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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity ▼ | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9921 | 9921 | GOLDEN LIVINGCENTER - WAUSA | 285111 | 703 SOUTH VIVIAN | WAUSA | NE | 68786 | 2012-09-20 | 156 | C | 0 | 1 | BQ8V11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.06C Based on observations and staff interview the facility failed to post phone numbers and addresses on how to contact the Ombudsman (an advocate for residents) and/or information needed to submit a complaint to the State Agency in a prominent place. Facility census was 24. Findings are: During the environmental tour conducted on 9/20/12 from 9:20 AM until 10:30 AM, the phone numbers for the Ombudsman and/or information to submit a complaint to the State Agency were not posted in a prominent place. This information was placed in a notebook, on a table by the front entrance. The notebook identified the contents included Resident Information and Survey Inspection Results . Interview with the Administrator on 9/20/12 from 9:30 AM until 9:35 AM verified the information was in a notebook and not posted in a prominent place and readily visible to residents, employees and the public. | 2016-04-01 |
| 9980 | 9980 | THE REHABILITATION CENTER OF OMAHA LLC | 285218 | 910 SOUTH 40TH STREET | OMAHA | NE | 68105 | 2013-01-23 | 356 | C | 0 | 1 | O26211 | Based on observation and interview; the facility failed to post daily nurse staffing information in a prominent place that was readily accessible to all residents and visitors. The facility sample size was 52 and the facility census was 50. Findings are: Observation on 1/15/13 at 9:00 AM revealed no posted nurse staffing daily information. Observation after inquiry of it's whereabouts revealed that the daily nurse staffing information was located in a 3 ring binder on the reception desk and was not in a prominent place or easily accessible to residents or visitors without having to ask it's location. Interview on 1/15/13 at 9:13 AM with the facility Staffing Coordinator (SC) confirmed that the daily nurse staffing information was not posted but was maintained in a book at the reception desk. Interview on 1/22/13 at 8:40 AM with the Director of Nursing confirmed that the daily nurse staffing information should be posted in a prominent place so people could see it. | 2016-04-01 |
| 9992 | 9992 | PONDEROSA VILLA | 285250 | P O BOX 526, FIRST & PADDOCK STREET | CRAWFORD | NE | 69339 | 2013-04-11 | 167 | C | 0 | 1 | 58PJ11 | Licensure Referance Number: 175 NAC 12-004.08 Based on observations, record review, and interview, the facility failed to: 1) identify where facility residents may access state survey results for residents, families, or visitors; and 2) provide the results in a manner residents may review the survey without assistance. Facility census was 24. Findings are: Observation on 4/11/13 at 8:00 a.m. revealed documents were kept in a plastic bin by the front entrance of the facility. Review of the documents revealed the state survey results from the facility's previous survey were in the bin. Further observation of the bin revealed no signage identifying the bin by the front entrance to alert residents, families, or visitors that the survey results were kept in the bin. The observation further revealed the bin was affixed to the wall at standing height and could not be reached by residents in wheelchairs. Interview with the Director of Nursing on 4/11/13 at 8:13 a.m. confirmed the plastic bin by the front entrance of the facility was the only place residents could obtain the results of the previous state survey. The Director of Nursing also verified there was no signage to direct residents, families, or visitors identifying the results were kept in this bin. The Director of Nursing also verified residents in wheelchairs would need assistance to reach the survey results. | 2016-04-01 |
| 10006 | 10006 | BEAVER CITY MANOR | 285269 | P O BOX 70, 905 FLOYD STREET | BEAVER CITY | NE | 68926 | 2012-10-24 | 356 | C | 0 | 1 | IOMF11 | Based on observation, record review and staff interview, the facility failed to ensure that Nurse Staffing was posted and accessible to residents and visitors and contained the name of the facility, the total number and the actual hours worked by licensed and unlicensed nursing staff. this affected all residents. The facility census was 19 at the time of the survey and the survey sample size was 23. Findings are: A. Observation on 10/17/2012 at 9:15 AM revealed that posting of Nurse Staffing was documented on a dry erase board behind the Nurse's Station; however, the Nurse Staffing did not contain the facility name with the total number and actual number of nursing hours worked on that day. B. Observation on 10/18/2012 at 1:30 PM revealed that posting of Nurse Staffing was again documented on a dry erase board behind the Nurse's Station; however, there was no documentation of the facility name or the total number and actual number of nursing hours worked on that day. C. Observation on 10/23/2012 at 10:00 AM revealed that posting of Nurse Staffing was documented on a dry erase board behind the Nurse's Station; however, again the name of the facility and the total number and actual number of nursing hours were not posted. D. Interview on 10/23/2012 at 2:00 PM with the DON (Director of Nursing) revealed that a permanent record of Nurse Staffing was documented in a notebook; however, the DON confirmed that the total number and actual number of hours worked by nursing staff was not documented. E. Interview on 10/23/2012 at 2:35 PM with the DON revealed that the notebook with Nurse Staffing hours was kept in the filing cabinet under the Nurse's Station table and not accessible to residents or visitors. F. Review on 10/23/2012 of the Nurse Staffing notebook revealed that the name of the facility and the total number and actual number of hours worked by nursing staff was not documented in that record either. | 2016-04-01 |
| 10107 | 10107 | GREELEY CARE HOME | 285286 | 201 E O'CONNOR AVENUE | GREELEY | NE | 68842 | 2012-09-27 | 167 | C | 0 | 1 | 3KGB11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(11) Based on observation and interview, the facility failed to display past survey results in a manner making them accessible to residents. The resident sample size was 17 and the census was 19. Findings are: An Environment Tour conducted on 9/26/12 revealed that past survey results were not displayed in a way to be accessible to all residents. The results were displayed between the entryway doors to the facility. During an interview with the Administrator, on 9/26/12 at 2:45 PM, the Administrator stated that the survey results were not displayed in a manner that would make them assessable to all residents. | 2016-03-01 |
| 10125 | 10125 | HERITAGE OF BEL AIR | 285089 | P O BOX 429, 1203 NORTH 13TH STREET | NORFOLK | NE | 68702 | 2012-10-23 | 356 | C | 0 | 1 | QM9Q11 | F 356 Based on observations, record review and staff interview; the facility failed to post the daily nurse staff information as required in a prominent place that was current, accessible and visible to residents, families and/or visitors. Facility census was 98. Findings are: A. Observations during the initial tour of the facility on 10/15/12 from 10:00 AM until 10:45AM revealed 3 daily nurse staffing information sheets specific to the respective units were posted on walls by the front entrance for the 100/200 Wings, by the Social Services Office for the 300, 400 and 500 Wings and at the 600 Wing Nurses ' Station for the 600 and 700 Wings. Residents and/or family members of the 700 Wing did not have access to the posting located at the 600 Wing Nurses Station. The information at the 3posting sites was approximately 6 feet off the floor and was not accessible to wheel chair residents/families. Review of the daily nurse staffing on 10/15/12 at 10:45 AM revealed the information was not current as the posting for the 300, 400, 500, 600, and 700 Wings was for 10/12/12 (3 days prior). The 100/200 Wings posting was dated 10/13/12 (2 days prior). Observation on 10/22/12 at 7:00 AM revealed the 3 daily staff postings for all the wings were dated 10/19/12 (3 days prior). Interview with Staff Member-Q on 10/23/12 from 10:00 AM until 10:10 AM verified the staffing information was not posted on the weekends and was not accessible to wheel chair residents/families; nor was the information available to the residents /families residing on the 700 Wing. | 2016-02-01 |
| 10160 | 10160 | GOOD SAMARITAN SOCIETY - COLONIAL VILLA | 285185 | 719 NORTH BROWN STREET | ALMA | NE | 68920 | 2012-10-11 | 356 | C | 0 | 1 | 9UN611 | Based on observation, record review and interview; the facility failed to post the Nurse Staffing information in a prominent place, ensure information was easily readable, and included the total number hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. The facility census was 39 and the survey sample size was 39. Findings are: Observation during the initial tour of the facility on 10/3/12 at 8:46 AM revealed an inability to find where the daily Nurse Staffing was posted. After the receipt of directions from the charge nurse, the Nurse Staffing was located in the front lobby, next to the receptionist office, on the lower shelf of a magazine rack. Observation revealed the printed information was small and the total number of hours for licensed and unlicensed staff was not documented. On 10/10/12 at 11:39 AM, an interview with Dietary Assistant (DA) -A revealed the DA worked part time in the dietary department. DA-A revealed (gender) didn't know where the Nurse Staffing information was posted. In an attempt to find it, DA-A entered the chart room and looked on the walls, then stated if the Director of Nursing (DON) was asked, the DON probably would know where it was. During an Interview on 10/10/12 at 11:43 AM, Licensed Practical Nurse (LPN) -G revealed the Nurse Staffing information was located in the magazine rack in the lobby. LPN-G stated it was low enough for residents to see, even seated in a wheelchair. LPN-G stated visitors probably wouldn't see the Nurse Staffing information unless they were looking for it. LPN-G revealed staff tried to write the information large enough to be read easily, but said we have some nurses that write pretty small. During an interview with Resident 36 and Resident 16's child on 10/10/12 at 2:54 PM, Resident 36 revealed (gender) didn't know the facility had any thing like a nurse staffing posting. Resident 16's child revealed (gender) thought that was probably on the big screen television in the living that displayed picture… | 2016-02-01 |
| 10216 | 10216 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 356 | C | 0 | 1 | NRZX11 | Based on record review, observation, and staff interview, the facility failed to ensure Nurse Staffing was accessible, visible and contained the total number and the actual hours worked by licensed and unlicensed nursing staff. This affected all residents. The facility census was 30 at the time of the survey and the survey sample size was 26. Findings are: Observation on 7/25/2012 at 10:38 AM of the Nurse Staffing information posted on the bulletin board in the cove area of the south hallway next to the Nurse's Station revealed there was no documentation of the total number and actual hours worked for licensed and unlicensed nursing staff. In addition, the Nurse Staff posting was posted above eye level creating difficulty for a person seated in a wheelchair to easily access the posting, the area was not well lit and the posting not always legible. A scale, copy machine and treatment cart were located in front of the bulletin board making it difficult to access the posted information. The Nurse Staff posting was located on that bulletin board at all times during the survey, making it difficult to read or review. Interview on 07/25/2012 at 10:58 A.M. with the DON (Director of Nursing) confirmed that the Nurse Staff posting had not been completed as of 10:58 AM on 7/25/2012 for the total number of staff and hours worked on the day shift. Further observation on 7/25/2012 at 3:39 PM revealed that the evening Nurse Staff hours had not been posted as the evening shift started work at 2 PM. | 2016-02-01 |
| 10265 | 10265 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2012-07-11 | 356 | C | 0 | 1 | JX1V11 | Based on observation and interview; the facility staff failed to post daily nurse staffing information in the facility. This had the potential to effect 98 residents that resided in the facility. The facility census was 98. Findings are: Observation on 7/2/12 during the facility entrance initial tour revealed no daily nurse staffing information posted in any area of the facility. Interview on 7/2/12 at 10:18 AM with the Director of Nursing confirmed that the daily nurse staffing information had not been posted in the facility since January, 2012. | 2016-01-01 |
| 10323 | 10323 | GOLDEN LIVINGCENTER - NORFOLK | 285101 | 1900 VICKI LANE | NORFOLK | NE | 68701 | 2012-04-04 | 253 | C | 0 | 1 | 51KT11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observations, record review, resident and staff interview; the facility failed to maintain a functional, sanitary and odor free environment as resident room walls and doors were scratched and marred; consistent urine odors were noted in hallways and in resident rooms/bathrooms; bedpans, urine catch pans and personal resident items were lying directly on the floor; the floors of resident rooms and storage areas contained dust and paper residue; resident floor mats were soiled; and counter tops were stained with water deposits. This affected 15 resident rooms/bathrooms (Resident Rooms 1, 9, 16, 18, 21, 26, 27, 28, 29, 31, 32, 34, 35, 39 and 40). The exterior window sills on the entire facility were paint chipped with the bare wood exposed, and the east Dining Room windows were soiled with an accumulation of bird droppings. Facility census was 55. Findings are: A. The following were observed on the Alzheimer's Care Unit (ACU): -Observation on 3/26/12 from 7:55 AM until 9:00 AM revealed the consistent odor of urine in the North hallway of the ACU. The sitting room at the end of the North hallway had 2 cat litter boxes, one with a cover over it and one without a cover, located in a cove behind the entry door. Litter was scattered outside the boxes and there was cat feces accumulated in the uncovered box. There was an odor of cat urine in the room and extending into the hallway outside the room. There were 2 cats observed on the ACU; one in Resident Room 12 and one in Resident Room 8. -Observation on 3/26/12 from 11:19 AM until 12:30 PM revealed the consistent odor of urine in the North hallway of the ACU. Urine odors were also noted in the bathrooms of Resident Room 18 at 11:40 AM and Resident Room 9 at 12:20 AM, located on the ACU. -Observation on 3/26/12 from 2:03 PM until 3:30 PM revealed the consistent odor of urine in the North hallway of the ACU. -Observations on 3/27/12 at 6:25 AM and 7:23 AM revealed the odor of urine in the North hallway of the ACU. 2 cat… | 2016-01-01 |
| 10501 | 10501 | BETHANY HOME, INC. | 285270 | 515 WEST FIRST STREET | MINDEN | NE | 68959 | 2012-08-16 | 356 | C | 0 | 1 | MRMB11 | Based on observation, record review and staff interview, the facility failed to ensure Nurse Staffing was accessible, visible and contained the total number and the actual hours worked by licensed and unlicensed nursing staff. This affected all residents. The facility census was 45 at the time of the survey and the survey sample size was 27. Findings are: Observation on 8/12/2012 at 7:30 PM of the Nurse Staffing information revealed that the total number and the actual hours worked for the evening shift were not written on the posting of Nursing hours. In addition the Nursing Hours were posted on a window by the door to the medication room behind the Nurse's Station, which was not accessible to residents or visitors. Interview on 8/12/2012 at 7:30 PM with LPN (Licensed Practical Nurse) M revealed that most of the evening staff had come on duty at 2 PM and as the charge nurse, LPN M had come on duty at 6:00 PM. Interview on 8/12/2012 at 7:30 PM with LPN M revealed that each shift is to fill out their hours and LPN M confirmed that it had not been done for the evening shift of 8/12/2012. Record review on 8/12/2012 of the Nurse Staffing information from 8/1/2012 to the present date of 8/12/0212 revealed that 7 of 12 days, the day shift had not filled in the total hours and actual hours worked. Review of the same time period for the evening shift revealed that 12 of 12 days, the evening shift had not filled in the total hours and actual hours worked. Interview on 8/15/2012 at 8:55 AM with LPN L revealed that the day shift had come on duty at 6:00 AM. Review on 8/15/2012 at 11:30 AM of Nurse Staffing information revealed that the total number and actual hours working on the day shift of 8/15/2012 had not been documented or posted in an accessible area as there was a medication cart parked in front of the window where the information was hung. In addition the Nurse Staffing was not posted at eye level for a person in a wheelchair. Interview on 8/15/2012 at 4:05 PM with the DON (Director of Nursing) confirmed that there… | 2016-01-01 |
| 10621 | 10621 | ELMS HEALTH CARE CENTER | 285191 | P O BOX 628, 410 BALL PARK ROAD | PONCA | NE | 68770 | 2012-01-24 | 356 | C | 0 | 1 | UH3O11 | Based on observations, review of nurse staffing information, and staff interview; the facility failed to assure the nurse staffing information was posted in a timely manner on 2 of 4 days of survey. Furthermore, review of nurse staffing information from 1/17/12 through 1/23/12 indicated information was not complete as related to the total number of staff on duty, information covering the entire 24 hour day, and lack of specifics related to the actual shift worked. Facility census was 36. Findings are: A. The following were noted during the initial tour of the facility on 1/17/12 from 10:30 AM until 10:50 AM: Licensed Practical Nurse (LPN) - A indicated during interview that there were 4 Nursing Assistants (NA), 1 Medication Aide (MA), 2 Registered Nurses (RN) and 1 LPN on duty. It was observed that the form used to post nurse staffing information was displayed on a bulletin board next to the nurses ' station in the main area of the nursing home. The nurse staffing information displayed on the bulletin board was dated 1/16/12. LPN-A posted new nurse staffing information dated 1/17/12 that indicated the shift from 6:30 to 7:00 (AM and/or PM were not indicated), and that there were 2 RN ' s, 1 LPN and 4 NA ' s on duty. The nurse staffing information did not indicate there was 1 MA on duty. During interview, LPN-A indicated MA ' s were not normally posted on the nurse staffing information, and LPN-A changed the number of NA ' s from 4 to 5, likewise adjusting the total hours worked for NA ' s on the 1/17/12 posting. B. Review of the nurse staffing information for 1/19/12 revealed there were 2 separate postings with that date; 1 for the shift from 6:30 to 3:00 (AM and/or PM were not indicated), and 1 for the shift from 10:30 PM to 7:00 AM. There was no nurse staffing information provided for the evening shift (3:00 PM to 10:30 PM) on 1/19/12. C. Review of the nurse staffing information for 1/20/12 revealed there were 3 separate postings with that date; 2 postings indicating the shift from 6:30 to 7:00 (AM and/or PM we… | 2015-12-01 |
