Health inspection·December 13, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure CNA A properly transferred Resident #1 via mechanical lift (a device designed to help caregivers transfer patients) on 12/11/224 resulting in Resident #1 having a significant laceration to her scalp with exposure to underlying skull. The noncompliance was identified as PNC. The IJ began on 12/11/24 and ended on 12/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. Findings include: 1. Record review of the face sheet dated 12/13/24 indicated Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, dysphagia (difficulty swallowing foods or liquids), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Record review of the MDS dated [DATE] indicated Resident #1 rarely/never understood others and was rarely/never understood by others. The MDS indicated Resident #1 did not have a BIMS score. The MDS indicated Resident #1 was dependent with dressing, personal hygiene, bathing, and transfers. Record review of the care plan dated revised on 11/20/24 indicated Resident #1 had an ADL self-care performance deficit with interventions including requires 2-staff participation with mechanical lift transfers. Record review of the Nurse's Progress note dated 12/11/24 at 6:00 a.m. indicated, CNA getting resident out of bed. had resident in [mechanical lift] and while she was fixing to put resident in Geri-chair (a large, padded chair designed to help people with limited mobility sit and stand comfortable) roommate got up to bathroom all upset because lights were turned on and people talking and wouldn't let her sleep and pushed Geri chair back out of the way when CNA turned to get Geri chair resident leaned over and fell out of [mechanical lift] sling hitting head on side table has laceration to top of head and hematoma to right side of head and hematoma to right index finger. while in room assessing resident roommate continued fussing and complaining to staff. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676235 Printed: 05/15/2026 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 676235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482 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)