Oak Creek Rehabilitation Center Of Kimberly

F-F600, at past non-compliance, and found to be in compliance as of 6/25/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 135084 Department of Health & Human Services Printed: 09/18/2025 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 135084 B. Wing 07/04/2024

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

Oak Creek Rehabilitation Center of Kimberly 500 Polk Street East Kimberly, ID 83341

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20243 Residents Affected - Few Based on policy review, record review, facility investigation review, and staff interview, it was determined the facility failed to report an allegation of physical and verbal abuse and neglect to the State Survey Agency.

This was true for 1 of 3 residents (Resident #15) reviewed for abuse. This failure resulted in harm to Resident #15 when the allegation of physical and verbal abuse was not acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation. Findings include:

The facility's Abuse policy, undated, stated, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriate of resident property, and exploitation are reported immediately, but not later than two hours after the allegation is made, if the events that cause

the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where State law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Resident #15 was admitted on [DATE REDACTED], with multiple diagnoses including personal history of a traumatic brain injury.

A quarterly MDS assessment, dated 5/17/24, documented Resident #15 was severely cognitively impaired.

A facility investigation report, undated, documented an incident occurred on 2/28/24. The report documented NA #1 was assisting LPN #1 to get Resident #15 off the floor and back into his wheelchair. LPN #1 attached

the [gait] belt [an assistance safety device that can be used to help a patient sit, stand, or walk around, as well as to transfer them from a bed to a wheelchair] around Resident #15's chest to get him up and she was yelling at him to get up and get on his feet. NA #1 went to grab him under his arm to help him and LPN #1 said no, he can do it, he knows how. After about a minute of LPN #1 pulling on Resident #15 and yelling, LPN #1 said, I'm not [expletive] doing this tonight and proceeded to pull him to the floor and as she was doing so, he hit his head on the door frame of his room as a result of her being rough and yanking him around. LPN #1 took the belt off, grabbed under his arms and pulled him part way into his room. He was holding his head in pain and LPN #1 said to NA #1 to leave him there. NA #1 did as she was told and left the room. NA #1 returned 45 minutes later to check on Resident #15 who was still on the floor. Resident #15 was soaked in urine and his shirt was pulled over his head. The investigation report documented the incident was reported by NA #1 to the facility's HR personnel on 2/29/24, the day after the incident occurred.

During an interview on 7/3/24 at 6:29 PM, RN #1 stated when she came on duty at 6:00 AM on 2/29/24 (the next day), NA #1, NA #2 and NA #3 reported what happened the evening before. RN #1 stated that she, NA #2, and NA #3 wrote a statement, and the statements were given to the former Administrator.

During an interview on 7/4/24 at 12:23 PM, NA #1 confirmed that she did not report the alleged incident until

the next morning, 2/29/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 135084 Department of Health & Human Services Printed: 09/18/2025 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 135084 B. Wing 07/04/2024

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

Oak Creek Rehabilitation Center of Kimberly 500 Polk Street East Kimberly, ID 83341

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 0609 On 7/4/24 at 7:30 PM, the facility provided a copy of their Corrective Action Plan. The facility's actions included the following: Level of Harm - Actual harm Steps taken by Current Administrator since 5/13/24: Residents Affected - Few - On 5/24/24, the Administrator had mandatory all staff in-service and included in the agenda was Grievance policy and procedure, Abuse Coordinator, types of abuse and abuse reporting policy.

- On 6/1/24, information was placed in common areas with Key Personnel that specifically named Current Administrator as abuse coordinator and phone number.

- On 6/2/24, 27 residents were interviewed and asked if they felt safe and who they report concerns to. If

they did not know, they were educated.

- On 6/6/24, Abuse Training education was placed in the information book.

- On 6/25/24, a QAPI [Quality Assurance and Performance Improvement] meeting was held. Reviewed Reportable incidents and grievances with Medical Director and Interdisciplinary Team (IDT) were reviewed.

The survey team validated the Corrective Action Plan was in place before the survey entrance and there were no further instances of failure to report alleged abuse to the State Agency. Therefore, the facility was cited at Past Non-Compliance and was found to be in compliance as of 6/25/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 135084