| 10683 | 10683 | THE LODGE AT HERITAGE ESTATES | 285071 | 2325 LODGE DRIVE | GERING | NE | 69341 | 2011-12-01 | 156 | C | 0 | 1 | 5NPI11 | Based on observations, family and staff interviews, the facility failed to post, for the residents and the public, the telephone numbers of the State Survey and Certification Agency; and/or the information necessary to file a complaint concerning resident abuse, neglect, and misappropriation of funds with the State Agency. The Facility census was 98 and 25 resident were on the stage 2 survey sample . Findings are: Observation of the facility during the initial tour on 11/28/11 at 9:00AM revealed no posting of the telephone numbers to the State Survey and Certification Agency or the information to file a complaint with the State Agency. In an interview on 11/28/11 at 1:10PM, a family member of Resident 75 stated he/she was not aware of how to contact the ombudsman or the state hotline/complaint number. In an interview on 11/28/11 at 3:35P, RN (Registered Nurse) -G stated the ombudsman and reporting hotline information were posted in the facility Ice Cream Parlor. A check of the Ice Cream Parlor revealed a Survey notebook available to the public, forms for employee praise in a pamphlet stand on the counter, and grievance forms in one of the drawers. No postings of the State Agencies information were noted. On 11/30/11 at 6:00AM, the area between the two front doors where other information was posted was observed for the State Agency and complaint information, no such postings were found. At 6:30AM, the facility Ice Cream Parlor was checked for any postings and none were noted, although the grievance forms were now in the pamphlet stand with the employee praise forms. In an interview at 2:47PM on 11/30/11, the Assistant Director of Nurses (ADON) stated the requested information was posted between the two doors as you enter the building. At 2:50PM on 11/30/11, observation of the area the ADON described did not reveal any posting of the requested information. At 2:52PM on 11/30/11, the Administrator looked for the requested information. He/she stated It should be on a yellow piece of paper . No, it is not here. The Ad… | 2015-11-01 |
| 10826 | 10826 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2015-06-09 | 356 | C | 1 | 0 | 2ZRV11 | Based on observation, record review and interview; the facility staff failed to post staffing information in accordance with federal requirements. Federal requirements mandate the facility post nursing staff information on a daily basis at the beginning of each shift. This information must contain the following data: -Facility name. -Current date. -Resident census. -Facility-specifics shifts. -Categories of nursing staff. -Actual time worked for the specified categories of nursing staff. -The number of nursing staff working per shift. -Posted in a prominent place readily accessible to residents and visitors. -Maintain the posted daily nurse staffing data for minimum of 18 months. This had the potential to affect all residents in the facility. The facility staff identified a census of 93. Findings are: Observation on 6-08-2015 at at 7:55 AM of the daily nurse staff posted information revealed the actual hours worked for specific nursing categories of nursing were not identified. Record review of the Daily Staff Posting sheet from 6-01-2015 through 6-07-2015 revealed the actual hours worked for the specific nursing categories were not identified on the sheets. An interview on 6-08-2015 at 9:10 AM with the facility Staffing Coordinator (SC). The SC confirmed during the interview the specific hours worked for each nursing categories and actual hours worked were not on the Daily Nurse staffing sheet. | 2015-10-01 |
| 10837 | 10837 | GOLDEN LIVINGCENTER - PLATTSMOUTH | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2015-06-11 | 356 | C | 1 | 0 | 9Q4811 | Based on observation and interview; the facility staff failed to post daily nurse staffing information and retain 18 months of facility nurse staffing information in accordance with federal requirements. This had the potential to affect all 98 residents who resided in the facility. The census was 98. Findings are: Record review of the Code of Federal Requirements at F356 mandates the facility post nurse staffing information on a daily basis at the beginning of each shift. This information must contain the following data: - Facility name - Current date - Resident census - Facility-specific shifts - Categories of nursing staff employment - Actual time worked for the specified categories of nursing staff - The number of nursing staff working per shift The daily nurse staffing information must be posted in a prominent place readily accessible to residents and visitors and maintained for a minimum of 18 months. Observation on 6/10/15 between 8:15 AM and 8:20 AM revealed that there was no nurse staffing information posted in the facility. Observations were conducted of the Central nurse station area, South Nurse station and the Alzheimer unit nurses station.Interview on 6/10/15 between 8:15 AM and 8:20 AM with the facility Director of Admissions confirmed that there was no daily nurse staffing information posted in the facility. Interview on 6/10/15 at 8:20 AM with the Director of Admissions confirmed that the daily nurse information was usually posted on the bulletin board by the Central Nurses station and that it was not present. Observation on 6/10/15 at 8:30 AM with the Director of Nursing confirmed that there was no daily nurse staffing information posted in the facility. Interview on 6/10/15 at 8:30 AM with the Director of Nursing confirmed that the daily nurse staffing information should be posted on the bulletin board by the Central nurses station and that it was not present. Record review of 18 months of daily posted nurse staffing information revealed 40 days had been retained over the course of the past 18 m… | 2015-10-01 |
| 10874 | 10874 | GOOD SAMARITAN SOCIETY - ALBION | 285197 | P O BOX 271, 1222 SOUTH 7TH STREET | ALBION | NE | 68620 | 2012-03-05 | 356 | C | 0 | 1 | FWY111 | Based on observation and interview, the facility failed to ensure that the nurse staffing information was posted in a visible and readable fashion for the residents. The facility census was 57 with 40 residents taken on sample. Findings are: Observation of the staffing information revealed that the posting was at the central nurses station at a height of approximately 55 inches and in a regular font size. In an interview with the Director of Nursing (DON) on 3/5/12 at 4:45 PM the DON acknowledged that there were residents who would be unable to read the staffing information as posted. | 2015-10-01 |
| 11110 | 11110 | GOLDEN LIVINGCENTER - SORENSEN | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2012-01-05 | 522 | C | 1 | 1 | 9QU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number: 175 NAC 12-006.01 (6 & 7) Based on record review and interviews the facility failed to notify the state agency of a change of administrators. This had the potential to affect all residents. Sample size was 27 plus 7 non-sampled. Facility Census was 61 Findings Are: Review of a fax " Transmission Report " dated 10-30-2011 revealed a fax was sent to the State agency informing of the changes in administrators. The report reveals the following: ? The former administrator left the faciity on [DATE] ? The Interim administrator was in the facility from May 13, 2011 until October 25, 2011 ? The current administrator started as the Executive Director on October 25, 2011. Interview on 1-3-2012 at 10:30 AM with the Director of Operations revealed that no evidence could be found that the change of administrators was reported to the state agency at the time the change occured and was not reported until 10/30/2011 when the current administrator assumed the duties. | 2015-08-01 |
| 11224 | 11224 | LOGAN VALLEY MANOR | 285090 | 1035 DIAMOND STREET | LYONS | NE | 68038 | 2015-02-05 | 361 | C | 1 | 1 | WDPT11 | Licensure Reference Number: 175 NAC 12-006.04D1 Based on record review and interviews, the facility failed to ensure the Dietary Manager had completed a course to become certified and failed to employ a dietician on a full time basis. This had the potential to affect all residents. Facility census was 31. Interview on 1/29/2015 at 10:30AM with Dietary Manager revealed the Dietary Manager was currently enrolled in a class to become certified. Dietary Manager states the course will not be completed until May 2015. Interview on 2/3/15 at 12:55PM with Dietary Manager revealed a dietician comes in to review any dietary concerns once a month along with a corporate dietician who has a weekly conference call on Mondays with other dietary managers and dieticians. There is no registered dietician working in the facility full time. Record review of the Dietary Managers personnel file revealed no certification for a dietary manager at this time. Record review of facility job description for Director of Food Services dated 2003 listed under education expectation revealed the following: Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. | 2015-07-01 |
| 11239 | 11239 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2012-08-09 | 226 | C | 0 | 1 | G3Q011 | F 226 LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on observations, record review and staff interview the facility failed to protect all residents from potential abuse/neglect. The facility failed to re-educate a staff member who was accused of neglect of Resident 16 before allowing the staff member to return to work. Facility census was 34. Findings are: On 8/6/12 at 11:00 AM the Administrator indicated an allegation of neglect involving Resident 16 and Nursing Assistant (NA) M had been reported to the State Agency that morning. The Administrator stated NA-M had been suspended until the investigation was completed. Review of the written investigation for this allegation dated 8/8/12 revealed NA-M was placed on extended probation and was to be re-educated regarding facility abuse and neglect policy. Additional staff training was to be done with all staff regarding abuse and neglect recognition and reporting. On 8/8/12 at 5:30 PM the suspended employee NA-M was observed working the 2:00 PM to 10:00 PM shift. Interview with the Director of Nursing (DON) on 8/9/12 from 10:20 AM until 10:30 AM, revealed DON thought the investigation was completed; however the interventions for re-education of the suspended employee and other staff members had not been completed. The DON stated the suspended employee was informed on 8/8/12 while working the evening shift of the need for the DON to visit with employee regarding the incident. Interview with the Administrator on 8/9/12 from 10:30 AM until 10:35 AM, revealed the suspended employee should not have returned to work until the interventions were in place to prevent further neglect of residents. | 2015-07-01 |
| 11265 | 11265 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 258 | C | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(3) Based on observations, confidential resident interviews and staff interview; the facility failed to ensure comfortable noise levels related to an audible chime alarm in the corridor of Wing 1 which sounded repeatedly. This had the potential to affect the comfort of all residents as the noise could be heard throughout the Wing 1 corridor and extended into the dining room area. Facility census was 33. Findings are: A. On 11/19/14 at 6:56 AM, a motion alarm (an alarm activated by movement) was observed positioned on the ceiling in the corridor outside of Resident 40's room. The motion alarm sounded an audible chime alarm each time Resident 40 entered or exited the room and whenever anyone passed by in the corridor. The audible chime alarm sounded repeatedly between 6:56 AM and 8:37 AM as residents and staff passed by in the corridor. The sound from the audible chime alarm was heard throughout the Wing 1 corridor and extended into the dining room area. At 9:45 AM, Resident 40 repeatedly walked in and out of the room triggering the audible chime alarm. B. 2 confidential resident interviews conducted on 11/19/14 between 10:48 AM and 11:31 AM indicated they were able to hear the audible chime alarm. 1 resident stated "I hear it and try not to pay attention to it. I don't complain". Another resident stated the audible chime alarm had started recently and "It's a nuisance". C. The audible chime alarm in the corridor of Wing 1 sounded repeatedly on 11/20/14 between 8:35 AM and 9:30 AM as staff and residents walked by Resident 40's room. The sound was heard throughout the Wing 1 corridor and extended into the dining room area. D. Interview with the Director of Nurses (DON) on 11/25/14 at 8:40 AM revealed the audible chime alarm was placed outside Resident 40's room in an effort to monitor the resident's whereabouts. The DON verified the audible chime alarm needed to be re-set as it sounded when anyone passed by in the corridor. | 2015-07-01 |
| 11276 | 11276 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 356 | C | 0 | 1 | ZQ0211 | Based on observations and staff interview; the facility failed to post and retain the required daily nurse staffing information. This had the potential to affect all residents, family members and visitors. Facility census was 33. Findings are: Observations during entrance tour of the facility on 11/18/14 at 12:00 noon revealed the nurse staffing information was not posted. During interview on 11/18/14 at 12:15 PM, the Director of Nursing (DON) verified the nurse staffing information was not posted. Interview with the DON at 7:35 AM on 12/2/14 revealed nurse staffing information had not been posted since the end of 7/2014. The DON further indicated nurse staffing information had not been retained since that time. Therefore, nurse staffing records were not maintained for 18 months as required. | 2015-07-01 |
| 11441 | 11441 | HAVEN HOME | 285166 | P O BOX 10, 100 WEST ELM AVENUE | KENESAW | NE | 68956 | 2013-01-10 | 156 | C | 0 | 1 | LE5L11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.06C Based on observations and staff interview the facility failed to post phone numbers and addresses of the State Survey and Certification Agency and/or information needed to submit a complaint to the State Agency and/or the information on how to apply for and use Medicare and Medicaid in a prominent place. Facility census was 45 and this failure had the potential to affect all residents of the facility. Findings are: During the environmental tour conducted on 1/9/13 at 1:25 PM, the phone numbers and addresses of the State Survey and Certification Agency and information needed to submit a complaint to the State Agency and the information on how to apply for and use Medicare and Medicaid were not posted. Interview with the Administrator on 1/9/13 at 1:25 PM verified the information was not posted and readily accessible to residents, employees and the public. Interview with the Social Services Director on 1/9/13 at 1:37 PM confirmed the information was not posted in the facility. | 2015-06-01 |
| 11517 | 11517 | COMMUNITY MEMORIAL HEALTH CENTER LTC | 285257 | P O BOX 340, 295 NORTH 8TH STREET | BURWELL | NE | 68823 | 2011-08-16 | 156 | C | 0 | 1 | OXF111 | F 156 Based on observations, resident and staff interviews, the facility failed to prominently display for residents and the public the Medicare and Medicaid information, telephone numbers of advocacy groups, the state survey and certification agency; and the information necessary to file a complaint with the survey agency. Facility census was 36. Findings are: A. Observation with the Administrator on 8/15/11 from 11:00 AM until 11:10 AM revealed the mandatory posting of information for residents and the public regarding Medicare and Medicaid, phone numbers of advocacy groups and the state survey and certification agency; and the information needed to file a complaint with the survey agency was not posted. B. Interview with the Administrator from 11:05 AM until 11:10 AM revealed the information had been moved to a different location (next to the employee break room) which was not assessable to residents, families and/or the public. C. During a resident confidential interview conducted during the survey revealed no knowledge of this information or where it was posted. | 2015-06-01 |
| 11518 | 11518 | COMMUNITY MEMORIAL HEALTH CENTER LTC | 285257 | P O BOX 340, 295 NORTH 8TH STREET | BURWELL | NE | 68823 | 2011-08-16 | 167 | C | 0 | 1 | OXF111 | F 167 Based on observations and staff interview the facility failed to post the results of the most recent survey and plan of correction in a place readily accessible to residents and families. Facility census was 36. Findings are: A. Observation with the Administrator on 8/15/11 from 11:00 AM until 11:10 AM revealed the survey results from the 2009 survey were posted in a hanging wall file located on the wall next to the front entrance. The 6/14/10 survey results and plan of correction were not in the hanging file. In addition, the hanging file did not identify the contents and was not accessible to wheelchair residents. B. During interview on 8/15/11 from 11:10 AM until 11:15 AM the Administrator verified the deficiency statement was not from the most recent survey and was not accessible to wheelchair residents. | 2015-06-01 |
| 11519 | 11519 | COMMUNITY MEMORIAL HEALTH CENTER LTC | 285257 | P O BOX 340, 295 NORTH 8TH STREET | BURWELL | NE | 68823 | 2011-08-16 | 253 | C | 0 | 1 | OXF111 | F 253 175 NAC-12-006.18A Based on observations and staff interview the facility failed to maintain a functional and sanitary environment as the wood doors and door jams to resident rooms and bathrooms were gouged and splintered in A Wing 114, 115,119, 120,121, 123, 124, 125; in B Wing 100, 102, 103, 105, 106, 109, 110, 201, 203, the B Wing Whirlpool room; and the facility interior courtyard was in need of lawn and weed care. Facility census was 36. Findings are: A. During the environmental tour of the facility with the Maintenance Supervisor on 8/15/11 from 1:45 PM until 3:15 PM the following issues were identified: -The wood doors and door jams to resident rooms and bathrooms were gouged and splintered in A Wing 114, 115,119, 120,121, 123, 124, 125; in B Wing 100, 102, 103, 105, 106, 109, 110, 201, 203 and the B Wing whirlpool room. B. The interior courtyard off of the A Wing Dining Room was not maintained as: -The cracks of the courtyard sidewalk contained weeds which were approximately 1 foot tall which provided the potential for residents to be unable to walk with ease on the sidewalk.. -A push lawn mower was sitting on the sidewalk which would make it difficult for residents to pass by when walking on the sidewalk. -Weeds approximately 1 foot tall were growing next to the building and the grass in the courtyard was tall and in need of mowing. -3 large planters located in the courtyard contained tall weeds and grass approximately 1 foot tall. C. Interview with the Maintenance Supervisor on 8/15/11 from 2:20 PM until 2:25 PM revealed the resident room and bathroom doors needed repair work and the courtyard was in need of routine lawn and garden care. | 2015-06-01 |
