because the CNA was not using a gait belt.

Review of a Witness Statement completed by Registered Nurse #4 on 11/13/2024 revealed, Went to investigate an allegation of reported neglect. Talked with [Resident #148] who stated that [CNA #5] helped them into the bathroom to use the toilet and they stated, the [CNA #5] is so big and strong, I always remind him that I am old and slow because he will just pick me up. Resident #148 continued stating that CNA #5 did not use a gait belt when he took them to the bathroom, and he did not use the gait belt when walking them back from the bathroom back to the wheelchair. Resident #148 stated that CNA #5 was watching television instead of paying attention to them and told them to go ahead and back up to the wheelchair. Resident then told the CNA #5 that they were losing balance and fell back into a seated position on the bed. Resident stated that they sat in a wash basin on the bed. Family Member and Resident #148 felt that CNA #5 was neglectful in care by not using a gait belt and not staying close to the resident. Family Member stated, if the resident fell the other direction, they could have had a head injury or a broken bone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 045465 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045465 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Apple Creek Health and Rehab, LLC 1570 W Centerton Blvd Centerton, AR 72719

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 0689 Review of a Witness Statement done by CNA #5 on 11/13/2024 stated that I transferred the resident without

the gait belt to the bathroom my first thought was to transfer the resident to the bathroom sitting on their Level of Harm - Immediate wheelchair, but family refused. Family member insisted on using the walker instead. Resident walked fine to jeopardy to resident health or the bathroom on the way back to the wheelchair the resident got tired and sat on the side of the bed. They safety did not complain of pain. After the resident grasp their air, I stood the resident up and sat them in the wheelchair which was right next to the bed. Residents Affected - Few

Review of the Closet Care Plan reveals that Resident #148 was a one assist transfer with a gait belt for all transfers.

Review of Competencies revealed that CNA #5 completed return demonstration of transfers and return demonstration of care plans on 07/22/2024.

Review of Office of Long-Term Care (OLTC) Incidents and Accidents Report states Findings and Action Taken: Resident has interstitial pulmonary disorder and requires oxygen .becomes short of breath upon exertion .resident is medically stable without any acute distress and no injuries noted related to incident. The allegation is found on the basis that CNA #5 was not using a gait belt while assisting resident. Resident closet care plan required one person assisted.

Review of an In-service on 11/13/2024 for Closet Care Plan, revealed, Closet care plans are in place for a reason and are to be always followed. If there is not a closet care plan in residents' closet notify the charge nurse or team lead immediately so it can be placed.

Review of an In-service on 06/26/204 and 06/28 2024 on Transferring with a Gait Belt, states 9. Never chicken wing someone-gait belts should be used on all transfers whether one person or two person transfers.

Review of an In-service on 09/18/2024 and 09/20/2024 on Abuse/Neglect, Transfers, Resident Rights/Dignity/Civil Rights and General, revealed the CNA #5 signed off for attending in-services.

On 01/08/2025 at 1:47 PM, the Surveyor had a phone interview with Resident #148 who recounted the incident and stated that I want you to know that CNA #5 was a couple steps behind me watching television when fall occurred, they did not have a hold of me as they did not use a gait belt for transfer.

On 01/08/2025 at 1:53 PM, the Surveyor attempted to call Registered Nurse #4 with no response.

On 01/08/2025 at 1:55 PM, the Surveyor attempted to call CNA #4 with no response.

5. A review of Resident #300's Admission Record revealed the resident had a diagnosis of dysphagia/oropharyngeal phase.

On 01/06/2024 at 10:50am, straws were observed in Resident #300's drinks sitting on the over the bed table.

In an interview with Resident 300's spouse, it was discussed that the closet care plan was not being followed by staff. The closet care plan was observed and indicated resident has difficulty swallowing and has orders for no straws.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 045465 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045465 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Apple Creek Health and Rehab, LLC 1570 W Centerton Blvd Centerton, AR 72719

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 0689 On 01/07/2024 at 8:42am, a drink was observed on Resident 300's over the bed table with a straw in it.

Level of Harm - Immediate On 01/07/2024 at 3:00pm, an observation was made of Resident 300's beverages on the over the bed table. jeopardy to resident health or All three cups had straws in them. safety

On 01/08/2024 at 8:55am, CNA #2 stated that the closet care plan is their resource for knowing what type of Residents Affected - Few care needs the resident requires. CNA #2 confirmed that Resident 300's closet care plan indicates no straws under the liquids portion of the closet care plan. CNA #2 confirmed that resident had straws in his drink on

the over the bed table. CNA #2 confirmed that residents who are ordered no straws should not be given straws as it poses a choking hazard.

On 01/08/2024 at 8:59am, CNA #3 confirmed that the CNA's are instructed to use the closet care plan as a resource guide to provide resident's care. CNA #3 confirmed that it's important not to give straws to residents with a diagnosis of dysphagia or difficulty swallowing, as it poses a choking hazard to them. CNA #3 stated that Resident #300 had difficulty swallowing and the speech therapist had ordered the resident to have no straws.

On 01/08/2024 at 9:07am, the Assistant Dietary Manager (ADM) confirmed that the dietary staff are responsible for fixing the resident's beverages. The ADM stated that the kitchen staff provide straws, but the CNAs who assist in passing meal trays to residents are the ones that get the straws.

A care plan, dated 12/26/2024, indicated that Resident #300 was ordered a pureed diet, has swallowing problems due to dysphagia, and do not use straws. Date initiated was 12/27/2024.

A policy on Accidents and Hazards along with staff in-services were provided by the Administrator. It indicated that staff were educated on the importance of looking at closet care plans.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 045465