Inspection Reports for
Apple Creek Health and Rehabilitation

The complaint investigation substantiated multiple failures in care including burns from hot liquids, unsafe transfers, and failure to follow care plans. Immediate jeopardy was identified and removed after corrective actions.

The facility failed to follow care plans and interventions for multiple residents, resulting in an immediate jeopardy situation due to a burn injury from hot coffee, unsafe transfers causing falls, and failure to follow no-straw orders. The immediate jeopardy was removed after the facility implemented a removal plan including staff in-services and signage prohibiting microwaving resident food/drinks.

The facility was found deficient in accurately assessing a resident's dental status, implementing care plans for residents with visual impairments and swallowing difficulties, and maintaining proper food safety and hygiene practices in the kitchen, including hand hygiene and labeling of food items.

The complaint investigation substantiated immediate jeopardy related to failure to follow care plans and safety protocols, including burns from hot liquids and unsafe transfers. The immediate jeopardy was removed after the facility implemented a removal plan including staff in-service, signage, and monitoring.

The facility failed to follow care plans and safety protocols resulting in immediate jeopardy to resident health, including a resident burned by hot coffee heated in a microwave, unsafe mechanical lift transfers causing falls, failure to use gait belts during transfers, and failure to follow no-straw orders for a resident with swallowing difficulties. The immediate jeopardy was removed after corrective actions were implemented.

The facility was found deficient in accurately assessing a resident's dental status, implementing resident care plans related to visual devices and dysphagia precautions, and maintaining proper food safety and hand hygiene practices in the kitchen.

The facility was found deficient in multiple areas including failure to maintain resident wheelchairs in good condition, failure to maintain clean bed linens, inadequate storage of potentially hazardous hygiene products, presence of expired medications in storage and medication carts, and failure to consistently provide resident dietary preferences such as fluids. Several policies were noted as absent, including those for environment, storage of personal/hazardous care items, and dietary preferences.

The facility was found deficient in multiple areas including failure to maintain resident wheelchairs and bed linens in good condition, inadequate storage of hazardous hygiene products, presence of expired medications in storage and medication carts, and failure to consistently provide resident dietary preferences such as fluids. Several staff interviews confirmed lack of policies and inconsistent practices.

The complaint investigation found that Resident #1 was transferred by one staff member instead of two as required, causing a skin tear injury. The CNA admitted to transferring the resident alone and was suspended. The incident was reported to the Administrator, Director of Nursing, provider, family, and police.

The facility failed to ensure two staff members assisted Resident #1 during transfers as required by the care plan, resulting in a skin tear injury requiring sutures. Multiple staff and the Director of Nursing confirmed the resident requires two-person assistance with a gait belt for transfers. The CNA involved was suspended and corrective actions including staff training and audits were implemented.

The complaint investigation substantiated that Resident #1 was transferred without the required two-person assistance, causing a skin tear injury. The CNA was found to have neglected the care plan requirements and was suspended. The facility took corrective actions including notification of relevant parties, resident interviews, skin audits, abuse inservice training, and staff competency demonstrations.

The facility failed to ensure two staff members assisted Resident #1 during transfers as required by the care plan, resulting in a skin tear injury during a transfer performed by one staff member. Multiple staff and the Director of Nursing confirmed the resident requires two-person assistance with a gait belt for safe transfers. The CNA involved was suspended and corrective actions including staff training and audits were implemented.

The facility failed to ensure pureed food items were blended to a smooth consistency, food items in the refrigerator were not properly covered or discarded when expired, leftover foods were not reheated before serving, the ice machine was not properly cleaned, and hot food items were not maintained at safe temperatures. These deficiencies posed minimal harm or potential for actual harm to residents.

The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency, failed to maintain proper food storage and sanitation practices including expired and uncovered food items, and did not maintain hot food items at safe temperatures, posing potential risks of choking, foodborne illness, and contamination to residents.