| 11522 | 11522 | COMMUNITY MEMORIAL HEALTH CENTER LTC | 285257 | P O BOX 340, 295 NORTH 8TH STREET | BURWELL | NE | 68823 | 2011-08-16 | 356 | C | 0 | 1 | OXF111 | Based on observations and staff interview, the facility failed to post the daily nurse staffing information in a prominent place that was accessible and visible to residents and visitors. Facility census was 36. Findings are: Observations during initial tour of the facility on 8/9/11 from 10:40 AM until 11:05 AM revealed the daily nurse staffing information was on a clipboard in the nurses ' station/office. A sign on the door to the room indicated the area was for staff members only. Interview with Licensed Practical Nurse M at this time revealed the daily nurse staffing information was normally left on the clipboard in the nurses ' station/office and was not posted anywhere else in the facility for resident or visitor access. The Director of Nurses verified during interview on 8/11/11 from 6:45 AM until 6:50 AM that the daily nurse staffing information was not accessible to residents and visitors. | 2015-06-01 |
| 11692 | 11692 | COMMUNITY PRIDE CARE CENTER | 285208 | 901 SOUTH 4TH STREET | BATTLE CREEK | NE | 68715 | 2011-07-21 | 465 | C | 0 | 1 | I3NN11 | LICENSURE REFERENCE NUMBER 175 NAC-12-006.11e Based on observations and staff interview the facility failed to maintain food service equipment in a clean and sanitary manner as the ice machine, milk machine, Dining Room sink cabinet and the Kitchen floor grease trap were soiled. Facility census was 45. Findings are: A. During the sanitation tour conducted on 7/20/11 from 11:00 AM until 11:45 AM the following issues were identified: -The side panel on the Dining Room ice machine was covered with a lime deposit. The seam line in the panel was wet to touch and contained a 1/8 inch thick lime deposit. -The rubber gasket on the inside of the milk machine door contained a black soil deposit. -The floor of the sink cabinet located in the Dining Room was soiled with a wet stain. 2 boxes of gloves located in the cabinet were wet. -The metal door of the grease trap located in the floor of the Kitchen was paint chipped and rusty. B. Interview with the Dietary Manager on 7/20/11 from 12:50 PM until 12:55 PM revealed awareness that these areas were in need of cleaning and repair. C. Review of the 7/1/2007 version of the " Food Code " , based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food sanitation practices, revealed the following: -4-601.11: " Non food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. Non-food contact surfaces of equipment must be cleaned at a frequency to prevent accumulation of soil residue " . | 2015-02-01 |
| 11708 | 11708 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2011-07-14 | 167 | C | 0 | 1 | L3U611 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05 (11) Based on observations, record review and staff interview the facility failed to post the results of the last survey of the facility to be accessible to the residents without asking for staff assistance. This had the potential to affect all residents and visitors that could not reach 5 fee and 10 inches in height. Facility census was 26. Sample size was 10. Findings are: A. Entrance into the faciliy on 7/13/2011 at 8:00 AM found the most recent survey results of the faciliy in a file box 5 feet and 10 inches off the floor by the activity office. B. During the General Observation tour of the facility on 7/14/2011 between 9:00 AM and 9:30 AM the Last Survey Results were no visible and accessible to the residents or families. The notebook with the the last survey results were in a file box by the activity office 5 feet and 10 inches from the floor. C. Interview with the Maintenance Director on 7/14/2011 at 9:30 AM confirmed the most recent survey results were located in a file box by the activity office 5 feet and 10 inches off the floor not accessible to the residents and/or families. | 2015-02-01 |
| 11726 | 11726 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2011-03-16 | 167 | C | 0 | 1 | 0EQX11 | Based on observation and interview; the facility staff failed to ensure prior state survey results were readily accessible to all residents without request. The survey consisted of 18 sampled and 14 non-sampled residents. The facility staff identified a census of 88. Findings are: Observation on 3/15/2011 at 8:30 AM revealed a sign posted on the counter at the receptionist station, identifying that the state survey results were available for viewing upon request. Observation on 3/16/2011 at 8:10 AM revealed the posted sign on the receptionist counter remained indicating the the survey results were available for viewing. The survey results were not available to residents without the need to request. An interview was conducted on 3/16/2011 at 8:10 AM with the facility Administrator. During the interview, the facility Administrator confirmed the survey results were not readily accessible to the residents. | 2015-01-01 |
| 11779 | 11779 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2011-05-24 | 356 | C | 0 | 1 | 6TPT11 | Based on observations and staff interview, the facility failed to post Nurse Staffing information on a daily basis. In addition, the facility failed to maintain the Nurse Staffing information for a minimum of 18 months as required. This potentially affected all 38 residents who currently resided in the facility. Findings are: A. Observations on 5/17/11 at 9:45 AM, 5/18/11 at 7:00AM and 1:20 PM, and 5/19/11 at 6:20 AM and 10:00 AM revealed the Nurse Staffing information was not posted. B. Interview with the Director of Nursing on 5/19/11 from 10:00 AM until 10:12 AM revealed the facility had not been posting the Nurse Staffing information and there were no past records to indicate the information had been completed and maintained. | 2015-01-01 |
| 12055 | 12055 | LITZENBERG MEMORIAL COUNTY HOSPITAL | 28A050 | 1715 26TH STREET | CENTRAL CITY | NE | 68826 | 2011-03-31 | 287 | C | 0 | 1 | 17OG11 | Based on record review and interview, the facility failed to ensure that Resident Assessments were transmitted within the required time frame for 9 of 9 residents reviewed (Residents 1,5, 8, 9, 11, 17, 18, 19 and 20.) Sample size was 10 plus 10 non sampled residents. The facility census was 31. Findings are: Interview with the MDS (Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) Coordinator on 3/30/11 at 2:34 PM revealed that the facility's software had been having technical difficulties and that the facility has not been able to transmit with out late submission errors since September of 2010. The MDS Coordinator went on to report that the software vendor had been notified of the technical errors numerous times since the errors began and that the technical errors still continued. Review of the facility's CMS (Centers for Medicare and Medicaid Services) Submission Final Validation Reports dated 3/15/11, 3/16/11, 3/21/11, 3/23/11 and 3/24/11 revealed that Resident's 1, 5, 8, 9, 11, 17, 18 and 19 had a submission message of "Record Submitted Late: The submission date is more than 14 days after the (MDS Completion Date) or (Care Plan Completion Date).." Review of the Long - Term Care Resident Assessment Instrument User's Manual 3.0 dated July 2010 revealed, "Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date." | 2014-11-01 |
| 12056 | 12056 | QUALITY LIVING, INC | 28A060 | 6404 NORTH 70TH PLAZA | OMAHA | NE | 68104 | 2010-09-14 | 167 | C | 0 | 1 | S03O11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-004.08 AND 12-006.05(11). Based on observation and interview; the facility staff failed to ensure accessibility of past survey results and failed to post a notice as where the survey results are located. The survey consisted of 20 sampled and 2 non-sampled residents. The facility staff identified a census of 97. Findings are: On 9/13/2010 from 11:35 AM to 12:55 PM a environment inspection was conducted with the Maintenance Supervisor and Vice President of Residential Services (VPRS). During the inspection, the previous survey results were behind and next to the nurses station in the administrative building. The survey results were at a height of approximately 5 feet ant 8 inches. Further inspection revealed there was not a notice posted to inform residents of the location of the pervious survey results. On 9/14/2010 at 4:30 PM an interview was conducted with the VPRS. During the interview, the VPRS stated there was not a "notice posted" to inform residents of the location of the previous survey. | 2014-11-01 |
| 12182 | 12182 | NEBRASKA SKILLED NURSING & REHAB | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2010-08-11 | 167 | C | 0 | 1 | EGGE11 | LICENSURE REFERENCE NUMBER 12.006.05(11) Based on record review and interview; the facility staff failed to include deficiency statements that resulted from past complaint investigations in the most recent survey book to ensure that these were made available for examination by residents. This had the potential to effect all residents that resided in the facility. The facility census was 143. Findings are: Record review of the book containing the results of the most recent survey of the facility conducted by the State surveyors revealed the presence of the statement of deficiencies that resulted from the last annual survey and complaint investigation of the facility on 5/14/09. The book did not contain statements of deficiencies which resulted from past substantiated complaint investigations which were conducted in the facility on 4/19/10, 5/17/10 and 6/23/10. Interview on 8/10/10 at 9:15 AM with the facility Administrator confirmed that the survey result book did not contain the statements of deficiencies which resulted from past substantiated complaint investigations which were conducted in the facility on 4/19/10, 5/17/10 and 6/23/10. | 2014-09-01 |
| 12209 | 12209 | GOLDEN LIVINGCENTER - NORFOLK | 285101 | 1900 VICKI LANE | NORFOLK | NE | 68701 | 2011-04-13 | 167 | C | 1 | 1 | J6Z911 | Based on observations, record review and staff interview the facility failed to post the results of the last survey and/or complaint investigations for resident and family access. Facility census was 52. Findings are: Findings are: During the initial tour of the facility on 4/5/11 at 8:45 AM the Survey Inspection Notebook was observed on a table next to the Social Services Office. The notebook contained a deficiency statement from the 2009 annual survey. There was no deficiency statement for the 2010 annual survey. Further observations from 8:00 AM until 8:03 AM on 4/5/11, 4/6/11, 4/711, 4/11/11, and 4/12/11 revealed the 2010 deficiency statement had not been placed in the notebook. During interview on 4/12/11 from 2:30 PM until 2:35 PM the Administrator verified the deficiency statement was not present in the Survey Inspection Notebook. | 2014-09-01 |
| 12210 | 12210 | GOLDEN LIVINGCENTER - NORFOLK | 285101 | 1900 VICKI LANE | NORFOLK | NE | 68701 | 2011-04-13 | 170 | C | 0 | 1 | J6Z911 | Based on record review and resident and staff interviews the facility failed to deliver mail to residents routinely on Saturdays. Facility census was 52. Findings are: A. Review of the facility's Admission Packet (information given to residents and families on admission) on 4/13/11 revealed, "The US (United States) Post Office delivers and picks up mail daily Monday-Saturday, except on holidays". B. During the Resident Council interview conducted on 4/11/11 from 9:45 AM until 10:10 AM, the resident representative for the group revealed that the residents do not routinely receive their mail on Saturdays. The representative stated the mail is delivered by the mailman but does not get sorted until Monday; "It depends who is working". C. Interview with the Business Office Manager (BOM) on 4/11/11 from 10:30 AM until 10:35 AM revealed the mail is not delivered to the residents every Saturday. The BOM indicated that the manager on duty is supposed to sort the mail and deliver it to residents however; it is not always happening. | 2014-09-01 |
| 12216 | 12216 | GOLDEN LIVINGCENTER - NORFOLK | 285101 | 1900 VICKI LANE | NORFOLK | NE | 68701 | 2011-04-13 | 356 | C | 0 | 1 | J6Z911 | Based on observations and staff interview the facility failed to post Nurse Staffing information on a daily basis, in a prominent place, readily accessible to residents and visitors at the beginning of each shift. This potentially affected all 52 residents who currently resided in the facility. Findings are: A. Observation on 4/5/11at 8:45 AM revealed the Nursing Staffing sheet was not posted. B. On 4/6/11 at 8:00 AM the Nurse Staffing sheet was posted on a clipboard next to the main lobby area of the facility. The names of the staff on duty in the traditional area of the facility were identified, however the actual hours worked and the total hours were not posted. In addition, staff members on duty in the Alzheimer's Care Unit (ACU) were not identified on the Nurse Staffing sheet. C. On 4/7/11, 4/11/11, and 4/12/11 at 8:00 AM the Nursing Staffing sheets were not posted. D. Interview with the Director of Nursing on 4/12/11 from 2:45 PM until 2:50 PM verified the hours had not been posted as required. The Director of Nursing further verified the Nursing Staffing sheets were probably lying on the desk at the Nurses' Station. | 2014-09-01 |
| 12288 | 12288 | ROCK COUNTY HOSPITAL LTC | 2.8e+279 | 100 EAST SOUTH STREET | BASSETT | NE | 68714 | 2011-01-31 | 356 | C | 0 | 1 | DTVN11 | Based on observations, review of nurse staffing postings, and staff interview the facility failed to post the daily nurse staffing information in a prominent place that was accessible as well as visible to the residents and any visitors. The staffing information was not posted in a timely manner on two out of the three days of the survey and review of staff postings from 1/13/11 through 1/30/11 indicated that information had not been filled in completely. Facility census was 27. Findings are: A. During the initial tour on entrance to the facility 1/26/11 at 9:30 AM it was observed that the form used for staff posting was on display in a plastic sleeve posted on the wall behind the nurse ' s station but no information was listed on the form. Interview with Charge Nurse E regarding daily staffing information posting from 10:00 -10:05 AM revealed that " we normally post it about 10:00 AM. " Staffing information was then completed and posted by this nurse. B. On 1/27/11 the nurse staffing information was not posted when checked at the following times; 6:50 AM, 7:30 AM, 8:10 AM, 8:40 AM, 9:15 AM, 10:30 AM, 11:00 AM, and 12:30 PM. C. Review of nurse staffing data postings from 1/11/11 through 1/30/11 revealed that on the following dates the resident census was not completed for the 2:00 PM to 10:00 PM shift, 1/12/11. 1/20/11, 1/22/11 and 1/28/11 and resident census was not completed for the 10:00 PM to 6:00 AM shift on 1/17/11, 1/18/11, and 1/29/11. In addition staffing hours were not completed for the 6:00 AM to 2:00 PM shift on 1/20/11, and hours were not posted for the 2:00 PM to 10:00 PM shift for the dates of /12/11 and 1/20/11 D. On 1/26/11 and 1/31/11 the nurse staffing information was posted in a plastic sleeve located behind the nurse ' s station. The information was printed in small print with a pencil on letter sized paper which made the information inaccessible and not visible to residents and visitors. | 2014-09-01 |
| 12308 | 12308 | GOLDEN LIVINGCENTER - NELIGH | 285124 | P O BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2010-11-17 | 465 | C | 0 | 1 | RWEZ11 | LICENSURE REFERENCE CODE: 175 NAC 12-006.18 Surveyor Based on observations and staff interview the facility failed to maintain the kitchen in a clean and sanitary manner as soiled rubber floor mats were placed in a dish rack on the dish line of the mechanical dishwasher. Dietary staff used the dish sprayer to spray water on the soiled floor mats. This practice had the potential to affect all 66 residents who ate out of this kitchen. Sample size was 15. Facility census was 66. Findings are: A. During the initial tour of the kitchen on 11/4/10 from 1:35 PM until 1:45 PM, 2 soiled rubber floor mats approximately 5 foot by 3 foot were observed sitting in a dish rack on the dish line of the mechanical dishwasher. The floor where the mats had been removed from contained a heavy deposit of dirt, water and food soil. B. Interview with the Dietary Manager on 11/4/10 from 1:43 PM until 1:45 PM revealed that is how the floor mats are cleaned daily. The Dietary Manager further stated the mats were previously run through the dish washer but too much dirt accumulated in the bottom of the dishwasher, "so now we just put them in the dish rack, use the dish sprayer and spray them off with water". | 2014-08-01 |
| 12360 | 12360 | MONTCLAIR NURSING AND REHABILITATION CENTER | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2011-03-03 | 167 | C | 1 | 1 | 7MFM11 | LICENSURE REFERNCE NUMBER: 175 NAC 12.006.05(11) Based on observation and interview the facility failed to ensure that the state agency survey results book was available for public viewing. This had the potential to affect all residents that resided in the facility. The facility census at time of survey was 159. Findings are: Observation was conducted by the state surveyors on March 1, 2011 for the book containing the results of the most recent survey of the facility. There was no book, or signage indicating where the survey results book was located, in either the front entry, dining room or sitting area of the facility. Inquiry was made to Acting DON of the book location and the Acting DON was unable to locate the survey results book. Interview on 3-1-11 at 12:40 PM with the Acting DON and Interim Administrator confirmed that the survey result book was not located anywhere within the facility; thus the survey results book was not available for public viewing. | 2014-07-01 |
| 12409 | 12409 | WAVERLY CARE CENTER | 285143 | 11041 NORTH 137TH ST | WAVERLY | NE | 68462 | 2010-10-28 | 167 | C | 0 | 1 | 242Q11 | Licensure Reference Number 175 NAC 12-006.05(11) Based on observation and staff interview, the facility failed to ensure all survey results from the past year were contained in the survey results book available for review. Facility census 52. Survey sample 13. Findings include: Tour of the facility on 10/28/10 at 10:45am, revealed that the survey results book located on the nursing counter adjacent to the main entrance to the facility, contained past years of survey reports, but failed to contain a copy of the complaint survey deficiency report from July 2010. Interview with Administrator at time of tour revealed that had neglected to get a copy of the July 2010 survey deficiency statement in the book, but would get included and remove the older reports from 2007 and 2008. | 2014-07-01 |
