Dermott City Nursing Home

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

transferring residents at the facility was that residents with immobility deficits were care planned with how

the transfer should be done. NP #4 stated she knew Resident #1 was care planned for two person-assistance for transfers and her expectation was to have two CNA's to transfer them.

During an interview on 12/23/2025 at 4:45 PM, the Compliance Officer (CO) stated her expectation for staff locating, reviewing and following the resident's Care Plan was if staff did not know how a resident should be transferred, the staff would go to the [facility's electronic computer system] and look at the Care Plan to see how to transfer a resident and what care the resident needed. The CO stated her expectation for resident transfers was for staff to know what kind of transfer was needed, such as if the resident needs the stand-up lift.

Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated that the comprehensive care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

This policy also indicated services provided for or arranged by the facility and outlined in the comprehensive care are provided by qualified persons. This policy revealed care plan interventions are chosen after gathering data, proper sequencing of events, careful consideration of the relationship between

the resident's problem areas and their causes and relevant decision making.

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

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dermott City Nursing Home

702 West Gaines St Dermott, AR 71638

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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

12/22/2025, the DON identified 26 residents, including Resident #1, who required assistance with transfers from mechanical lift with the potential to be affected from the deficient practice, all were assessed with no negative findings by the DON and designee. 6. To ensure the deficient practice does not happen again, beginning 12/22/2025, all licensed nurses and CNAs will be educated to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death, beginning 12/22/2025. 7. Beginning 12/22/2025, the DON/designee will visually monitor residents being transferred, visually monitor licensed nurses and certified nurse assistants on locating, reviewing the plan of care, and implementing the plan of care, also proper steps taken when a resident sustains a fall, by CNA, and licensed staff, to prevent serious harm, serious injury, or death 5 times a week for 8 weeks or until compliance is verified by Office of Long-Term Care. 8. The DON/designee will present all findings to the monthly QAPI (Quality Assurance & Performance Improvement) committee for further review and recommendations. All corrections were completed on 12/23/2025. Onsite Verification: The IJ was removed

on 12/23/2025 at 4:34 PM, after this surveyor performed an onsite verification that the removal plan had been implemented as follows: 1. and 2. On 12/23/2025, this surveyor reviewed an in-service dated 12/22/25-12/23/25, presented by the DON with the subject of: a. Accident and incident-investigating and reporting-policy- investigating and reporting-policy- fall-clinical protocols-policy- fall assessment-policy- fall and fall risk managing-policy-assessing falls and their causes b. Proper transfer technique and guidelines-policy- safe lifting and movement of residents-check list-transferring resident from bed to wheelchair using gait belt-mechanical lift manufacturer Vera lift II transfer procedure written & video-stand up lift manufacturer Vera lift II transfer procedure written & video-hands on in-service with physical therapist in-house-safety when transferring.Different signatures and titles were observed on the in-service. 3. On 12/23/2025, this surveyor reviewed an in-service dated 12/22/25-12/23/25, presented by the DON with the subject of: a. Reviewing and implementing care plan-one on one training from DON to Nurses to CNAs on how to access plan of care-CNAs to check care plan daily for any changes-educated to inform DON/MDS if changes to care plan need to be updated to correlate with residents change in condition.Different signatures and tittles were observed on the in-service. 4. Review of hospital records indicated the resident was sent to an acute care facility on 12/02/2025. 5. Review of a document titles transfers listed 11 residents who required a stand-up lift for transfers and 16 residents who required a body lift, for a total of 27, instead of 26 residents who required assistance with transfers. 6. Review on an in-service dated 12/22/25-12/23/25, covered to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death beginning 12/22/2025 and different signatures and titles were observed on the in-service. 7. On 12/23/2025, the DON provided a hand-written survey monitoring sheet which indicated which staff was monitored, with the date of the observation, for resident transfers, staff locating and reviewing the plan of care. 8. No QAPI meeting has been performed, but findings to be reviewed in the January 2026 QAPI meeting per DON. On 12/23/2025, 4 -7AM/3PM shift CNAs, 2-3PM/11 PM CNAs, 2-11PM/7AM CNAs, 2- day shift nurses and 2 evening shift nurses were interviewed regarding

the topics of the in-services provided with no negative findings.

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dermott City Nursing Home

702 West Gaines St Dermott, AR 71638

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, interview and facility policy review, the facility failed to ensure a Licensed Administrator was hired to oversee the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities for one of one facility reviewed for administrative duties.

Residents Affected - Many

The findings include:

Review of a facility Administrator Job Description, with a revision date of October 2022, indicated that the primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current, federal, state and local standards, guidelines and regulations that govern the nursing facilities to assure the highest degree of quality care can be provided to residents at all times. Experience indicated as, must have a current unencumbered nursing home Administrator's license or meet the license requirements of the state.

Review of a facility policy titled Administrative Management Governing Body with a revision date of January 2025, indicated that the governing body shall be responsible for the management and operation of the facility. This policy indicated that the governing body has the responsibility for the management and operation of the facility and that the governing body is responsible for but not limited to oversight of facility care and services in accordance with professional standards of practice and principles.

Review of an Office of Long-Term Care (OLTC) Incident & Accident Report (I&A) dated 12/02/2025 at 10:34 AM, indicated that Certified Nursing Assistant (CNA) #1 performed an improper transfer of Resident #1, which resulted in Resident #1 sustaining an acute right femur (thigh bone) fracture which required surgical intervention. The I&A indicated that the Compliance Officer (CO) name was in the area designated for the name of the Administrator.

During the entrance conference on 12/19/2025 at 9:15 AM, the Director of Nursing (DON) stated the facility had an interim administrator, [the CO], who was not in the facility at that time. A review of the Key Personnel Sheet did not list the name for the Administrator.

During an interview with the CO on 12/22/2025 at 3:38 PM, she stated she was not the Administrator, and

she does not have an Administrator's license. She stated no one was filling the capacity as the Administrator at the facility at that time and they were currently working on hiring someone.

During an interview with Human Resources (HR) on 12/22/2025 at 4:17 PM, she stated the last Administrator resigned and her last day was 07/28/2025.

On 12/23/2025 at 3:51 PM, this surveyor unsuccessfully attempted to reach the Board President (BP) by telephone and a voicemail with contact information was provided with a request for a return call. As of 12/23/2025 at 5:40 PM, this surveyor had not received a return call.

During an interview with the CO on 12/23/2025 at 4:45 PM, she stated the facility had been without an Administrator since July 2025. She stated no candidates had been interviewed for the Administrator position since July 2025. She stated the facility was advertising on [an internet site] and in the local newspaper for the open Administrator position at the facility.

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

Event ID:

Facility ID:

If continuation sheet