| 12506 | 12506 | SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE | 2.8e+294 | 645 OSAGE STREET | SIDNEY | NE | 69162 | 2011-09-07 | 356 | C | 0 | 1 | 9BH911 | Based on observations, record reviews, and interview, the facility failed to: 1) display accurate information regarding staff providing direct care to residents; and 2)identify hours worked by shift for Registered Nurses, Licensed Practical Nurses, and Nurse Aides on the staff posting form. Stage 2 Sample size was 17. Facility census was 52. Findings are: Initial tour of the facility on 8/31/11 between 10:50 a.m. and 11:10 a.m. revealed the facility had posted a form indicating the licensed staff, unlicensed nursing staff, other staff, and facility census. The form was posted at the front entrance to the facility next to the nurse's station. The form identified a census of 52 residents and day shift staffing documented as one licensed nurse staff on duty and 5 unlicensed nursing staff on duty. An interview with the charge nurse, RN (Registered Nurse)-D on 8/31/11 at 11:10 a.m. was conducted. The RN stated the staff on duty providing direct care to residents included one RN; one LPN (Licensed Practical Nurse), five Medication Aides, one Restorative Medication Aide, and one staff member working the floor between 6 a.m. and 9 a.m. These staff were verified on duty by observation. At 1:00 p.m. on 8/31/11 the posted staffing form had been revised to indicate 6 unlicensed staff were on duty for the day shift and the census was corrected to show 53 residents. Record review of facility posting forms displayed between 8/30/11 and 9/6/11 revealed the facility does not separate to distinguish the licensed staff as RN or LPN. The form does not identify the actual hours each of the direct care staff provide personal care to the residents. Interview with the DON (Director of Nursing) on 9/7/11 at 9:00 a.m. verified the staff posting on 8/31/11 had not matched the actual numbers of staff providing direct cares to residents. The DON also verified that charge nurses are responsible to complete the forms at the beginning of each shift and was not aware if these nurses had any education related to the regulatory requirement for sta… | 2014-07-01 |
| 12666 | 12666 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2010-12-09 | 356 | C | BMMD11 | Based on observations and staff interview, the facility failed to include the resident census on the daily nursing staff posting. The facility census was 80. Findings are: Observation on 12/6/10 at 8:30 AM, during the initial tour of the facility, revealed the daily staff posting form at the front nurses' station. Further observation revealed that the section for the total resident census was blank. Observations on 12/7/10 at 1:30 PM, on 12/8/10 at 8:30 AM, and on 12/9/10 at 9:00 revealed no resident census posted on the form. Interview on 12/9/10 at 10:40 AM with the DON (Director of Nursing) confirmed that the resident census was not posted as required. | 2014-04-01 | ||
| 12970 | 12970 | THE LUTHERAN HOME | 285171 | 530 SOUTH 26TH STREET | OMAHA | NE | 68105 | 2010-09-23 | 167 | C | ZEZV11 | LICENSURE REFERENCE NUMBER 12.006.05(11) Based on record review and interview; the facility staff failed to include deficiency statements that resulted from past complaint investigations in the most recent survey book to ensure that these were made available for examination by residents. This had the potential to effect all residents that resided in the facility. The facility census was 45. Findings are: Record review of the book containing the results of the most recent survey of the facility conducted by the State surveyors revealed that the book did not contain statements of deficiencies which resulted from past substantiated complaint investigations which were conducted in the facility on 1/28/10 and 7/15/10. Interview on 9/20/10 at 4:40 PM with the facility Administrator confirmed that the survey result book did not contain the statements of deficiencies which resulted from past substantiated complaint investigations which were conducted in the facility on 1/28/10 and 7/15/10. | 2014-01-01 | ||
| 1 | 1 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2019-02-20 | 644 | D | 0 | 1 | J44111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a level 2 PASARR ( Pre-Admission Screening and Resident Review) Program had been completed on one resident (Resident 2) of 1 sampled resident, when newly diagnosed with [REDACTED]. The facility census was 96. Findings are: Record Review of PASSAR Level one completed in 2012 did not recommend the Level II. This PASSAR identified Bi-Polar Disorder but did not identify the Schizo-effective Disorder, Mania, [MEDICAL CONDITION] Disorder, and Depression with psychiatric features, treatment refractory [MEDICAL CONDITIONS], Atypical [MEDICAL CONDITION]. Record review of Note to Attending Physician/Prescriber revealed; Resident 2 received antipsychotic medication and the clarification for [DIAGNOSES REDACTED]. Record review of initial [DIAGNOSES REDACTED]. An interview on 02/19/19 at 04:17 PM with the DON (Director of Nurse) confirmed; Resident 2 had not been reassessed for PASSAR level 2 after the [DIAGNOSES REDACTED]. An interview on 02/21/19 at 03:29 PM with the SSD (Social Services Director) confirmed the re-evaluation PASSAR had not been submitted. An interview on 02/21/19 at 03:40 PM with the SSD confirmed; that information had been sent to the psychiatrist on 02/19/19. The information had been received by the facility on 02/21/19 and had been sent to Ascend for re-evaluation. | 2020-09-01 |
| 2 | 2 | SUMNER PLACE | 285002 | 1750 SOUTH 20TH STREET | LINCOLN | NE | 68502 | 2019-02-20 | 656 | D | 0 | 1 | J44111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License and Reference Number 175 NAC 12 Based on observation, record review and interview, the facility failed to ensure that residents care plans were individualized to meet the the residents fluid needs. This had the potential to effect 2 residents, Residents # 21 and # 28. The facility census was 96. Resident #21 02/14/19 03:38 PM observed in room and does not respond to verbal cues. 02/19/19 10:30 AM observed in room and does not respond to verbal cues. Record review of the residents MDS (Minimum Data Set is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements dated 08/28/18 revealed a BIMS (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment) of 2 indicated severely impaired cognition. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 4/28/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an Interview with LPN(Licensed Practical Nurse)3 D confirmed the resident does not have the ability to choose what fluids to consume, when to consume fluids or how much fluids to consume. Resident #28 On 02/14/19 at 2:35 PM resident observed in bed with eyes open does not respond to verbal cues. On 02/20/19 at 10:16 AM resident observed in bed with eyes open does not respond to verbal cues. Record review of the residents MDS dated [DATE] revealed a BIMS of 2. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 12/3/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids … | 2020-09-01 |
| 3 | 3 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 241 | D | 0 | 1 | X2RI11 | Licensure Reference Number: 175 NAC 12-006.05 (4) Based on observation, record review and interview; the facility failed to ensure one resident (Resident 102) of 41 sampled was treated with respect and dignity related to communication. The facility census was 109. Findings are: Review of Resident 102's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 9/20/16 revealed Resident 102 was cognitively intact, had no speech, understood what was being said and was usually understood. Review of Resident 102's Care Plan dated 4/20/16 revealed Resident 102 was able to mouth words but was difficult to understand and would use a spell board to communicate. Review of a Family Meeting Note for Resident 102 dated 10/12/16 revealed, The patient has identified the following goals/expectations of the program: Res (Resident) asked that staff use (Resident 102's) the communication board more. An interview with Resident 102 was conducted on 12/20/2016 at 03:16 PM with the assistance of Registered Nurse (RN) C using Resident 102's communication board (also referred to as the spell board). Resident 102 indicated staff needed to improve communication with Resident 102. Resident 102 further reported staff do not look at Resident 102's face when they are in the room and could not tell when Resident 102 was attempting to communicate with them. RN C then asked Resident 102 if the staff utilized the spell board when communicating and Resident 102 responded no. Observation of Nursing Assistant (NA) D and NA [NAME] on 12/28/2016 at 2:03 PM revealed while NA D and NA [NAME] were assisting Resident 102 with repositioning. Resident 102 mouthed a sentence in an attempt to communicate without either NA noticing. NA D and NA [NAME] were talking to each other and occasionally made eye contact with each other while continuing to provide cares for Resident 102. Resident 102 attempted an additional five times to mouth the same sentence before either NA noticed. NA D then noted Resident 102 mouthing words and aske… | 2020-09-01 |
| 4 | 4 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 318 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFEFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview and record review; the facility failed to prevent the potential for a decrease in range of motion for one resident (Resident 163) of 41 sampled residents. The facility census was 109. Findings are: On 12/20/16, Resident 163 was observed seated in a wheel chair. The resident was noted to have both arms pulled up to sides, wrists bent and fingers drawn up into the palms. Restorative Aide - A (RA-A) was interviewed on 12/27/16 at 10:29 AM about the restorative program for Resident 163. RA-A said that the resident received range of motion (ROM) three times per week and that the focus had been on the contractures (a condition of fixed high resistance to the passive stretch of a muscle) of the lower extremities. When asked if Resident 163 was getting ROM to fingers and wrists, RA-A said orders had not been received for this and ROM was not being done to the upper extremities. Review of the Occupational Therapy (OT) Evaluation dated 10/3/16 revealed that Resident 163 had a [DIAGNOSES REDACTED]. The evaluation further revealed, Range of motion significantly limited by contractures throughout upper extremity joints and rigidity. The OT then referred to the functional maintenance program (FMP) in the chart for the R[NAME] Review of the personal FMP dated 10/3/16 for Resident 163 revealed the resident was to have ROM to both upper extremities including shoulders, elbows, wrists, fingers and thumbs. On 12/29/16 at 4:35 PM, Unit Manager B was interviewed about Resident 163's restorative program. The Unit Manger confirmed that ROM should have started right after the OT evaluation was completed on 10/3/16. The manager confirmed there was a communication mix up and ROM to the upper extremities had not started until 12/28/16. | 2020-09-01 |
| 5 | 5 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 329 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interview, the facility failed to provide non pharmacological interventions prior to the administration of an antianxiety medication and failed to evaluate the effectiveness of the medication after administration for one (Resident 265) of 41 residents sampled. The facility had a census of 109. Findings are: Review of Resident 265's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) dated 12/11/16 revealed Resident 265 was cognitively intact with disorganized thinking, had indicators of depressed thoughts or feelings and no behaviors. Resident 265 required assistance to complete tasks of daily living, had occasional pain and had [DIAGNOSES REDACTED]. Review of Resident 265's Care Plan dated 12/20/16 revealed an identified problem of a potential for complications related to the use of antianxiety and antidepressant medication. Interventions included Compliment drug therapies, encourage participation in activities on the unit and therapies. Offer use of holistic cart with music and aroma therapies. Provide a quiet calm atmosphere when able. Review of Resident 265's Active Orders for (MONTH) (YEAR) revealed an order for [REDACTED]. Review of a Work List printed on 1/3/17 from the electronic medical record revealed Resident 265 was administered [MEDICATION NAME] .25 mg (milligrams) on 18 occasions during the month of (MONTH) (YEAR) at various times in the afternoon and evening. Further review of the electronic medical record revealed no documentation regarding what non pharmacological interventions were administered prior to administering the PRN antianxiety and no documentation of whether or not the [MEDICATION NAME] had been effective in treating the anxiety. Inter… | 2020-09-01 |
| 6 | 6 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 467 | D | 0 | 1 | X2RI11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observations and interview, the facility failed to ensure the ceiling vents were working in 2 resident rooms (Rooms 300 and 427) out of 39 resident rooms. The facility census was 109. Findings are: A) Observation on 1-03-17 at 12:40 PM revealed the ceiling vent in the bathroom of Room 427 was not working. Interview on 1-3-17 at 12:40 with the MS (Maintenance Supervisor) revealed the ceiling vent was closed and required a maintenance staff to open it. The MS confirmed the vent should not have been closed. B) Observation on 1-3-17 at 1:15 PM revealed the ceiling vent in the bathroom of [RM #]0. Interview on 1-3-17 at 1:15 PM with the MS revealed the ceiling vent was open and confirmed it was not working. Interview on 1-3-17 at 2:33 PM with the MS revealed the room ceiling vents were to be checked monthly by the Housekeeping staff and documented on an Environmental Services Inspection Sheet form. Review of the Environmental Service Inspection Sheets revealed Room 427 was last inspected on 12-16-16 and no concerns were documented about the ceiling vent. [RM #]0 was last inspected on 11-11-16 and no concerns were documented about the ceiling vent. | 2020-09-01 |
| 7 | 7 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2018-01-30 | 658 | D | 0 | 1 | BRED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10A2 Based on observation, record review and interview; the facility failed to provide a nourishment within the facility policy time frame for a short acting insulin. This violation had the potential to affect one resident (Resident 14) out of 5 insulin dependent residents. The census was 105. Findings are: During an observation on 1/18/18, LPN A (Licensed Practical Nurse) administered [MEDICATION NAME] ([MEDICATION NAME]) insulin (a short acting insulin) to Resident 14 at 12:12 PM. Resident 14 went to the dining room and was served lunch at 12:38 PM. An interview on 1/30/18 at 08:30 AM with LPN A revealed that short acting insulin should be given 15-20 minutes before meals. A record review of the policy entitled: medications: [REDACTED]. An interview with the Unit Director confirmed that within 15 minutes of administration of short acting insulin a nourishment should be offered or given to the resident. | 2020-09-01 |
| 8 | 8 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 561 | D | 1 | 1 | GLUX11 | > Licensure Reference Number 175 NAC 12-006.05(4) Based on interviews and record reviews, the facility failed to ensure residents bathing preferences were assessed and provided according to the resident's preferences. This failure had the potential to affect two residents, Resident #62 and 102. The facility census was 115. Findings; [NAME] 05/28/19 03:31 PM an interview with Resident #62 revealed that the resident wants 2 showers a week in the evenings, but is only receiving one a week during the day. Record review of MDS (Minimum Data Set, a health status screening and assessment tool used for all residents of long term care nursing facilities dated 4/9/19 revealed a BIMS (Brief interview of mental status) score of 14 (BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment , Record review of the residents care plan revealed bathing not addressed on the care plan. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. Record review of Worklist Report Visit task Shower dated from 3/4/19 to 5/31/19 revealed resident to receive 2 showers a week. Week of 3/10/19 received one shower, week of 3/17 received no showers, week of 4/7/19 received one shower, and week of 4/21/19 received one shower. Weeks 5/8/19 through 5/31/19 resident received one shower a week. Three of these showers were given in the evening. Record review of the resident's electronic medical record revealed no documentation related to the resident's choices related to bathing. 06/04/19 04:39 PM DON (Director of Nursing) confirmed resident #62 was only receiving one shower a week and preferences are not documented. B An interview on 05/28/19 at 12:34 PM with Resident 102 who had expressed the preference to have a bath every other day, the resident reported that the facility had a bath schedule for twice a week. An interview on 05/30/19 at 12:08 PM with RN C confirmed that the Resident were placed on the bathi… | 2020-09-01 |
| 9 | 9 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 578 | D | 0 | 1 | GLUX11 | Based on record review and interview, the facility failed to ensure that the residents advanced directives were included on resident care plans. This had the potential to affect 6 Residents (Resident #6, 53, 62, 94, 102 and 207). The facility census was 115. Findings; A Record review of St Jane de Chantel LTC (Long Term Care) Team Care Plan dated 5/22/19 for Resident # 6 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/9/19 for Resident # 53 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 4/17/19 for Resident # 62 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/7/19 for Resident # 94 revealed advanced directives were not documented on the residents care plan. Record review of St Jane de Chantel LTC Team Care Plan dated 5/23/19 for Resident # 207 revealed advanced directives were not documented on the residents care plan. Record review of the Advanced Directives for Patients including Do Not Resuscitate Status policy revealed; no documentation to include advanced directives on the residents care plans. On 05/29/19 at 02:19 PM an interview with the DON (Director of Nursing) confirmed the facility does not include advanced directives on the residents care plans. E. Record review of Resident 102's Advanced Directives revealed the preference for a Full Code Status. Record review of St Jane de Chantel LTC Team Care Plan dated 5/14/19 revealed the Advanced Directives were not documented on the resident's care plan. An interview on 05/29/19 at 02:43 PM with the DON (Director of Nurses) confirmed that the facility had not included Advanced Directives on the care plan. | 2020-09-01 |
| 10 | 10 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 623 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-0060.5(5) Based on interview and record review, the facility failed to notify the resident's representative of the reason for transfer to the hospital in writing. This affected 2 residents (Residents 58 and 29) of 4 residents reviewed. The facility census was 113. Findings are: [NAME] Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the reason for transfer in writing was given to the resident or resident's representative. Interview on 6/4/19 at 2:17 PM with the DON revealed the facility did not provide the reason for transfer in writing to the resident or resident's representative. B. Record review of Resident 29 face sheet revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Record review of Documentation of Communication / Event dated 12/12/18 revealed that Resident 29 was sent to the hospital for continued swelling, discoloration and pain to the right upper leg. The resident was admitted to the hospital for [MEDICAL CONDITION] (swelling) and pending tests. Interview on 5/29/19 at 3:14 PM with the family confirmed that the resident was discharged to the hospital and stated that no written information related to the reason for discharge was provided at the time of the transfer. Interview on 5/30/19 at 2:53 PM with the facility Administrator confirmed that no written notice of the reason for the transfer was provided to the resident or family at the time of the transfer. | 2020-09-01 |
| 11 | 11 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 625 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide information regarding bed hold to the resident at the time of transfer. This affected 1 resident (Resident 58) of 4 residents reviewed. The facility census was 113. Record review of Resident 58's History and Physical dated 5/14/19 revealed [DIAGNOSES REDACTED]. Record review of Documentation of Communication/Event dated 5/2/19 revealed the Resident 58 was transferred to the hospital due to a change in vital signs and level of consciousness. The resident's representative was notified at the time of transfer. The documentation revealed an absence of mention that the bed hold policy was given to the resident. Review of Resident's Rights policy dated 8/31/10 revealed the nursing staff, social worker, or admission personnel will ask if the resident wanted a bed hold if the resident would be out of the facility. Interview on 6/4/19 at 2:17 PM with the DON (Director of Nurses) revealed the DON was unable to find Resident 58's completed bed hold form. The DON revealed the bed form was not provided to the resident or completed for Resident 58's transfer to the hospital. | 2020-09-01 |
| 12 | 12 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 644 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit a Pre-Admission Screening and Resident Review (PASARR, an assessment used to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for reevaluation after identification of a new mental health diagnosis. This affected 1 resident (Resident 53) of 1 resident reviewed. The facility census was 113. Findings are: Record review of Nebraska Level I Form PASARR dated 9/13/11 revealed the Resident 53 did not have any serious mental illness, including [MEDICAL CONDITION] Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), under Section 1 - Mental Illness. Record review of History and Physical dated 7/25/14 revealed Resident 53's past medical history included [MEDICAL CONDITION] Disorder. Record review of Resident 53's comprehensive MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/16/19 revealed the resident did not have a Level II PASARR (evaluation of if the resident needed specialized services). The MDS did note the resident had [MEDICAL CONDITION] Disorder. Record review of Resident 53's care plan dated 4/9/19 revealed the resident was evaluated for PASARR II with a start date of 7/30/18. Interview on 6/4/19 at 1:55 PM with the DON (Director of Nursing) revealed Resident 53 was admitted to the facility with the [DIAGNOSES REDACTED]. Interview on 6/4/19 at 1:56 PM with SW-A (Social Worker) revealed the PASARR form was completed in 2011 and was unable to provide details on why the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. SW-A revealed the resident was a Level I PASARR, and was unable to provide details on why the care plan noted PASARR II. Interview on 6/4/19 at 2:13 PM with the DON revealed the facility did not submit the PASARR for re-evaluation when the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 13 | 13 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 693 | D | 0 | 1 | GLUX11 | Licensure Reference Number 175 NAC 12-006.09D6 (1) Based on observation, record review and interview the facility staff failed to ensure the method to check residual (stomach fluids) for placement of a feeding tube was completed according to facility policy for 1 resident (Resident 9) of 4 sampled residents. The facility census was 115. Findings are: An observation on 06/04/19 at 12:00 PM of Nurse LPN H of medication administration for Resident 9 via PEG (Percutaneous Endoscopic Gastrostomy- a tube passed into a residents stomach through the abdominal wall to provide a means for feeding and medication administration when oral intake is inadequate) tube. LPN H checked the PEG tube for proper placement by aspiration of stomach contents with a 60 cc syringe the total amount of stomach contents aspirated was 210cc. Resident 9 had been eating lunch at the time of the aspiration. LPN H disposed of the stomach contents. Record review of the Feeding tube management policy dated 4/16/19 revealed; for Residual Procedures if the gastric residual volume 300 ml or less replace the entire residual volume obtained, Flush with 30 Ml water. Interview on 06/04/19 03:19 PM with the DON confirmed that if the residual with a tube feeding is less than 300 cc the residual is to be replaced not wasted. | 2020-09-01 |
| 14 | 14 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 758 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure that a [MEDICAL CONDITION] as needed medication did not exceed the required 14 day stop date for 1 (Resident 40) of 6 residents reviewed for unnecessary medication use. The facility census was 115. Findings are: Record review of a facility policy entitled Automatic Stop Orders dated 4/1/14 revealed that PRN (as needed) [MEDICAL CONDITION] (a group of medications that affect behaviors) medications have a 14 day limit. These medications may be renewed for subsequent 14 days if deemed appropriate by the licensed practitioner. Record review of Resident 40's Face sheet showed an admission date of [DATE]. Record review of Resident 40's [DIAGNOSES REDACTED]. Record review of Resident 40's admission Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/29/19 identified that resident 40 used a Hypnotic (a medication used to induce sleep) medication 3 times in the look back period for the assessment. Record review of Active orders dated 6/4/19 revealed an order for [REDACTED]. The order included nurse instructions that read: Time frame for administration is limited to 14 days unless a longer time frame is deemed appropriate by the prescribing practitioner. Record review of Resident 40's Medication Administration Records revealed that Resident 40 received the hypnotic medication 4 times in (MONTH) 2019, 7 times in (MONTH) 2019 and 4 times in (MONTH) 2019. Interview on 6/4/19 at 11:23 AM with the Director of Nursing confirmed that the stop date on the hypnotic was past the required 14 day time limit. It should have been stopped after 14 days and reordered as necessary. | 2020-09-01 |
| 15 | 15 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2019-06-04 | 759 | D | 0 | 1 | GLUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D The facility failed to maintain a medication error rate of less than 5 %, which affected 3 residents (Resident 9, 51 100). The medication error rate was 24.14%. The facility census was 115. FINDINGS ARE: [NAME] An Observation on 6/3/19 at 12:05PM of medication administration by LPN (Licensed Practical Nurse) J for Resident 100. LPN J performed hand hygiene, donned gloves, and prepared Guar Gum (fiber supplement) by mixing it with 60 mL (milliliters-a unit of volume) of water. LPN J measured [MEDICATION NAME] (a medication used for [MEDICATION NAME]) 10mL and mixed it with the Guar Gum. LPN J doffed gloves and donned new gloves. LPN J checked the residual (stomach contents) of the PEG tube (Percutaneous Endoscopic Gastrostomy- a tube passed into a residents stomach through the abdominal wall to provide a means for feeding and medication administration when oral intake is inadequate) tube it was zero. LPN J pushed 60cc of water for the flush prior to the medication administration. LPN J administered the commingled medications. LPN J changed gloves. LPN J administered a 15 cc flush. Gloves changed and the tubes were exchanged for enteral feeding. LPN J primed the tubing and administered 237Ml of Pedisure Peptide (a feeding) that was hung for gravity flow. Gloves were changed and LPN J added 30 mL water flush. Gloves were changed and the tubing was removed. Hand Hygiene was performed. B. An observation on 6/3/19 at 12:55PM of medication administration by RN (Registered Nurse) K for Resident 51 revealed RN K measured the medications [MEDICATION NAME] 30m. RN K donned gloves. RN K measured tap water 100mL. RN K checked residual and equaled 60MmL and this was replaced. RN K mixed approximately 30mL of water with the measured medication and drew it into the syringe. No flush was performed by RN K. RN K administered the medication/water mixture by push and the remainder of the water was administered via gr… | 2020-09-01 |
| 19 | 19 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 657 | D | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, facility failed to ensure care plans were updated with resident individualized preferences for activities for 4 residents (Residents 226, 195,136, 79). Facility census was 232. Findings are: Resident 79 On 01/21/19 a record review of annual MDS (Minimum Data Summary) (part of the federally mandated process for clinical assessment of all residents) dated 2/16/18 revealed Resident 79 likes were completed by staff and include having family or friend involved in discussions about care, listening to music, being around animals such as pets, doing things in group of people, doing favorite activity, and going outside weather permitting. On 01/22/19 a record review of Recreation Initial Assessment, Past and Present Leisure Interests, Activity List Quick Reference, dated 2/25/18 for Resident 79, revealed a current interest in small group dining out, holiday celebrations, drive/outings, and individual watching movies, listening to music, watching TV, getting outside, and pets. On 01/22/19 a record review of Care Plan for Resident 79 revealed goals of attending social/entertainment groups off neighborhood monthly, participating in activities such as music groups sensory stimulation or pet therapy monthly and attend at least one community outing of choice in next 90 days. Interventions are invite resident to activity and escort, encourage participation in activities of choice, provide socially stimulating activities, providing pet therapy, invite on outings, provide choices, hang outing slip in room as a reminder of day/time of community outing. Resident 136 On 01/21/19 a record review of annual MDS dated [DATE] for Resident 136 revealed listening to music as very important, keeping up with news as somewhat important, and to do/attend favorite activities as somewhat important. 01/22/19 12:14 PM Record review of Recreation Annual assessment dated [DATE] for Resident 136 revealed resident has a current interest in ind… | 2020-09-01 |
| 20 | 20 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-01-23 | 661 | D | 0 | 1 | AD1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, facility failed to develop a discharge summary for Resident 234 of 3 residents sampled. The facility census was 232. Findings are: Review of Resident 234 closed medical record revealed Resident 234 was admitted on [DATE] from the hospital for rehabilitation. Resident 234's condition improved during the stay and Resident 234 was discharged home with home health care to assist on 10/29/2018. Review of Resident 234's medical record revealed no discharge summary. Review of Resident 234's Home Health Face to Face Encounter form dated 10/26/2018 revealed Resident 234 had the following: - Diagnosis: [REDACTED]. - Services needed through home health. - No recapitulation (summary) of Resident 234's progress during the admission addressing the required information from the Interdisciplinary Team. Interview on 01/23/19 at 8:43 AM with the Director of Nursing (DON) revealed no discharge summary with a recapitulation of residents stay is completed. Short term stay rehabilitation residents have discharge summary of therapy and ongoing needs. The physician completes a summary for Home health needs titled Home Health Face to Face Encounter Form. No other discharge summary is completed. | 2020-09-01 |
| 22 | 22 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 580 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC12-006.04C3a(6) Based on interviews and record reviews, the facility failed to notify the resident's representative related to a transfer to the emergency room for 1 resident (Resident 3) of 5 residents sampled. The facility staff identified the census as 231. The findings are: A review of Resident 3's Care Plan dated 2-16-18 revealed that Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 3's Nurses Notes dated 2-22-18 at 10:25 AM revealed that Resident 3 was unable to put weight on their left leg when working with therapy. An order was obtained to get an x-ray of the resident's left leg. A review of Resident 3's Nurses Notes dated 2-22-18 at 2:40 PM revealed that the medical practitioner was notified of the x-ray results and an order was obtained to send the resident to the emergency room . A review of Resident 3's Nurses Notes dated 2-22-18 at 2:45 PM revealed that the resident left the facility by ambulance to the emergency room with a nursing assistant escort. A review of Resident 3's Nurses Notes dated 2-22-18 at 7:00 PM revealed that the facility received a call from the emergency room notifying them that the resident was admitted to the hospital. The House Supervisor was notified and transportation was notified to go to the hospital and pick up the nursing assistant that had escorted the resident. A voicemail was left for the resident's representative to call the facility. An interview conducted on 3-15-18 at 12:01 PM with Registered Nurse (RN) B confirmed that Resident 3's representative was not notified when the resident was sent to the emergency roiagnom on [DATE] and should have been notified. An interview conducted 3-15-18 at 12:52 PM with the Assistant Director of Nursing revealed that the resident representative should be notified of transfers to the emergency room prior to the resident going to the emergency room . A review of the facility's… | 2020-09-01 |
| 23 | 23 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 689 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-00.09D7b Based on observation, interview, and record review, the facility failed to evaluate falls for potential causal factors and implement interventions to prevent reoccurrence for 2 (Residents 2 and 5) of 5 sampled residents. The facility had a total census of 231 residents. Findings are: [NAME] Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's care plan revealed a [DIAGNOSES REDACTED]. Observations on 3/15/18 at 8:43 AM revealed Resident 5 being assisted to transfer from recliner to wheelchair by Nurse Aide A with use of a gait belt and walker. A note attached to Resident 5's closet door reminded Resident 5 to use the call light. Resident 5's Care Plan included a problem dated of self care deficit/high risk for falls dated 1/9/18. The care plan listed the following interventions for falls: -Call light within reach. Check frequently and anticipate all needs. 15 minute safety checks or one to one supervision as needed for safety. -Resident 5 is at high risk for falls. Ensure oxygen tubing isn't a trip hazard. Assist of one for all mobility. -Fall 1/20/18 no injuries -Fall 1/25/18 no apparent injuries -Fall 2/8/18 no apparent injuries -Fall 2/21/18 no injuries noted -Fall 2/25/18 abrasion to right buttock A review of Fall Risk assessment dated [DATE] identified Resident 5 at a high risk for falling. A review of Resident 5's Nurses Notes revealed the following falls: -2/25/18 7:50 AM Resident noted to be in sitting position next chair with table partially tipped over. Resident 5 reported Resident 5 was going to get clothes. Resident had abrasion to lower buttock. Notes taped to Resident's closet to remind to ask for help. -2/21/18 9:15 PM Resident 5 observed sitting on floor in room on bottom. Resident 5 reported feet slipped out in front of Resident 5. No injuries noted. Resident encouraged to use call light. -2/8/18 7:30 AM Resident 5 slid out of recliner chair at 6:45 AM. No appa… | 2020-09-01 |
| 26 | 26 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 690 | D | 1 | 0 | 7ED912 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to provide scheduled toileting for 2 (Resident 21 and 25) of 2 sampled residents. The facility staff identified a census of 130. Findings are: [NAME] Record review of Resident 25's Comprehensive Care Plan (CCP) printed on 1-11-2019 revealed Resident 25 was incontinent of bowel and bladder and that staff were to provide frequent toileting. Observation on 10-09-2019 at 6:30 AM revealed Resident 25 was ambulating in the hall of the secured unit. Observation on 10-09-2019 at 10:15 AM revealed Resident 25 was ambulating in the hall of the secured unit. Further observation revealed the back of Resident 25's red sweat pants had a large wet area to the buttock area extending down to the middle of the back of the upper legs. Observation on 10-09-2019 at 10:20 AM revealed Nursing Assistant (NA) F escorted Resident 25 to Resident 25's room and into the bathroom. NA F removed a saturated brief Resident had been wearing and placed Resident 25 onto the toilet. On 10-09-2019 at 10:30 AM an interview was conducted with NA F. During the interview NA F confirmed Resident 25 had been incontinent through Resident 25's clothing. When asked the last time Resident 25 was assisted with toileting needs, NA F reported this was the first time since 6:30 AM. On 10-09-2019 at 10:35 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview LPN D reported Resident 25 is a heavy wetter . and that Resident 25 should be toileted every 2 hours. On 10-09-2019 at 12:05 PM a follow up interview was conducted with LPN D. During the interview LPN D reported had spoken with the nursing assistants on the unit and none of the NA's reported taking Resident 25 to the bathroom. LPN D confirmed Resident 25 had been up since at 6:30 AM and should have been toileted prior to 10:20 AM. B. Record review of Resident 21's CCP revealed on 8-26-2019 an update to Resident 21 CCP directing the facility staff to to… | 2020-09-01 |
| 27 | 27 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 152 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility staff failed to obtain permission from a guardian on a behavioral modification plan to restrict privileges for 1 (Resident 7) of 1 resident sampled. The facility staff identified a census of 236. Findings are: Record review of an undated Social History sheet revealed Resident 7 had a had a Guardian to manager Resident 7's care. Record review of Resident 7's Comprehensive Care Plan (CCP) dated 6-04-2009 revealed the following: -Restrict (Resident 7) to the unit if Resident 7's blood sugars are equal or greater to 225. -If Resident 7 refuses to get up for breakfast or drinks a Glytol (supplement type of liquid), Resident 7 was to remain on the unit until the following meal for observation. -If refuses to get up for lunch or drink a [MEDICATION NAME], Resident 7 is to remain on the neighborhood until the following meal. -If verbally or physically abusive with staff or peers and unable to direct, Resident 7 was to remain on the neighborhood for 24 hours. -If resident must have a breathing treatment after smoking, there would be no smoking allowed for the remainder of the day. Review of Resident 7's medical record revealed there was no evidence that Resident 7's Guardian had given permission for the restriction of privileges. On 9-19-2016 at 9:09 AM an interview was conducted with Registered Nurse (RN) B. During the interview RN B confirmed Resident 7 had a behavioral modification plan that restricted privileges. During the interview, RN B reported that the behavioral modification plan had not been discussed with the Guardian and there was not any evidence any other staff had spoke to the guardian about the behavioral modification plan. The facility was not able to provide any evidence of the Guardian giving permission for the behavioral modification plan at the time of exit from the facility. | 2020-09-01 |
| 29 | 29 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2016-09-21 | 412 | D | 0 | 1 | 7TIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.14 Based upon observations, interviews and record reviews; the facility failed to follow-up a dental appointment for Resident 210. The facility census was identified as 236. Findings are: [NAME] An observation of Resident 210 on 09/14/2016 at 1:31 PM revealed Resident 210 was observed to be missing several teeth. A record review of Resident 210's care plan dated 02/26/15 revealed under the care plan that for problem #4-Self-care deficit: bathing, hygiene, dressing and grooming. In the interventions section it is noted DCHC Dental clinic without and dates or time frames. A record review of Resident 210's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 02/10/2016 revealed under section L-Oral/Dental Status it was marked: Obvious or likely cavity or broken natural teeth. Interviews with Registered Nurse L (RN L) and Unit Secretary M (US M) on 09/19/2016 at 12:35 PM revealed that Resident 210 has not been seen by a dentist since 04/07/2015. A record review of Dental Chart dated 04/7/2015, revealed the following: patient seen for annual exam and [MEDICATION NAME]. Teeth are badly worn but patient reports no pain, plaque is soft, no significant gingivitis. Recommend 3 month recall. A record review of an undated list of unit's clients needing dental services revealed that Resident 210 was listed and was to be followed up in 3 months from the 04/7/2015 visit. An interview with Director of Nursing (DON) 09/19/2016 02:57 PM revealed that the unit or neighborhood is responsible for scheduling dental appointments. An interview with Social Services Specialist K, (SSS K) on 09/20/2016 at 07:40 AM, revealed that social services does not have any documentation concerning the Resident 210's Power of Attorney (POA) not wanting to have the resident to be seen by the dentist. An interview with the DON on 09/20/2016 at 02:10 PM revealed the DON was not able to find … | 2020-09-01 |
| 32 | 32 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2019-07-03 | 695 | D | 0 | 1 | RRGD11 | Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observations, record reviews and interviews; the facility failed to ensure the oxygen tubing and nasal cannula were not left on the floor, and failed to ensure oxygen tubing was changed per facility policy. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation on 07/02/19 at 09:46 AM revealed Resident 9 sitting up in recliner chair, oxygen off and oxygen tubing including the nasal cannula lying on the floor. Observation on 07/02/19 at 01:00 PM revealed Resident 9 sitting up in recliner chair finishing eating lunch. Oxygen off and oxygen tubing including the nasal cannula lying on the floor. Review of Oxygen Therapy Protocol dated 9/26/12 revealed that if using PRN oxygen, change nasal cannula and tubing every other week. Record review of (MONTH) and (MONTH) Treatment Administration Record (TAR) 2019 revealed no documentation of oxygen tubing being changed. Interview with Director of Nursing (DON) on 07/02/19 at 03:35 PM confirmed that nasal cannula tubing should not be on the floor and that tubing information should be documented on the TAR. Interview with DON on 07/03/19 at 12:57 PM confirmed that no documentation was present to reflect that the oxygen tubing had been changed on Resident 9. | 2020-09-01 |
| 33 | 33 | EASTMONT TOWERS | 285036 | 6315 O STREET | LINCOLN | NE | 68510 | 2019-07-03 | 880 | D | 0 | 1 | RRGD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to ensure staff followed facility policy to wash hands and change gloves after handling used dressings. This had the potential to affect one resident, Resident 9. The facility census was 10. Findings are: Observation of wound care on 07/02/19 at 09:46 AM- 09:46 AM by RN (Registered Nurse) A revealed RN A washed hands and set up supplies on towel placed on chair, applied gloves, took Resident 9's shoe and sock off right foot, cleansed scissors with alcohol pad and cut off outer Kerlix dressing, then removed [MEDICATION NAME] pad and with same gloves on, went to sink and wet wash cloth, applied soap and washed wound. Then RN A removed gloves, washed hands and applied clean gloves, applied gauze drsg to wound and then wrapped area with Kerlix, applied tape, dated dressing, applied Resident 9's sock and shoe and then removed gloves and washed hands. Review of hand washing guidelines dated 12/14 revealed hand washing should be done after handling used dressings. Interview on 7/2/19 at 3:35 PM with DON (Director of Nursing) confirmed that after removing dirty dressings, gloves should be removed, hand hygiene completed and clean gloves applied before continuing with wound treatment. | 2020-09-01 |
| 34 | 34 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 166 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on record reviews and interviews, the facility failed to resolve grievance / complaints for 1 resident (Resident 603) out of 3 residents sampled. The facility census was 138. Findings are: Review of the undated face sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Resident 603 was frequently incontinent of urine. Review of the Grievance Log dated 3-01-16 through 3-30-17 provided by the facility revealed absence of a grievance for Resident 603. Interview via phone on 4-26-17 at 4:35 PM with the Family revealed a grievance was completed on 3-30-17 and the Family handed the grievance to Staff D. The Family never received a response back from the facility since that night for a resolution of the 3 issues the Family had concerns about. Family revealed the 3 issues were. 1) The resident had expressed concern to the staff about wheezing and requested an inhaler to help relieve the resident's lungs wheezing and it took 7 days for any of the staff to believe the resident and obtain the orders and medication from the Physician. 2) The Family had concerns the resident had to sit in incontinent urine for up to 15 minutes on multiple occasions after staff was aware of the situation. 3) The resident was not supposed to be transferring independently but the resident had reported to the Family this had occurred occasionally because staff were not available to transfer the resident. The Family revealed on… | 2020-09-01 |
| 35 | 35 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 312 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1 Based on observations, record review, and interviews; the facility failed to provide assistance with a shower and left the dependent resident unattended for 2 and 3/4 hours for 1 resident (Resident 603) out of 3 sampled residents. Resident was unable to use the call light to call for needed assistance. The facility census was 138. Findings are: Review of the face undated sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Interview on 04-26-17 at 10:00 AM in the resident's room revealed a few weeks ago Staff A put the resident into the shower and performed a 10 minute rinse to the left leg. When completed, Staff A left and said Staff A would be back in 5 minutes and the resident was left sitting in the shower without a call light for over 2 and 1/2 hours. At first the resident thought time was just going by slowly, then the resident realized the resident had been forgotten. At one time the resident thought the resident heard someone come into the resident's room so (gender) yelled out is anyone out there. Resident 603 revealed however the resident's voice was very soft and no one came into the bathroom. Resident 603 revealed the bathroom had a call light but it was across the room by the toilet and the cord was not long enough to have reached the resident. The resident revealed at that time, the resident was not to transfer alone and the wheelchair was not close so the resident could have reached it … | 2020-09-01 |
| 36 | 36 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 578 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation; the facility failed to implement advanced directives for 1 of 2 residents sampled. This had the potential to affect Resident #330. The facility census was 131. Findings are: Review of Resident #330's Resident Face sheet dated 05/09/2018 revealed Advanced Directive: there are no Advanced Directives selected for this resident , Review of Resident #330's CONSENT FOR DO NOT RESUSCITATE (DNR) dated 05/09/2018 revealed NO I do not wish Cardiopulmonary Resuscitation efforts in the event of [MEDICAL CONDITION]. Review of Resident #330's PHYSICIAN'S DO NOT RESUSCITATE (DNR) ORDER FOR THE MEDICALLY ILL dated 05/09/2018 revealed the form was marked/selected DO NOT INTUBATE means that I do not wish a tube placed in my airway to maintain my respirations artificially and DO NOT RESUSCITATE (DNR) I understand that DNR means that if my heart stops beating or breathing is inadequate, that no artificial resuscitation will be initiated or continued. I understand that I will continue to receive support supportive medical care as deemed appropriate by health care personnel, through cardiopulmonary resuscitation will not take place. Review of Resident #330's Summary of Care Document printed 5/9/18 at 2:13 PM revealed : Current Code Status DNR On 05/16/18 at 04:08 PM Record review of Resident #330's physician's orders [REDACTED]. Interview with Staff-D on 05/21/18 at 08:36 AM revealed that Resident #330 was a DNR. Staff-D reviewed Resident #330's physician's orders [REDACTED].>Review of the facility's undated Advance Directives policy revealed: 3. Prior to admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive. 4. Information about whether or not the resident has executed an advance directive shall be prominently displayed in the medical record. 5. If the resident indicates that he or she ha… | 2020-09-01 |
| 37 | 37 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 582 | D | 0 | 1 | HJ5H11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.05.5b Based on record review and interview, the facility failed to provide the required SNFABN (forms designed to notify the residents of their right to appeal discharge from a facility based on discontinuation of Medicare Part A services). notices for residents, this had the potential to affect 3 of 4 residents sampled, (Residents 116, 103 and 98). The facility census was 131. Record review of SNFABN forms for Residents # 116 and 103, revealed the Request for Medicare Intermediary Review did not have the designations of choice of wanting bill for services submitted or not submitted. On 05/22/18 at 11:10 AM, an interview with SSD F (Social Service Designee) confirmed neither of the choices were selected. Record review for SNFABN notice for Resident 98 revealed there was no request for Medicare Intermediary Review form. On 05/22/18 at 11:10 AM an interview with SSD [NAME] confirmed there was no Request for Medicare Intermediary Review form. | 2020-09-01 |
| 40 | 40 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 660 | D | 1 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C2 Based on interviews and record review, the facility failed to develop a discharge plan based on the resident's wishes. This had the potential to affect 2 residents (Residents # 330 and 42). The facility census was 131. Findings are: [NAME] Review of Resident #330's Resident Face Sheet revealed the resident was admitted on [DATE]. Interview with Resident #330 on 05/16/18 at 03:09 PM revealed the resident wanted to return the the previous facility the resident had been. Interview on 05/21/18 at 04:25 PM with Staff [NAME] revealed that the resident was going to stay at this facility long term and that there was not a discharge plan. Review of Resident 330's Admission- Baseline Care Plan -Discharge Plan dated 5/9/18 section Discharge Plan revealed it wasn't completed. B. Review of Resident #42's Resident Face Sheet revealed the resident was admitted on [DATE]. Interview with Resident #42 on 05/16/18 at 2:10 PM revealed the resident wanted to go back to the resident's apartment. Interview with Staff [NAME] on 05/22/18 at 08:31 AM revealed that the resident wanted to return to an apartment but there were plumbing and electrical issues that have to be addressed. Review of Care Plan Snapshot on 5/17/18 revealed no care plan problem, goals or approaches related to discharging or returning to the resident's pervious apartment. | 2020-09-01 |
| 41 | 41 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 677 | D | 0 | 1 | HJ5H11 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observations and interview, the facility failed to ensure soiled clothing was changed and dirty glasses were cleaned for 1 resident (Resident 114). The sample size was 31 and census was identified as 131. Findings are: Observation of Resident 114 on 5-16-18 at 0930 revealed black and brown stains down the chest area of the resident's shirt. [NAME] and gray stains were observed on the resident's plaid pants. The lenses of the resident's glasses were smudged and dust covered. Observation of Resident 114 on 5-17-18 at 1414 revealed the resident was wearing the same shirt and pants from the prior day with brown and black colored stains down the chest. The resident's glasses remained dusty and smudged and pants were still noted to have gray and white substance. The resident was observed to be attempting to whipe the gray and white material from the pants. A Review of Resident 114's Minimum Data Set (MDS- a federally mandated comprehensive tool used for care planning) dated 4-18-18 revealed Resident 114 was severely cognitively impaired and required extensive assist for dressing, toileting and personal hygiene. Interview with Nurse Consultant A on 5-22-18 at 0719 reveals the expectation would be for staff to change a resident's clothing if stained and dirty prior to the next day. | 2020-09-01 |
| 43 | 43 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 758 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that physician orders [REDACTED].#68 and 330). The facility census was 131. Findings are: Review of Resident #330's Resident Face Sheet revealed the resident was admitted on [DATE] at 4:47 PM Review of Resident #330's Physician order [REDACTED]. [MEDICATION NAME] 0.25 mg, one tablet orally, as needed up to three times per day for anxiety disorder (a medication used to treat anxiety and panic disorders), Start Date 05/09/2018; End Date open ended [MEDICATION NAME] 25 mg, one half tab, orally, every 6 hours as needed for anxiety disorder. Start Date 05/09/2018; End Date open ended Both of these medications are psychoactive medications. Interview with Staff D on 5/21/2018 at 08:39 AM revealed Resident #330 takes Ambien, [MEDICATION NAME] and [MEDICATION NAME] as ordered, and as needed for behavior issues and anxiety. Review of Resident #330's PRN ADMINISTRATION HISTORY: 05/01/2018-05/17/2018 revealed: [MEDICATION NAME] PRN (as needed) was given on 5/10, 5/11, 5/12, 5/14, and 5/16 for other and behavior issue; [MEDICATION NAME] PRN (as needed) was given on 5/11, 5/12, 5/14 and 5/16 for other and behavior issue. Record review of Physicians orders dated 4/14/18 for Resident 68 revealed; [MEDICATION NAME] (a [MEDICAL CONDITION] medication used to treat anxiety) schedule IV concentrate; 2mg/ml; amount 1 mg; oral, start date 4/14/18 end date Open ended. Once a day on Wednesday and Saturday-PRN(as needed) 30 minutes before bath. Record review of the Physician orders [REDACTED]. Start Date: 04/25/2018, End Date: 04/25/2018. Every 6 hours PRN. Record review of the MAR (Medication Administration Record) dated 5/1/18 -5/17/18, revealed the resident was administered the above medications during this time. | 2020-09-01 |
| 44 | 44 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-05-22 | 791 | D | 0 | 1 | HJ5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.14 Based on observation, record review, and interviews, the facility failed to assist with making dental appointments for 1 resident (Resident 19) of 31 sampled residents. The facility staff identified the census as 131. Minimum Data Set information for resident 19 dated 5-2-18 revealed a [DIAGNOSES REDACTED]. Resident 19 admitted to the facility in (MONTH) of (YEAR). Observation of Resident 19 on 5-17-18 at 0830 reveals the resident's right front tooth is cracked and shortened. Interview with the resident on 5-17-18 at 0830 reveals the front right tooth was broken about two years ago. The resident had not been seen by a dentist in about four years. The resident's tooth bothers him when eating and would like to be seen by a dentist. Interview with Nurse Consultant A on 5-17-18 at 1545 revealed Resident 19 had no information charted regarding dental consultations or that the resident or their representative had declined a dentist's evaluation. Interview with the Director of Nursing on 5-21-18 at 0839 revealed the expectation of staff would be for the mouth to be assessed and have a dentist appointment set up. The expectation would be for social worker to annually check with the resident regarding dental visit and/or cleaning. There should be something on the resident's chart regarding talking with the family regarding dental cleaning. | 2020-09-01 |
| 47 | 47 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 242 | D | 0 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interview and record review, the facility failed to ensure a resident was provided with a choice related to bathing for one (Resident 109) of 3 sampled residents. Facility had a total census of 131. Findings are: Resident 109 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interviews on 5/22/17 at 8:45 AM and 5/25/17 at 11:19 AM, Resident 109 reported not getting a choice related to number of baths per week. Resident 109 reported receiving two baths per week and stated would like more at times. A review of undated bath schedule revealed Resident 109 was schedule for two baths per week. In an interviews on 5/23/17 at 2:57 PM and 3:19 PM, Social Worker A reported that bathing preference are being reviewed with residents on admission. Social Worker A reported that Resident 109 had not been asked about bathing preferences. | 2020-09-01 |
| 50 | 50 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 281 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.10B1 Based on observations and interview, the facility failed to ensure medication was observed until administration to the resident in accordance with facility policy for one sampled resident (Resident 29) of 6 sampled residents. The facility had a total census of 131. Findings are: Observations on 5/23/17 at 9:29 AM revealed a medication cup with medications in it, two medication cups full of pro stat, eye drops, and nasal spray on over bed table in room next to Resident 29. No staff member was observed in the room. In an interview on 5/23/17 at 9:29 AM, Resident 29 reported that Resident did not like to take medications until after breakfast. In an interview on 5/23/17 at 9:35 AM, Registered Nurse B reported giving Resident 29 the medications at 8:30 Am. Registered Nurse B stated that Resident 29 doesn't like to take medication until after breakfast. Registered Nurse B reported leaving medications for Resident 29 as Resident 29 had been at facility for a long time and then returning to remind Resident 29 to take the medications. Registered Nurse B was not aware of any directives that indicated that Resident 29 could have medications at bed side. A review of Resident 29's medical record did not reveal any assessment of Resident 29's ability to self-administer medication. In an interview on 5/23/17 at 1:58 PM, Registered Nurse Consultant confirmed no assessment of Resident 29 ability to self-administer medications. Facility policy titled medication Administration Orals dated 10/07 stated the following: -Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. | 2020-09-01 |
| 51 | 51 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 312 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility failed to assist one resident (Resident 187) of three sampled residents with wearing eye glasses as needed. The facility census was 131 residents. Findings are: Review of Resident 187's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/7/17 revealed Resident 187 had moderately impaired vision and required extensive assistance for dressing and grooming. Review of Resident 187's Care Pan revised 4/4/17 revealed Resident 187 required assistance of one with grooming and to complete all activities of daily living. There was no specific mention of Resident 187's impaired vision or need for eye glasses on Resident 187's Care Plan. Review of a Resident Assignment sheet dated 5/22/17 indicated that Resident 187 wore glasses. Interview with Family Member A on 05/18/2017 at 03:16 PM revealed Family Member A noted that Resident 187 was often not wearing Resident 187's glasses. Observation of Resident 187 on 05/23/2017 at 10:49 AM revealed Resident 187 had been assisted out of bed to the wheelchair for the lunch meal and was not assisted with donning glasses. Interview with Nursing Assistant (NA) P on 5/24/17 at 9:30 AM revealed staff found Resident 187's glasses on the floor so NA P picked them up and put them back in the case so they wouldn't get broken. Observation of Resident 187 on 5/24/17 at 12:10 PM revealed Resident 187 at the dining room table without any glasses on. After asking NA Q on 5/24/17 at 12:10 PM to obtain Resident 187's glasses and put them on Resident 187 observation revealed Resident 187 did not attempt to remove the glasses. Interview with NA Q on 5/24/17 at 12:17 PM revealed Resident 187 just liked to have something to hold onto and if Resident 187 had something to hold that Resident 187 would not attempt to remove the glasses. NA Q went on to say that staff had not tried interventions such as waiting till right before meal time or giving Resident 1… | 2020-09-01 |
| 52 | 52 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 315 | D | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC: 12-006.09D3 (1 and 2) Based on observation, interview, and record review; the facility failed to identify the need for an individualized toileting program to restore urinary continence (ability to control bladder)for one (Resident 194) of three sampled residents and the facility failed to provide pericare (washing the genitals and anal area which prevents skin breakdown of perineal area, and infections) in a manner to prevent the potential for cross contamination for two (Residents 187 and 194) of three sampled residents. The facility census was 131. Findings are: [NAME] A review of MDS (Multidisciplinary Data Set-a mandatory comprehensive assessment tool used for care planning) information for Resident 194 revealed full assessments completed on 10/28/17 for admission, and on 1/31/17 for a significant change in condition. The CAA (Care Area Assessment) page of both assessments indicated urinary incontinence triggered as an area of concern and needed to be included on the resident's care plan. A review of Resident 194's Care Plan (CP), last reviewed/revised on 5/6/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An entry on the CP indicated a problem identified on 11/01/2016 documented Resident 194 exhibited 'Functional' urinary incontinence, with the goal of 'will not develop skin breakdown related to incontinence. The interventions included to use pull ups or briefs when in and out of bed. Another problem identified on 11/01/2016 indicated Resident #194 had a Self-care deficit related to [DIAGNOSES REDACTED]. Resident 194 required assistance from 2 staff members for transferring and toileting. The CP indicated on 2/8/17, the resident experienced bladder incontinence related to diuretic (medication used remove excess fluid) therapy and decreased mobility. Interventions included: incontinence care with each incontinent episode, provide minimal assist with toiletin… | 2020-09-01 |
| 54 | 54 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 364 | D | 0 | 1 | 18U611 | Licensure Reference Number: 175 NAC 12-006.11D Based on observation and interview, the facility failed to ensure pureed food was prepared in a manner to maintain nutritional value. This practice had the potential to affect 9 residents receiving pureed food. The facility had a total census of 131 residents. Findings are: Observations on 5/23/17 at 1:25 PM revealed 15 slices of chicken sandwich meat, 5 slices of cheese and 10 slices of bread were blended with unmeasured amount of chicken broth and thickener to pureed consistency. Six half cup servings of pureed mixture were portioned into serving dishes. Then an additional 15 slices of chicken sandwich meat, 5 slices of cheese and 10 slices of bread were blended with unmeasured amount of chicken broth and thickener to pureed consistency for the second 5 servings of pureed food. The second batch produced 9 half cup servings of pureed sandwiches. In an interview on 5/23/17 at 1:25 PM, Cook C reported preparing 10 servings of pureed food in two batches of 5 servings. Cook C confirmed the first batch produced 6, half cup servings and the second batch produced 9, half cup servings. A review of undated document titled Pureed Food Guidelines revealed pureed sandwiches were to be made with 2 ounces meat, 1 ounce cheese and 2 slices of bread or 1 bun. Directions stated that bread, then food to be pureed is to be placed in blender or food processor. A half cup of liquid is to be added and mixture is to be pureed. Liquid is to be added in half cup amounts until product reaches the correct consistency. The document did not list a serving size for the pureed food. In an interview on 5/25/17 at 9:19 AM, Dietary Director confirmed that initially half cup liquid should be added and then more added as needed. Dietary Director reported serving size of purred sandwiches was supposed to be a full cup. | 2020-09-01 |
| 55 | 55 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 428 | D | 0 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify potential medication irregularities related to use of psychotropic medications for 2 (Resident 106 and 163) of 5 sampled residents. The facility had a total census of 131 residents. Findings are: Resident 106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 106's 5/2017 Medication Administration Record [REDACTED]. A review of Resident 106's care plan revealed a problem dated 3/28/17 related to Resident 106 being at risk for adverse consequences related to use of antipsychotic medications for treatment of [REDACTED]. A review of order history for Resident 106 revealed Resident 106 was started on Seroquel 25 mg daily on 12/23/2015. Resident 106's Seroquel was increased to 50 mg on 5/6/2015 according to order history. A review of progress note from nurse practitioner dated 9/2/16 revealed Resident 106's Seroquel was increased to 75 mg for [DIAGNOSES REDACTED]. A review of pharmacist monthly reviews for Resident 106 revealed no irregularities were noted during the following reviews: 9/22/16, 10/24/16, 11/16/16, 12/19/16, 1/23/17, 2/27/17, 3/21/17, and 4/25/17. In an interview on 5/25/17 at 10:50 AM, Pharmacist D reported progress notes are reviewed during monthly medication reviews. Pharmacist D reported that gradual dose reductions are not recommended for residents being seen by a mental health practitioner as Pharmacist D trusts the mental health practitioner's judgement. B. A review of the MAR (Medication Administration Record) dated (MONTH) 1-24, (YEAR) for Resident 163, revealed the resident was admitted to the Memory Care Area of the facility on 8/2/14. The resident's [DIAGNOSES REDACTED]. Current medication administration orders indicated the resident was taking medications including: Citalopram (an antidepressant) 40 mg (milligrams) daily, Neurontin (used to treat neuralgia (nerve pain) and seizures) 400 mg threes times a day given … | 2020-09-01 |
| 56 | 56 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-25 | 441 | D | 1 | 1 | 18U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.17 Based on observation, interview and policy review; the facility failed to ensure the glucometer was sanitized in a manner to prevent cross contamination for five residents( Resident 197, 110, 104 31, and 209) of seven residents who used the glucometer, failed to ensure hand washing and glove changes occurred in order to prevent the potential for spread of infection for two residents (Resident 98 and 194); and failed to ensure the mechanical lift was sanitized between resident use for two residents (Residents 194 and 158) which had to potential to cause cross contamination. The facility census was 131. Findings are: [NAME] Observation on 5/24/2017 at 11:35 AM of Licensed Practical Nurse (LPN) V revealed LPN V remove a glucometer (a portable machine used to test the amount of glucose in one's blood) labeled PRN 2 from the medication cart and laid it down on top of the cart. LPN V then took the glucometer into Resident 209's room and laid it down directly on Resident 209's bedside table. LPN V then picked up the glucometer to test Resident 209's blood and laid it back down onto Resident 209's bedside table. LPN V gathered the rest of the supplies, picked the glucometer back up and went back to the medication cart, laying the glucometer back down on top of the medication cart. LPN V proceeded to remove a Sani-Cloth Bleach Germicidal disposable wipe from an individual size packet and wrap the sani cloth around the glucometer machine from front to back. The cloth was not big enough to stay wrapped around the back of the machine. LPN V then laid the glucometer back on top of the medication cart with the sani cloth wrapped around the top of the machine only. LPN V did not make any attempt to wipe the surfaces of the glucometer before wrapping it with the disposable sani cloth. At 11:45 AM (on 5/24/17) LPN V then took out another glucometer machine labeled PRN 3. LPN V took this machine into Resident 104… | 2020-09-01 |
| 57 | 57 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2018-06-13 | 607 | D | 1 | 0 | YEOP11 | > Licensure Reference Number 175 NAC 12-006.02(8) Based on interviews and record review, the facility failed to ensure staff followed the facility policy regarding reporting allegations of abuse to the state authority. This had the potential to affect one resident (Resident 7). Sample size was 3. Facility census was 131. Findings are: Interview with the Activity Director on 6/13/2018 at 9:00 AM revealed that on Monday at 9:30 that Resident 8 was in Resident 7's room exposing self and was undressing Resident 7. This incident was not consensual and the Activity Director reported this incident to the Charge Nurse and sent an E-mail to the Administrator. The Administrator sent an E-mail to the Activity Director that the incident was being handled by the Director of Nursing and Nurse Consultants. Interview with Resident 7 on 6/13/2018 at 10:00 AM revealed that on 6/11/18 Resident 8 came into Resident 7's room uninvited, exposed self and began disrobing Resident 7 before staff came in and intervened. Resident 7 said that this act was not consensual. Resident 7 did not want Resident 8 in the room at all. Record review of the facility Abuse Policy revealed the administrator or designee shall report allegations of abuse to their state agency and should be reported within 2 hours of the incident. Interview with the Administrator, Director of Nursing and Nurse Consultant on 6/13/18 at 2:30 PM confirmed that the incident did happen and the facility failed to report the incident because the facility felt that the incident was consensual. Interview with the Activity Director on 6/13/2018 revealed the incident that was witnessed was not consensual between Resident 7 and Resident 8. | 2020-09-01 |
| 59 | 59 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 561 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (4) Based on Interview and record review the facility failed to ensure resident bathing preferences were honored for 2 residents (Residents 114, 329) and the facility failed to accommodate resident's care giver preferences for 1 resident (Resident 10). The facility census was 123. Findings are: [NAME] An interview on 09/23/19 at 2:45 PM revealed resident has not had choice when bath is performed. Resident states (gender) documents when baths were given and not given. The following are from Residents 10 calendar notes: 9/5/19 no bath, 9/9/19 no bath, 9/10/19 received bath, 9/12/19 no bath, 9/13/19 no bath, 9/16/19 received bath, 9/19/19 received bath, 9/23/19 received bath. Resident states that bath aide is often taken off baths and used on the floor due to short staffing, sometimes bath aide comes in on off days to catch up on baths but doesn't always get them done as there are 13-15 baths a day. Record review of bath log dated 8/26/19-9/25/19 revealed resident bath schedule and preference of 2 baths a week has not been honored and the agreed upon Mondays and Thursdays are often not the days resident receives baths. The bathing record notes no bath was preformed for 7 days from 09/03/19- 09/09/19. An interview on 09/26/19 with DON confirmed that facility has been short a bath aide and residents have missed scheduled bath days and may only received 1 bath a week during those short staffing times. B. Record Review of care plan dated 5/19/19 Resident would like to get a shower 3x/week to keep from getting skin issues. Staff will try to give (gender) a bath 3x/week. Staff to offer an extra shower if they are available. Record review of dermatology office noted dated 02/22/19 revealed resident has seborrheic [MEDICAL CONDITION] (a skin condition that can cause the scalp to be itchy and causing dry skin and dandruff) located on face and scalp. Resident is to be bathed and have hair shampooed every othe… | 2020-09-01 |
| 62 | 62 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 584 | D | 1 | 1 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.18A Based on observations and interview, the facility failed to keep resident living areas clean for 2 residents (Resident 77 and Resident 324). Facility Census was 123. Finding are: An observation in the bathroom of Resident #77 and #324 on 9/24/19 at 2:28 PM revealed that the toilet riser was stained and the toilet had numerous areas of dried on feces. An observation and interview with the facility Administrator on 9/30/19 at 2:10 PM confirmed there was dried feces on the toilet riser, and the toilet itself has BM in it. This was in the bathroom that is shared by Resident #77 and Resident #324. | 2020-09-01 |
| 63 | 63 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 600 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.05 (9) Based on record review, observation, and interview the facility failed to ensure that residents were kept free from abuse resulting in an injury for 1 resident (Resident 87) of 1 resident reviewed, and the facility to report misappropriation of medications for 2 residents (Resident 326 and 333). The facility census was 123. Findings are: [NAME] Record review of the facility policy titled Abuse Prevention Program dated (MONTH) 2006 revealed: Preventing Abuse Step 1: Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Preventing Abuse Step 3i: The implementation of changes to prevent future occurrences of abuse. Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the Progress Notes and the Care Plan (a writt… | 2020-09-01 |
| 65 | 65 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 610 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that investigations of abuse were completed and that documentation of investigations of abuse were maintained for misappropriation of resident property for 1 resident (Resident 86), and for resident abuse resulting in injury for 1 resident (Resident 87). The facility census was 123. Findings are: A) Record review of the Progress note for Resident 86 dated 5/26/19 10:19 revealed that the family reported that the resident's watch was missing and that it was gold in color. Record review of the Progress note for Resident 86 dated 5/31/19 9:59 AM revealed that the resident's family member was here and reported that they bought the resident a new watch, gave the receipt to Social Services for reimbursement of the lost item and stated that it may have been stolen by a former employee. Record review of the facility grievances revealed an email dated 5/31/19 from the facility Social Services Director (SSD J) to the facility Grievance Officer. The email revealed that Resident 86 was missing a watch since 5/26/19. A resident family member bought a new watch for the resident on 5/31/19 and the receipt was submitted to the business office for reimbursement. Record Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2014 revealed Step 2 definitions: To help with recognition of incidents of abuse, the following definitions of abuse are provided: Step 2 h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Record review of the facility policy titled Abuse Prevention Program dated (MONTH) 2006 revealed the following steps: 3 f. Timely and thorough investigations of all reports and allegations of abuse; 3 g. The reporting and filing of accurate documents rel… | 2020-09-01 |
| 66 | 66 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 622 | D | 1 | 1 | UZYC11 | > Licensure Reference Number 175 NAC 12-006.12E8b Based on record review and interview, the facility failed to ensure discharge instructions to included medication instructions and medication reconciliation with the resident or resident representative. This had the ability to affect one resident (Resident 326) of 1 reviewed. The facility census was 123. Findings are: Record review of an APS (Adult Protective Services) report dated 07/01/19 revealed; an anonymous reporter reported that Resident 326 was discharged to home on a Friday. Resident 326 had been picked up by a friend, and asked the MA (Medication Aide) if they could speak with the nurse for instructions for the medications and discharge instructions. Resident/Resident friend was told that the nurse was not available, the mediations were bagged and ready to go. A Pharmacist at the pharmacy reported that the bagged medications were not Resident 326's medications. Record review of Resident 326 Nurses note dated 06/28/2019 at 10:46 Resident 326's vital signs were stable. Discharge paperwork was signed by the M.D. and resident and the paper work was reviewed with resident and medications were sent home with (gender). A friend picked Resident 326 up at approximately 10 am and (gender) will call the Primary Care physician with any questions or concerns. Also Resident 326 had Interim health care at home phone number and has met with HHC (Home Health Care) Representative for info regarding services they offer. An interview on 09/25/19 at 03:05PM with the CSC confirmed; that Resident 326 was sent home Resident 333's medications. Both Resident 326 and 333 had medications bagged for home and the nurse grabbed the wrong bag of medications. The nurse manager was sent to the Pharmacy and retrieved Resident 333's medication. | 2020-09-01 |
| 67 | 67 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 644 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure a PASARR (Pre-admission/Resident Review an assessment to determine placement recommentations and services for residents with serious mental illness or mental disability) level 2 referral was completed for two sampled residents (Residents 77 and 116). The faciilty census was 123. Findings are: [NAME] Record review of Resident 77's, Face Sheet printed on 9/24/19 revealed the resident was admitted to the facility on [DATE]. Among the psychiatric [DIAGNOSES REDACTED]. Record review of Resident 77's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed the resident had a Quarterly assessment completed on 8/14/19. The MDS recorded the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental [MEDICAL CONDITION] or a related condition. The MDS identified Psychiatric/Mood Disorder [DIAGNOSES REDACTED]. In the medication section of the MDS, the facility identified the resident received an Antipsychotic medication and an Antidepressant medication on 7 of the previous 7 days. Record review of Resident 77's PASRR documents from the resident's medical record revealed the resident received a PASRR Level I assessment on 1/18/05 and no PASRR Level II assessments during the resident's stay. Review of the PASRR Level I revealed the resident has substantial limitations for major life activities due to inability to make decisions, and capacity to independent living. The assessment did not record a [DIAGNOSES REDACTED]. The PASRR level I did not record that the resident received [MEDICATION NAME] (an antipsychotic medication) daily for dementia. Interview with CSC (Clinical Services Consultant) on 9/24/19 at 3:30 PM revealed there is not another PASRR for Resident 77 since the one that was completed on 1/18/05. The CSC confirmed Resident 77 was diagnosed with [R… | 2020-09-01 |
| 68 | 68 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 657 | D | 0 | 1 | UZYC11 | LICENSURE REFERENCE NUMBER 175 NAC 12-009.C1c Based on observation, record review, and interview the facility failed to ensure that the resident care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) was updated to include care for a facility acquired pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) for 1 resident (Resident 21) of 1 resident observed. The facility census was 123. Findings are: Record review of the physician Referral Form dated 8/29/19 confirmed that Resident 21 had a decubitus (pressure) ulcer on the 4th digit of the left foot. Record review of the nurse progress note for Resident 21 dated 8/29/19 at 5:35 PM noted a pressure ulcer to the resident's left foot 4th toe. Observation of wound care on 9/25/19 at 1:13 PM revealed Licensed Practical Nurse D (LPN D) entered Resident 21's room and removed the band aid from the resident's left 4th toe and the left great toe. A wound was observed on top of the resident's left 4th toe that was approximately 1 centimeter x 0.3 centimeter in size per visual measurement that was yellow and dry in the center with light red tissue around the wound edges. Record review of the resident care plan for Resident 21 revealed no interventions for the care of the resident's pressure ulcer. Interview with the Director of Nursing (DON) on 9/26/19 at 10:44 AM confirmed that the care plan for Resident 21 did not identify the resident pressure ulcer and required care. | 2020-09-01 |
| 69 | 69 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 661 | D | 1 | 1 | UZYC11 | > Based on record review and interview the facility failed to ensure a recapitulation of stay was completed for 1 resident of 1 reviewed (Resident 326). The facility census was 123. Findings are: Record review of Resident 326's medical record revealed; there was not a recapitulation of stay in the records. An interview on 09/26/19 at 10:33 AM with the CSC revealed; for Resident 326 there was not a recapitulation of stay that was documented. The facility had a PIP (Process Improvement Plan) in place on discharge planning and documentation. A part of the action plan was the facility was to do audits. The CSC reported that the employee that was in charge of the audits was no longer an employee. An interview on 09/26/19 at 10:46 AM with the CSC confirmed; that the employee had not kept the information from the audits for discharge planning PIP. | 2020-09-01 |
| 70 | 70 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 676 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D1c Based on record review and interview the facility failed to ensure that 1 Resident (Resident 332) received 2 baths per week. The facility census was 123. Findings are: Record review of MDS dated [DATE] revealed resident needed 1 assist during bathing. Record Review of care plan dated 02/26/19 revealed no documentation about residents bathing preferences. Record review of Preferences for Customary Routines sheet dated 12/30/17 revealed resident likes to shower in the evenings on Mondays and Thursdays. Record review of bathing log dated 01/01/2019-04/30/19 revealed no bath from 01/23/19- 03/18/19. Record review of bathing refusal dated 01/01/19- 04/25/19 revealed resident was in the hospital from 02/21/19-02/26/19, refused baths on 3/30/19,04/01/19,04/04/19, 04/06/19, 04/07/19, 04/21/19. An interview on 09/30/19 with DON confirmed Resident 332 did not receive baths from 01/23/19 - 03/18/19 with the exception of when the resident was in hospital or refused. | 2020-09-01 |
| 71 | 71 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 686 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review, and interview the facility failed to ensure that staff followed the standard of practice for wound care for pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), and the facility failed to document weekly assessment details for required wound assessment of a facility acquired pressure ulcer for 1 resident (Resident 21) of 1 resident observed. The facility census was 123. Findings are: [NAME] Record review of the physician Referral Form dated 8/29/19 confirmed that Resident 21 had a decubitus (pressure) ulcer on the 4th digit (toe) of the left foot. Record review of the facility procedure titled Wound Care dated (MONTH) (YEAR) revealed the following steps: 1. Use disposable cloth (paper towel is adequate) or disposable plastic cover to establish clean field on resident's over bed table or other appropriate area. Place all items to be used during procedure on the clean field. 6. Put on clean gloves. 7. Use tongue blades or applicators to remove ointments and creams from their containers. Observation of wound care on 9/25/19 at 1:13 PM revealed Licensed Practical Nurse D (LPN D) entered Resident 21's room and removed the band aid from the resident's left 4th toe. A wound was observed on top of the resident's left 4th toe that was approximately 1 centimeter x 0.3 centimeter in size per visual measurement that was yellow and dry in the center with light red tissue around the wound edges. LPN D placed the container of Silver [MEDICATION NAME] 1% cream (a topical antibiotic used on skin wounds to prevent infection) directly on the seat of the chair near the resident's bed along with two bandages with no cloth or barrier on the chair. LPN D performed soap hand washing and obtained a wash cloth with soap and water and cleaned the wound area on the top of the left 4th toe. LPN D dried the area lightly with a new wa… | 2020-09-01 |
| 72 | 72 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 689 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review, and interview the facility failed to ensure that a fall event was documented and root cause analysis was completed for 1 resident (Resident 45) of 2 residents reviewed, and the facility failed to ensure residents were assessed for smoking safety on admission for 1 resident (Resident 6) of 2 residents reviewed. The facility census was 123. Findings are: An 09/25/19 at 12:30 PM of staff in the hallway addressing the w/c (wheelchair) for Resident 45 the NA reported that the they felt the back of the chair did not go back and the resident was at risk for a fall. RN V told the staff member to wait and get Resident 45 up later and set them at the table. A Record review of Fall Event - Altitude fall form dated 5/24/19 revealed; the document had not been completed. An interview on 09/26/19 at 01:14 PM with the CSC confirmed; that the fall event Altitude fall form had not been completed. Progress note IDT (Interdisciplinary Team) Risk Note dated 05/24/19 revealed; Resident 45 had a fall from the w/c (wheelchair), Resident 45 had pulled out call light from the wall and had self-transferred from the w/c to the bed. The alarm was not place back on the resident post therapy. The intervention: Resident 45 would have a safety alarm before and after therapy. Record review of Care Plan dated 05/01/2019 revealed; Resident 45 was at risk for falls due to: TODD paralysis (a paralysis is a neurological condition experienced by individuals with [MEDICAL CONDITIONS]([MEDICAL CONDITION] (Stroke)) and confusion. An intervention dated 05/24/19 for Resident 45 was to have alarm placed on wheelchair during all therapies. Occupational Therapy, Physical Therapy, Speech Therapy Approach Start Date: 05/24/2019 An observation on 09/26/19 at 1:00PM of Resident 45 seated at the table in a tilt in space w/c. Record review of Resident 45's MDS (Minimal Data Set an assessment used to assist in dev… | 2020-09-01 |
| 73 | 73 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 758 | D | 0 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.12B Based on record review and interview the facility failed to ensure that antipsychotic (a medication used to treat serious mental health conditions) gradual dose reduction (the periodic physician review of the amount of an antipsychotic medication to consider a decrease in the amount of the medication) (GDR) was addressed by the resident physician for 1 resident (Resident 17) of 3 residents reviewed. The facility census was 123. Findings are: Record review of the current Physician Orders for Resident 17 confirmed that the resident had an order to receive [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION]) 400 milligrams by mouth daily at bedtime that started on 11/14/16. Record review of the face sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) confirmed that Resident 17 had a [DIAGNOSES REDACTED]. Record review of the facility policy titled Medication Management dated 9/10 revealed Guidelines for Psychotherapeutic Medication Monitoring of Antipsychotics step 1 g: Tapering of a medication dose/gradual dose reduction (GDR): Within the first year in which a resident is admitted on an antipsychotic medication or after the nursing care center has initiated an antipsychotic medication, the nursing care center must attempt a GDR in two separate quarters (a 3 month calendar period) (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually (yearly), unless clinically contraindicated. Record review of the health record for Resident 17 revealed a Note to Attending Physician/Prescriber dated 6/30/19 requesting that the physician evaluate the current dose and consider a dose reduction (GDR) for the [MEDICATION NAME] 400 milligrams. No documentation of the physician response to the GDR… | 2020-09-01 |
| 74 | 74 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 759 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation interview and record review the facility failed to maintain a medication error rate of less than 5 % which affected 2 residents (Residents 27 and 62) of 8 residents observed. The facility census was 123. Findings are: [NAME] An observation on 09/25/19 at 12:50 PM of RN (Registered Nurse) W prepared Humalog 100units/ML Kwik Pen, 10 units ( sub Q) subcutaneous ( a shot given in the skin between fat and musle layer) 3 times a day with meals. The Pen was dialed to 10 units. Hand Hygiene was performed with hand sanitizer. The insulin was taken to Resident 227 gloves donned and administered to the right abdominal area, gloves doffed, hand hygiene with hand sanitizer was completed. An interview on 9 at 12:55PM with RN W confirmed; the insulin pen had not been primed. The RN reported that they had not had training for priming the insulin pens. Record review of the Insulin Administration Policy dated [DATE] revealed; in the procedure step 11. When using an insulin pen, prime the pen, i.e. turn the vial dose to the select 2 units, press holding the dose button and make sure a drop appears. Record review of Insulin Administration Competency Check for Connie Blankenship RN revealed that the competency had not included insulin Pen. An interview on 09/25/19 at 245PM with CSC confirmed; the Insulin Administration Competency had not include the insulin pen. B) Observation on 9/25/19 at 7:20 AM of LPN-D (Licensed Practical Nurse) administering Resident 62's insulin revealed LPN-D drew 11 units of [MEDICATION NAME] 70/30 insulin (medication that lowers blood sugar - contains 70% intermediate-acting insulin and 30% short-acting insulin) into an insulin syringe and administered subcutaneous (under the skin, between the skin and muscle) into Resident 62's abdomen. Review of Resident 62's Physician order [REDACTED]. Interview on 9/25/19 at 2:33 PM with LPN-D confirmed LPN-D administered 11 units … | 2020-09-01 |
| 79 | 79 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-12-23 | 710 | D | 1 | 0 | BF8Z11 | > LICENSURE REFERENCE NUMBER 12-006.08 AND 12.006.08A The facility failed to ensure that the facility followed practictioners orders regarding the residents order for resident care. This affected 1 resident. Findings are: Record review revealed that the staff did not follow the practictioners orders in regards to the residents and specific orders for resident care. The record review confirmed that the facility staff allowed alternate practioners to write orders and follow thru with care areas by a different practioner. 12/23/2019 at 1:45 PM Interview with the Director of Nurses revealed that the facility staff did allow alternate practioners to write orders on resident 3. | 2020-09-01 |
| 80 | 80 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2019-03-13 | 561 | D | 1 | 0 | 4O5N11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) The findings are: Based on interview and record review the facility staff failed to ensure that 1 resident (Resident 2) of 1 sampled resident was bathed according to their bathing preference. Interview conducted on 3/12/19 at 1:00 PM with Resident 2 revealed that Resident 2 prefers a bath twice a week and had not had a bath since admission on 3/4/19. Record Review of bath preferences dated 3/5/19 revealed that Resident 2 preferred a shower twice a week. Record Review of progress notes since admission revealed no documentation of Resident 2 receiving or refusing a bath. Interview conducted on 3/13/19 at 1:43 PM with the Director of Nursing confirmed that Resident 2 had a preference of 2 showers a week and there was no documentation that resident 2 had received a bath. | 2020-09-01 |
| 81 | 81 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2019-03-13 | 657 | D | 1 | 0 | 4O5N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1b Based on record review and interview the facility failed to revise a care plan with current diet for 1 (Resident 4) of 1 sampled resident. The facility staff reported a census of 129. The findings are: Review of current physician orders [REDACTED]. Review of the meal intake documentation revealed that Resident 4 consumed 25-75% of meals. Review of Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/18/2019 revealed a functional status of supervision for eating. Record review of the current CCP (Comprehensive Care Plan) dated 1/6/19 and updated 2/20/19 revealed that Resident 4 was tube feeding dependent and NPO (Nothing by Mouth). Interventions included: 1. Calorie/Protein/Fluid needs will be met with tube feeding regime. 2. NPO per doctors' orders. 3. Provide tube feeding per doctors' orders. The CCP did not include the current dietary status for Resident 4 of Pureed Diet with Honey Thickened Liquids. Review of the Policy and Procedure dated (MONTH) (YEAR) revealed Assessments of residents are ongoing and care plans are revised as information about the residents' condition changes. Interview on 3/13/19 at 1:11 PM conducted with the Director of Nursing confirmed that the CCP should have been revised to include current dietary status for Resident 4. | 2020-09-01 |
| 82 | 82 | AZRIA HEALTH MONTCLAIR | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2017-06-06 | 157 | D | 0 | 1 | LLQX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the physician of low blood pressures for 1 (Resident 219) of 1 residents. The facility staff identified a census of 128. Findings are: [NAME] Record review of a Physician Order's Sheet for 6-2017 revealed an order for [REDACTED]. Record review of Resident 219's Medication Administration Record [REDACTED]. Review of Resident 219's medical record that included progress notes, physician progress notes [REDACTED]. blood pressures as directed. On 6-6-2017 at 10:41 am an interview was conducted with the facility Director of Nursing (DON). During the interview the DON reported not being able to locate any information that Resident 219's physician had been called when Resident 219's blood pressures were low as directed. | 2020-09-01 |
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CREATE TABLE [cms_NE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );