rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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,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 to consume. On 02/21/19 at 12:10 PM an interview with LPN D confirmed the resident does not have the ability to choose what to consume, when to consume fluids or how much to consume.",2020-09-01
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 asked if they could finish their cares before attempting to understand what Resident 102 was attempting to state. Resident 102 agreed. NA D and NA [NAME] finished by straightening the covers on the bed, situating the call light and supplies and removing their gloves. Resident 102 again attempted to mouth the sentence an additional 2-3 times before NA D gave up trying to read the resident ' s lips and went to get the spell board. Resident 102 was then able to spell out the sentence so NA D and NA [NAME] could understand what Resident 102 was requesting. An interview was conducted with NA D AND NA [NAME] on 12/28/16 at 2:25 PM to ask how they knew when Resident 102 was attempting to communicate. NA D and NA [NAME] revealed that staff needed to keep one eye on Resident 102 at all times. When informed that Resident 102 had attempted to communicate 6 times during the observed cares, NA D and NA [NAME] responded that Resident 102 would have wide eyes if it was important and they would noticed if that had occurred. NA D went on to report that Resident 102 did not like to use the spell board. A follow up interview with Resident 102 and a family member on 12/29/2016 at 3:32 PM revealed Resident 102's family member was aware this was a concern for Resident 102. The family member reported the staff needed to find a way to ensure Resident 102 was being heard when attempting to communicate. Resident 102 went on to state that staff just needed to make sure they were looking at Resident 102's face to know when Resident 102 was attempting to communicate.",2020-09-01
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,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. Interview with Registered Nurse (RN) G on 12/27/16 at 2:30 PM revealed staff had a couple of places they could document both the effectiveness of the medication and the non-pharmacological interventions attempted prior to administration including the Adult Assessment and Interventions. RN G then confirmed that, after reviewing the medical record, RN G was unable to find where any staff had evaluated the effectiveness of the antianxiety after administration. RN G was also unable to find consistent documentation that non pharmacological interventions had been attempted prior to the administration of the [MEDICATION NAME]. Review of the Adult Assessment & Interventions in (MONTH) (YEAR) for Resident 265 revealed Resident 265 was assessed to be anxious, agitated, angry, yelling, crying, restless, and screaming at times. The Assistive Device provided for these symptoms was Antianxiety medication. A non-pharmacological intervention was implemented two times out of the 18 occasions and was documented to be frequent verbal cues/redirection to get along with others and frequent checks. Interview with the Director of Nursing (DON) on 01/03/2017 at 4:22 PM revealed staff should be offering non pharmacological interventions prior to administration and evaluating the effectiveness of thee antianxiety medication once given.",2020-09-01
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,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,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 bathing schedule on admission. The facility has a set schedule and the new admissions were added to that, if the resident was unhappy with the schedule then they would be moved to the preferred days. RN reported that they do full showers 2 times a week and partial bed baths daily. An interview on 06/03/19 at 03:47 PM with the Administrator, the Administrator confirmed the facility ask residents at the initial care plan meeting. The Administrator confirmed the facility had offered 2 baths, no more that that per week. Record review of Active orders dated 05/29/19 revealed an Order that Resident 102 was able to shower in the trauma tub scheduled bath days were Tuesdays and Saturdays. Record review of Resident 102's care plan revealed no bathing preferences were documented An interview on 06/03/19 at 05:03 PM with the DON (Director of Nurses) confirmed that the facility did not have documentation of the personal preferences regarding bathing for Resident 102 on admission. The DON confirmed no documentation of bathing preferences in the care plan",2020-09-01
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,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,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,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,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,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,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 gravity flow. C. An observation on 6/4/19 at 12:00PM of medication administration by LPN H for Resident 9 revealed RN K did not perform hand hygiene upon entry to the room. LPN H donned gloves and prepared medications Medication [NAME]nochol 25mg (milligrams-a unit of measurement) and [MEDICATION NAME] (a medication given for high blood pressure) 20 mg was crushed, [MEDICATION NAME] was measured 10 mL and [MEDICATION NAME] was measured 30mL. Gloves were changed. No flush was given prior to the medication administration. LPN H checked residual of PEG tube and was 210mL and that was discarded. LPN H mixed the [MEDICATION NAME] 10mL with 30cc water drew it up in the syringe and pushed the medication in the PEG tube. No flush was administered. LPN H drew up [MEDICATION NAME] 30 mL and it was given push through syringe in the PEG tube. No flush was administered. The combination of the crushed medications [NAME]nochol 25mg and [MEDICATION NAME] 20mg was mixed with 20mL of water and administered by LPN H per push via PEG tube. LPN H administered 30mL water flush per push via PEG tube. Gloves were changed and eye drops were administered. LPN H doffed gloves and hand sanitizer was used. Record review of the Feeding tube management Policy dated 4/1/16 revealed that Daily use for Feeding and Medication Administration Procedure 1. Any time the tube is utilized intermittently or disconnected from a feeding pump it is vital to flush the tube with a minimum of 30 mL warm tap water. An interview on 06/04/19 at 04:43 PM with the DON (Director of Nurses) confirmed that the facility did not have a physician order [REDACTED]. The DON confirmed that prior to the use of a feeding tube the tube should be flushed. Record review of Resident 9 and Resident 100 Active Orders document dated 6/4/19 revealed that the residents did not have an order for [REDACTED].>",2020-09-01
16,ST JANE DE CHANTAL,285004,2200 SOUTH 52ND STREET,LINCOLN,NE,68506,2019-06-04,880,E,0,1,GLUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation interview and record review the facility failed to ensure that gloving and hand hygiene was performed when indicated to prevent the potential for cross contamination during treatments for 5 resident (Residents 42,101, 82, 84, 53) an during medication administration for 2 residents (Residents 9 and 51) of 23 sampled residents. The facility census was 115. Findings are: [NAME] An observation on 05/30/19 at 10:30 AM of wound care for Resident 82 revealed; on entry to room, RN I performed hand hygiene by using the hand sanitizer and donned gloves, RN I removed the packing from the wound and doffed gloves and without hand hygiene donned gloves. RN I used soap and water on a wash cloth to cleanse the wound. RN I rinsed the wound with wound cleanser. RN I changed doffed gloves and without hand hygiene and donned gloves. RN I applied skin prep ([MEDICATION NAME] no sting) to the skin surrounding the wound and applied gauze soaked with Vashe (a wound solution that has a skin friendly PH) into the wound. RN I doffed gloves and without hand hygiene donned gloves. RN I applied 4x4 Vaseline gauze applied and 4x4 followed by an ABD (Abdominal Pad thick dressing used for draining wounds) RN I doffed gloves and without hand hygiene donned gloves. RN I removed the dry Therabond (a wet to dry dressing used to help debride wounds) from the wound, cleansed the wound with soap and water, no glove change or hand hygiene was performed, a new piece of Therabond was cut to size, moistened and placed over wound. RN I doffed gloves and without hand hygiene donned gloves. RN I assisted with Resident 82's repositioning. RN I replaced supplies, cleansed table with wipes (Sani). RN I used hand sanitizer was used. B. An observation on 5/30/19 at 10:50 AM of wound care for Resident 101 performed by LPN (Licensed Practical Nurse) J of wound care for Resident 101. LPN J used hand sanitizer on entry to the room. LPN J donned gloves, had wet wash cloths. LPN J removed the dressing from the buttock wounds. LPN doffed gloves and without hand hygiene donned gloves. LPN J patted the wound with soap and water wet cloths. LPN doffed gloves and without hand hygiene donned gloves. The new dressings were prepared by soaking the Surgifoam (an absorbable gelatin sponge used for bleeding wounds) soaked with triple antibiotic ointment. LPN doffed gloves and without hand hygiene donned gloves. LPN J applied ointment and the soaked Surgifoam to the wounds. LPN J doffed gloves and without hand hygiene donned gloves and applied a third soaked Surgifoam sponge and moistened gauze was to the coccyx area. LPN doffed gloves and without hand hygiene donned gloves. LPN J assisted with dressing Resident 101. LPN J doffed gloves and used hand sanitizer. C. An observation on 6/3/19 at 12:55PM of medication administration by RN K for Resident 51 revealed hand hygiene was not performed prior to the medication administration. RN K measured the medications [MEDICATION NAME] 30mL (Milliliters metric system used to measure medications). 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 gravity flow. D. An observation on 6/4/19 at 12:00PM of medication administration by LPN H revealed hand hygiene was not performed prior to entry to the room for medication administration. Record review of infection prevention Hand Hygiene policy dated with review date of 4/19/19 revealed; when hands were visibly soiled or contaminated with protienaceous material or visibly soiled with blood or other body fluids wash hands with soap and water. Step: 1) Vigorously lather hands with soap and rub for 15 seconds under a moderate stream of running water at a comfortable water temperature. 2) Rinse hands thoroughly, hold hands down lower than wrists, do not touch the inside of the sink 3) Dry hands thoroughly with paper towel and then turn off faucets with those towels. 4) Discard towels into the trash do not dry hands with same towel used to turn off sink. If hands are not visibly soiled alcohol based hand rub may be used for routinely decontaminating hands using the following process 1) Apply enough product to thoroughly wet both hands to the palm of one hand. 2) Rub hands together covering all surfaces of hands and fingers until hands are dry. Use alcohol based hand rub or wash hands: 1) When coming on duty. 2) Before performing invasive procedures. 3) Before preparing or handling medications, 4) Before performing dressing care, 5) Before touching preparing or serving food, 6) Before and after having contact with patient or patient environment. 7) After contact with patients on isolation, 8) After handling used dressing, urinals, bedpans catheters, contaminated tissues, linen, or patient care item. 9) After offering incontinence care, Foley care. 10) Before and after manipulation of feeding tubes. 11) Before and after manipulation of IV sites even when wearing gloves. 12) Before and after empty Foley catheter or tubing even when wearing gloves. 13) After contact with blood, urine, feces, oral secretions, mucous membranes or broken skin, 14) After handling items potentially contaminated with any patient blood excretions or secretions. 15) After personal body function use of toilet, blowing nose, wiping nose, smoking or combing hair. 16) Before and after eating. 17) Upon completion of the day. E. Record review of Resident 53's physician progress notes [REDACTED]. Record review of Resident 53's Transfer/Discharge/Active Orders dated 5/29/19 revealed [MEDICAL CONDITION] (a surgically created opening through the neck into the windpipe with a tube place to provide an airway and to remove secretions from the lungs) care was ordered to be done 2 times per day. Observation on 6/3/19 at 9:45 AM of RN-B (Registered Nurse) and RN-C providing [MEDICAL CONDITION] care for Resident 53 revealed RN-B and RN-C used hand sanitizer and applied masks and gloves. RN-B removed the dressing from the [MEDICAL CONDITION] and discarded, then changed gloves without performing hand hygiene. RN-B cleaned around the edge of the [MEDICAL CONDITION] using swab sticks, discarding after use. RN-B changed gloves without performing hand hygiene. RN-B and RN-C removed the [MEDICAL CONDITION] ties (a band that goes around the neck to hold the [MEDICAL CONDITION] in place) and RN-C held the [MEDICAL CONDITION] while RN-B washed and dried the resident's neck. RN-B got the new [MEDICAL CONDITION] tie and RN-B and RN-C secured the [MEDICAL CONDITION]. RN-B changed gloves without performing hand hygiene and applied the new [MEDICAL CONDITION] dressing, then removed gloves and performed hand hygiene. RN-B offered suctioning (removes thick mucus and secretions from the trachea), but Resident 53 refused. F. Review of Resident 42's Pressure Ulcer/Wound record dated 5/29/19 revealed the resident had a closed stage 3 pressure injury (full thickness skin loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) to the right ankle, a closed stage 2 pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed), and unstageable deep tissue injuries (purple area of discolored intact skin due to damage of underlying soft tissue) to the left 5th toe, back of the right ankle, and back of the left ankle. The resident also had a partial thickness (loss of skin presenting as a shallow open ulcer with a red/pink wound bed) wound to the right shin. The resident also had a surgical incision to the right buttock. Record review of Resident 42's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform (dressing used to maintain a moist wound environment) and [MEDICATION NAME] (absorbent foam dressing) to the wounds on the back of the right and left ankles, on the left foot, and on the right shin. The resident also received Nutrashield lotion to the intact incision line and [MEDICATION NAME] AG (dressing impregnated with silver) to the small open area near the perineum. Observation on 05/30/19 at 11:01 AM of RN-E completing wound care for Resident 42 revealed RN-E cleaned the scissors used for cutting the dressings, performed hand hygiene, and gathered supplies for the dressing change. RN-E applied gloves and pulled the resident's blankets back and removed the prafo boot (boot that alleviates pressure from the heel) from the resident's left foot. RN-E removed the dressing from the back of the resident's ankle. RN-E removed gloves, used hand sanitizer, and applied new gloves. RN-E cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound and applied to the wound bed, and covered with a [MEDICATION NAME] dressing. RN-E removed the dressing from the resident's left foot, cleansed the area with a wash rag, cut a piece of Xeroform to the size of the wound, then applied to the wound and covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene, inspected the resident's heels and applied Nutrashield lotion to the foot. RN-E reapplied the resident's prafo boot and changed gloves without performing hand hygiene. RN-E removed the prafo boot from the resident's right foot and removed the dressing front the resident's right shin. RN-E cleansed the wound and changed gloves without performing hand hygiene. RN-E cut Xeroform to the size of the wound and applied, then covered with a [MEDICATION NAME] dressing. RN-E changed gloves without performing hand hygiene and lifted the dressing to the right ankle, observed the wound, then secured the same dressing back into place. RN-E then secured the prafo boot back onto the resident's foot. RN-E changed gloves without performing hand hygiene, and cleaned the bandage scissors. NA-F (Nurse Aide) entered the room and assisted RN-E with repositioning the resident to the side. RN-E removed the dressing from the surgical incision on the resident's buttock and cleansed the area with a washrag. RN-E applied Nutrashield lotion to the incision, cut a piece of [MEDICATION NAME] AG to size and applied it to the open area at the end of the incision. RN-E and NA-F then continued to give the resident a bed bath. [NAME] Review of Resident 84's Pressure Ulcer/Wound report dated 5/29/19 revealed the resident had an pressure injury to the right hip, a closed stage 2 pressure injury to the sacrococcyx (bottom of the spine to the tailbone), and a stage 3 pressure injury to the right ankle. Resident 84 also had wounds due to skin graft surgery to the right thigh, right hip, and left thigh. Review of Resident 84's Transfer/Discharge/Active Orders dated 5/29/19 revealed the resident received Xeroform secured with gauze to the right thigh, Xeroform covered with [MEDICATION NAME] to skin treated with skin prep swabs to the right hip, right ankle, and left thigh, and [MEDICATION NAME] and skin prep swabs to the coccyx. Observation on 5/30/19 at 2:13 PM of LPN-G (Licensed Practical Nurse) and RN-D performing Resident 84's wound care revealed LPN-G performed hand hygiene and gathered the supplies needed for the dressing change. LPN-G applied gloves and removed the resident's right prafo boot. LPN-G removed the dressing to the resident's right ankle, changed gloves without performing hand hygiene, and cleansed the wound. LPN-G prepped the skin surrounding the wound with a skin prep swab, changed gloves without performing hand hygiene, and cut Xeroform to fit the wound and applied it, then covered the wound with a [MEDICATION NAME] dressing. LPN-G changed gloves without performing hand hygiene and removed the dressings from the resident's right hip. LPN-G changed gloves without performing hand hygiene and cleansed the wound. LPN-G swabbed the skin surrounding the wound with skin prep and changed gloves without performing hand hygiene. LPN-G cut Xeroform to fit the lower right hip wound, applied to the wound, then covered both wounds with [MEDICATION NAME] dressings. LPN-G changed gloves without performing hand hygiene. The resident repositioned in bed and LPN-G removed the dressing from the resident's coccyx. LPN-G changed gloves without performing hand hygiene, cleansed the wound then changed gloves without performing hand hygiene. LPN-G applied a [MEDICATION NAME] dressing to the wound, changed gloves without performing hand hygiene, and secured the resident's brief. LPN-G and RN-D assisted the resident with repositioning, then LPN-G removed the wrap from the resident's left thigh, and changed gloves without performing hand hygiene. LPN-G cleansed the wound and prepped the skin surrounding the wound with the skin prep swab. LPN-G then changed gloves without performing hand hygiene, cut Xeroform gauze to fit the size of the wound, applied the Xeroform to the wound and covered the wound with a [MEDICATION NAME] border dressing. LPN-G changed gloves without performing hand hygiene, wrapped the resident's thigh with gauze, and assisted the resident with repositioning. LPN-G then removed gloves and used hand sanitizer. Review of Standard Precautions Guide dated 3/2018 revealed hand hygiene was required after glove removal, and gloves changes were required moving from a dirty to a clean task. Interview on 6/3/19 at 12:29 PM with RN-D revealed the expectation was that staff would use hand sanitizer or wash hands between glove changes.",2020-09-01
17,ST JANE DE CHANTAL,285004,2200 SOUTH 52ND STREET,LINCOLN,NE,68506,2019-06-04,926,E,0,1,GLUX11,"Based on observation, record review and interview, the facility failed to ensure there was a policy in place to protect smoking residents from accidents related to smoking. This failure had the potential to affect 6 smoking residents (Resident 8, 23, 27, 62, 95, and 155). The facility census was 115. Findings On 5/29/19 at 9:30 AM an observation revealed an unknown resident exit the West St Jane's entrance un accompanied and wheel self down the sidewalk next to the street smoking. On 05/30/19 06:50 AM an observation revealed Resident #155 exit the front door un accompanied and wheel self to the southwest parking lot and proceed to smoke On 06/04/19 10:05 AM an interview with the ADM (Administrator) confirmed the policy; Tobacco-Free Campus Areas, dated 9/17/2010 was a[NAME]campus smoking policy and did not specifically address St[NAME]residents. Record review of facility policy Tobacco-Free Campus Areas dated 9/17/10 revealed no documentation on how the facility will assess or protect residents that smoke from accidents related to smoking. On 05/30/19 at 3:00 PM the DON (Director of Nursing) provided a list of smoking residents that included; Residents #8, 23, 27, 62, 95 and 155.",2020-09-01
18,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2019-01-23,584,E,0,1,AD1911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER NAC 175 12-006.18 [NAME] Based on observation and interview, the facility staff failed to ensure food was removed from trays and placed in front of residents in a homelike manner for 119 residents that ate food in the facility dining rooms. The facility census was 232. The findings are: Observation of breakfast meal on 1/14/19 in Miracle Garden dining room revealed that residents were served their meal on trays. All liquids were served in plastic glasses. Observation of breakfast meal on 1/15/19 in Miracle Garden dining room revealed that residents were served their meal on trays. Observation of breakfast meal on 1/22/19 in Miracle Garden dining room revealed that residents were served their meal in Styrofoam dishes on a tray. Observation of breakfast meal on 1/23/19 in [MEDICATION NAME] dining room revealed that residents were served their meal in Styrofoam dishes on a tray. Interview conducted with C.N.[NAME] C on 1/15/19 at 10:15 AM revealed no knowledge of why residents were served on trays in Miracle Garden dining room. Interview conducted with RN D on 1/23/19 at 10:15 am revealed no knowledge of why meals are served on trays on some units and not on others. Interview conducted on 1/22/19 at 08:45 AM with Kitchen Service Worker [NAME] revealed the reason residents were served on Styrofoam was because the kitchen was short staffed and there was 2 units to cover. Interview conducted with Dietary Manager on 1/23/19 at 11:00 AM revealed that how the meal is served on the units is left up to the Kitchen Service Worker assigned to the unit. B. Observation on 1/14/19 at 12:20 PM in the Willow Springs neighborhood in the facility revealed that, as residents were being served lunch, the staff left the plates and glasses on the tray and placed the tray in front of the residents. Observation revealed that the residents were served food on Styrofoam plates and drinks in flexible plastic glasses in this area. Observation on 01/15/19 at 08:58 AM and on 01/16/19 at 08:55 AM and 01/23/19 at 09:28 AM in the Willow Springs neighborhood revealed that, as residents were being served breakfast, the staff left the plates and glasses on the tray and placed the tray in front of the residents. Observation revealed that the residents were served food on Styrofoam plates and drinks in flexible plastic glasses. Interview on 01/15/19 at 09:01 AM with FSW F confirmed that plates were left on trays in front of the residents. FSW F stated that there were not enough real plates so the food was served on Styrofoam plates and plastic glasses were used. Observation on 01/23/19 at 08:25 AM in the Field of Dreams unit revealed that residents were served fluids in flexible plastic glasses. Interview on 01/23/19 at 08:25 AM with RN G, when asked why residents were served liquids in plastic cups, confirmed that was RN G did not know the reason why. Interview on 01/23/19 at 09:28 AM with RN H on the Willow Springs unit, when asked why residents were served food on trays, confirmed that was RN H did not know the reason why. Interview on 01/23/19 at 10:26 AM with the Director of Nursing (DON) confirmed that it was not homelike to keep food on the trays when served or to serve with Styrofoam plates or plastic glasses. C. Observation on 01/14/19 at 12:12 PM on Wind Song Way at the lunch meal all residents received lunch trays delivered on a tray. Dishes were not removed from the trays. Trays were placed in front of residents. Liquids were served in disposable plastic cups. Coffee was served in regular cups. Observation on 01/15/19 at 09:13 AM of breakfast meal service on Wind Song Way revealed breakfast trays were delivered to the residents on trays and plates were not removed from the trays. Plastic disposable glasses were used. Interview on 1/23/2019 at 10:30 AM with Nursing Assistant (NA)-A revealed all resident's receive cold fluids are served in disposable cups. NA-A is not aware of why that is done and has asked the question and did not get an answer why some units use them and others do not. Interview on 1/23/2019 at 10:45 AM with the RN-B revealed receiving food on trays is not homelike.",2020-09-01
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 individual keeping up with current events, socializing, listening to music, watching the new, talk radio (listening), walking and pets. A current interest in small group shopping, dining out, drive/outings, listening to music, and current interest in large group shopping, dining out and listening to music. On 1/21/19 a record review of Care Plans for Resident 136 revealed goals are to participate in programs such as outdoor groups , music groups and sensory stimulation at least 3 times in next 90 days, to attend an outing 1 time in next 90 days, she will interact at least 3/12 times during 1:1's with TR staff in next 90 days. Interventions include provide opportunity for resident to visit courtyard. Invite to outdoor groups. Invite and escort resident to group activity and monitor responses, provide diversional activities for resident upon request, read calendar to resident and have resident choose group to attend, resident enjoys opera music, provide choices for community outings, announce presence when coming into room, and provide sensory stimulation. Resident #195 On 01/22/19 a record review of Recreation Annual Assessment, Past and Present Leisure Interests, Activity List Quick Reference, dated 12/27/18 for Resident 195, revealed current interest of in books/mags/newspapers,socializing, watching TV, talk radio, walking, getting outside, relaxation, and pets for individual, 1/1 and small groups. On 1/22/19 a record review of Care Plan for Resident 195 revealed interventions of offer resident the choice of community outings, offer transportation to and from activities, provide socially stimulating activities. Resident 226 On 01/17/19 a record review of annual MDS dated [DATE] for Resident 226, revealed a staff assessment of daily an activity preferences as family or significant other involved in care discussions, listening to music, doing things in a group of people, participating in favorite activities and spending time outdoors as checked for important. On 01/22/19 a record review of Recreation Annual Assessment, Past and Present Leisure Interests, Activity List Quick Reverence, dated 12/11/18, for Resident 226, revealed a current interest in individual socializing, dining out, holiday celebrations, and drive/outing, as well as individual watching movies, listening to music, and watching sports, and individual walking, bowling, and getting outside, and individual pets and a current interest in small group activities as dining out, holiday celebrations, and drive/outing. On 1/22/19 a record review of Care Plan revealed goals to increase his socialization, resident will attend activities with a social component monthly for next 90 days, resident will participate in programs such as music performances and pet therapy monthly in next 90 days. Interventions are to invite resident to activity and escort, provide pet therapy, provide sensory stimulation, invite on outings, provide choices, hang outing slip in room as a reminder of day/time of community outing and to monitor for future recreational interests and is to attend at least one community outing of choice during the next 90 days. On 01/23/19 at 02:10 PM an interview with the DON, who confirmed the care plans were not individualized.",2020-09-01
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
21,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2019-01-23,802,F,1,1,AD1911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04D Based on observation, interview and record review, the facility staff failed to ensure that meals were served on time. This had the potential to affect 228 resident served food from the kitchen. The findings are: [NAME] Review of Buffet Meal Service Long Term Care meal times dated 11/8/2018 revealed that Miracle Gardens Unit breakfast time of 7:20 AM - 8:00 AM. Safe Harbor Unit breakfast time of 8:00 AM-8:30 AM and [MEDICATION NAME] Unit breakfast time 7:50 AM - 8:30 AM. Observation on 1/15/19 on Safe Harbor breakfast was started at 08:30 AM. Observation on 1/22/2019 on Miracle Gardens Unit of breakfast was stared at 08:45 AM. Observation on 1/23/2019 on [MEDICATION NAME] Unit of breakfast being was started at 08:40 AM. Interview conducted with the Dietary Manager on 1/23/19 at 1:50 PM revealed that staffing for the kitchen included 10 food service workers, 4 Cooks, 1 pot and pan person, a youth center employee and a dish area worker. Review of dietary employee daily assignments revealed that on 1/15/19 there were 7 food service workers resulting in 3 food service workers covering 2 units. Review of dietary employee daily assignments revealed that on 1/22/19 there were 7 food service workers resulting in 3 food service workers covering 2 units. Review of dietary employee daily assignments for 1/23/19 revealed there were 5 food service workers resulting in each food service worker covering 2 units. Interview conducted with the Dietary Manager on 1/23/19 at 11:00 AM confirmed the kitchen was short staffed. B. Record review of Meal service times for Long Term Care revealed the following dining times: Willow Springs: 8:15, 12:10 and 5 PM Via [NAME]: 8 am, 12:10 and 5 PM Field of Dreams: 7:40 AM, 12:00 PM and 4:50 PM Observation on 1/14/19 at 12:20 PM in the Willow Springs neighborhood in the facility revealed that meal service did not start until 12:40 PM, 30 minutes later then the scheduled meal time. Observation on 01/15/19 at 08:45 AM in the Via [NAME] neighborhood revealed that meal service did not start until 8:45 AM, 45 minutes later then the scheduled meal time. Observation on 01/15/19 at 08:58 AM in the Willow Springs neighborhood revealed that meal service did not start until 8:50 AM, 35 minutes later then the scheduled meal time. Interview on 1/15/19 between 1:58 and 2:20 PM during the Resident Council meeting revealed a total of 7 alert and oriented residents attended the meeting. Several anonymous residents voiced the concern that meals are often served late which resulted in lukewarm food. The residents stated that this was unacceptable. Observation on 01/16/19 at 8:40 AM in the Via [NAME] neighborhood revealed that meal service did not start until 8:40 AM, 40 minutes later then the scheduled meal time. Observation on 01/16/19 at 08:55 AM in the Willow Springs neighborhood revealed that meal service did not start until 8:55 AM, 40 minutes later then the scheduled meal time. Observation on 01/23/19 at 08:20 AM in the Field of Dreams neighborhood revealed that meal service did not start until 8:20 AM, 40 minutes later then the scheduled meal time. Observation on 01/23/19 at 09:10 AM in the Willow Springs neighborhood revealed that meal service did not start until 9:10 AM, 55 minutes later then the scheduled meal time. Interview on 01/23/19 at 09:28 AM with RN H confirmed that meal service was late on that day due to kitchen staff called in due to the weather. Interview on 01/23/19 at 10:26 AM with the DON confirmed that the dining service times were later then the expected time frames for service and that this was due to staffing shortages in the dietary department. The DON confirmed that this had the potential to result in cold food and medication administration time frame issues. Interview on 01/23/19 at 11:07 AM with the DON confirmed that 21 residents on the Field of Dreams unit ate meals in the dining area, 33 residents on the Willow Springs unit ate meals in the dining area and 15 residents on the Villa [NAME] unit ate meals in the dining area. C. Observation on 01/15/19 at 8:30 AM revealed the kitchen service cart arrived in the dining area and prepared to serve the breakfast meal. At 9:13 AM the breakfast meal service on Wind Song Way was started to be delivered to the resident's seated in the dining room. The last resident tray was served at 10:00 AM. Review of the facility document dated 11/8/2018 titled Meal Service Times Long Term Care revealed meal service on Wind song Way for Breakfast is scheduled to begin at 7:55 AM. Interview on 01/23/19 at 3:09 PM with the Assistant Director of Nursing (ADON) revealed 4 residents are NPO (No oral intake) and do not eat food from the facility kitchen.",2020-09-01
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 Notification of Resident Condition Change/Room Change policy dated 2/06 revealed the following: Policy: In the event of an accident, acute medical emergency or significant change in the resident's condition or room change, the resident's family or legal guardian and the House Supervisor will be notified by the licensed nurse on duty.",2020-09-01
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 apparent injuries. -1/26/18 11:25 PM Resident 5 observed on the floor at 11:10 PM. Resident 5 had apparently got out of bed and slid. -1/20/18 1:45 AM Resident 5 sitting on floor next to chair. Resident 5 reported trying to get the cord that goes in my nose off the floor A review of falls questionnaire dated 1/20/18 for Resident 5 listed no recommendations for prevention of the fall. The falls questionnaires for Resident 5 dated 1/25/18, 2/8/18, and 2/25/18 all listed use call light as the recommendation for prevention of the fall. A review of Therapy Order Request Form for Resident 5 revealed order for physical and occupational therapy had been requested on 2/26/18. Order for physical and occupational therapy was signed on 3/9/18. In an interview on 3/15/19 at 12:16 PM, Physical Therapist C reported that an order for [REDACTED]. In an interview on 3/15/18 at 11:59 AM, Registered Nurse D reported the fall questionnaire is used to track falls and to monitor to ensure new interventions are put in place. Registered Nurse D reported that Registered Nurse D has not reviewed Resident 5's 2/2018 as Registered Nurse D just took over the unit. Registered Nurse D confirmed new interventions should have put in place for fall prevention. B. A review of Resident 2's Care Plan dated 3-21-17 revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Fall Tracking Log revealed that the resident had 27 falls since 12-3-17. The falls occurred on 12-3-17, 12-9-17, 12-21-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-5-18, 1-31-18, 2-1-18, 3 falls on 2-6-18, 2-13-18, 2-14-18, 2 falls on 2-16-18, 2-18-18, 2-20-18, 2-24-18, 2 falls on 2-26-18, 2-27-18, 2-28-18, 3-2-18, and 2 falls on 3-4-18. A review of Resident 2's Nurses Notes dated 12-3-17 revealed that the resident had fallen in the bathroom and sustained a laceration to their forehead. The resident was sent to the emergency room where the resident received staples to close the laceration and was admitted to the hospital for observation. A review of Resident 2's Care Plan dated 3-21-17 revealed the following fall events were documented on the care plan: 12-9-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-31-18, 2-12-18, 2-13-18, 2-14-18, 2-18-18, 2-20-18, 2-24-18, 2-26-18, 2-27-18, and 3-4-18. There were no new interventions put in place with the fall events. The fall events for 1-2-18 and 2-20-18 revealed that the resident continued on 15 minute checks. An interview conducted on 3-15-18 at 11:05 with Registered Nurse (RN) B revealed that the 15 minute checks for Resident 2 were not being used to prevent falls and that the checks were mostly for night time when the resident was sleeping. RN B reported that the nursing staff filled out fall questionnaires for each fall, but that RN B disposed of the questionnaires once they had processed the data. An interview conducted on 3-15-18 at 12:56 with RN B revealed that when a resident falls, the facility tracks the falls and interventions using the Care Plan. RN B reported that the Care Plan was read after each fall and the current interventions were reviewed to see what was in place at the time of the fall. The new interventions were then written on the care plan. RN B confirmed there were no new interventions on Resident 2's Care Plan for falls.",2020-09-01
24,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2019-08-01,689,E,1,0,RZY811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to ensure courtyard gates were secured to prevent potential elopement. The facility staff identified 29 residents who were cognitively impaired and were self mobile. The facility staff identified a census of 224. Findings are: Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 6-07-2019 revealed Resident 1 had the [DIAGNOSES REDACTED]. One of the goals identified for Resident 1 was Resident 1 would not leave the facility grounds without an escort. Record review of a investigation report dated 7-30-2019 revealed Resident 1 had eloped from the courtyard. Record review of a Security Incident Report (SIR) dated 7-30-2019 with a time of 7:53 AM revealed an unknown individual was seen on video walking past the south courtyard gate, According to the (SIR) Resident 1 and the unknown individual were seen conversing and then the unknown individual opened the gate and allowed Resident 1 to leave the court yard unsupervised. Record review of a SIR dated 7-30-2019 with a time of 8:10 AM revealed a temporary pad lock was placed on the South exit gate from the courtyard and at 12:35 PM a new combination lock was placed onto the south exit gate. Observation with Registered Nurse (RN) A on 8-01-2019 revealed the courtyard had 3 exit gates with locks on them. During the observation, the Compliance Offer (CO) of the facility joined the observations of the courtyard. Further observations revealed Master Gardner's (MG) entered the courtyard through the south gate of the courtyard by dialing the code on the combination lock. On 8-01-2019 at 9:10 AM an interview was conducted with MG D and MG E. During the interview MG D and MG [NAME] reported the lock to the south courtyard gate was missing on 7-27-2019. Both, MG D and MG [NAME] reported the missing lock to the south courtyard gate to the security guards. On 8-01-2019 at 10:55 AM an interview was conducted with Chief of Security (COS). During the interview COS reported that security staff did not physically check any of the courtyard gates. The COS further reported being informed the MG's had informed security on 7-27-2019. The COS confirmed the south courtyard gate had been unsecured until the morning of 7-30-2019. The COS confirmed during the interview that the courtyards gates are to be secured al all time. On 8-01-2019 at 3:35 PM a list was provided of 29 residents who were cognitively impaired and self mobile who would have access to the courtyard. On 8-01-2019 at 3:35 PM and interview was conducted with RN F. During the interview RN F confirmed the 29 residents on the list would have access to the courtyard.",2020-09-01
25,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2019-08-12,689,G,1,0,7ED911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement assessed interventions and failed to implement additional interventions to prevent falls for 3 (Resident 20, 21 and 23) of 4 residents. The facility staff identified a census of 225. Findings are: [NAME] Record review of Resident 20's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 6-19-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 1. According to the MDS Manuel, a score of 0 to 7 indicated severe cognitive impairment. -Extensive assistance with bed mobility and transfers requiring 2 persons physically assisting the resident. -Total dependence for locomotion on the unit, toilet use and personal hygiene requiring 2 persons to physically assist the resident. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 1-29-2019 revealed Resident 20 was at high risk for falls. The goal identified for Resident 20 was no falls or no falls with injury. The interventions identified on Resident 2's CCP included 2 persons to assist with dressing, hygiene, grooming/bathing and bed mobility. Resident 20's CCP also identified Resident 20 could stand and pivot with assistance. Other interventions included a mat next to the bed and to keep Resident 20's bed in a low position. Record review of a Abuse/Neglect/Misappropriation/Crime Reporting Form (ANMCRF) dated 7-24-2019 revealed Resident 20 had .fell out of bed yesterday ,striking (gender) head on the floor sustaining an abrasion and possible head injury. Record review of a investigation report dated 7-25-2019 revealed the Nursing Assistant (NA) A had been providing care to Resident 20 when Resident 20 fell from bed. Record review of a Documentation form dated 7-24-2019 revealed NA A reported working with Resident 20. According to the Documentation report, NA A reported getting Resident 20 cleaned and dressed and when NA A retrieved Resident 20's wheelchair, Resident 20 fell out of bed. Record review of an undated Fall Root Cause Analysis (RCA) form revealed Resident 20 had sustained a laceration and hematoma to the right side of the face and had altered mental status. According to the RCA, the family chose not to have Resident 20 sent to the hospital. On 8-12-2019 at 1:50 PM an interview was conducted with Registered Nurse (RN) B. During the interview RN review of Resident 20's MDS and CCP were reviewed. RN B confirmed during the interview Resident 20's CCP and MDS indicated Resident 20 was to have 2 people assist with cares. When asked how many staff were assisting Resident 20 when Resident 20 fell on [DATE] resulting in a laceration and hematoma, RN B stated 1 staff was working with (gender). B. Record review of Resident 21's MDS dated as completed on 5-29-2019 revealed the facility staff assessed the following about Resident 21: -BIM's score was a 3. -Required supervision with bed mobility, transfers, walking on the unit and eating. -Required extensive assistance with toilet use and personal hygiene. Record review of Resident 21's CCP dated 3-04-2019 revealed Resident 21 had a fall on 7-30-2019 resulting in a laceration 2 lacerations to Resident 21's forehead. Further review of Resident 21's CCP revealed there were not specific interventions implemented in an attempt to prevent re-occurrence. Record review of Resident 21's progress notes dated 7-31-2019 revealed Resident 21 was seated at a table ,stood up and fell . On 8-12-2019 at 12:25 PM an interview was conducted with RN B. During the interview RN B confirmed no additional interventions had been implemented when Resident 21 fell on [DATE]. C. Record review of Resident 23's MDS signed as dated as completed on 7-03-2019 revealed the facility staff assessed the following about the resident: -BIM's score was a 3. -Required supervision with eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of Resident 23's CCP dated 12-03-2018 revealed Resident 23 was at risk for fall related to multiple falls and poor safety awareness. Further review of Resident 23's CCP revealed Resident 23 had a fall on 6-30-2019 at 1:45 PM and on 6-30-2019 at 10:30 PM. Review of Resident 23's record revealed there was not evidence the facility had implemented interventions in an attempt to prevent additional fall when Resident 23 fell , twice on 6-30-2019. Record review of Resident 23 progress note dated 7-16-2019 revealed Resident 23 had slipped from the wheelchair sustaining a laceration on the left side of the head. On 8-12-2019 at 4:00 PM a interview was conducted with RN B. During the interview RN B. During the interview review of Resident 23's care plan was completed. During the interview, RN B confirmed additional interventions were not implemented after he falls on 6-30-2019. RN B further confirmed Resident 23 had sustained a laceration to the left side of the head. RN B confirmed additional interventions should have been implemented. Record review of the facility Policy and Procedure for Fall Risk Assessment sheet revised on 9-2005 revealed the following information: -Purpose: -2. To facilitate implementation of preventative measures. -Procedure: -7. Revise the residents care plan to reflect care needs and interventions based on the residents potential for falling. -Key Points: -Interventions must be implemented to aid in the prevention of falls.",2020-09-01
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 toilet Resident 21 every 2 hours. Observation on 10-09-2019 at 7:10 AM revealed Nursing Assistant (NA) B and NA C assisted Resident 21 into a wheelchair from bed. Further observation revealed Resident 21 was taken to the dining room for breakfast. Observation on 10-09-2019 at 10:07 AM revealed Resident 21 was asleep in the wheelchair located in the dining room. Observation on 10-09-2019 at 10:15 AM revealed Resident 21 remained in the dining room asleep in the wheelchair. Observation on 10-09-2019 at 10:40 AM revealed Resident 21 remained in the dining room asleep in the wheelchair. Observation on 10-09-2019 at 11:00 AM revealed NA [NAME] and NA F assisted Resident 21 into the bathroom. A span of 3 hours and 50 minutes from 7:10 AM to 11:00 AM for toileting assistance. On 10-09-2019 at 11:07 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview when asked how often Resident 21 was to be assisted with toileting, LPN D stated every 2 hours. On 10-09-2019 at 2:45 PM an interview was conducted with RN [NAME] During the interview RN A reported had asked all nursing staff on the unit if Resident 21 had been assisted with toilet use and confirmed Resident 21 had not been assisted with toileting needs every 2 hours.",2020-09-01
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
28,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2016-09-21,323,E,0,1,7TIB11,"Licensure Reference Number: 175 NAC 12-006.09D7a Based upon observations, interviews and record review; the facility failed to ensure Team 1's medication cart was secured when unattended on Wind Song Way unit. This had the potential to affect 14 cognitively impaired, self-mobile residents of the 44 residents that reside on the unit. The facility census was identified as 236. Findings are: [NAME] An observation on 09/21/2016 at 1:26 PM revealed that the Wing Song Way Neighborhood Team 1 medication cart was observed to be in the Wing Song Way Neighborhood commons area, with no staff members present. A check of the cart's medication drawers found them to be unsecured. There were 7 residents in the immediate area. This was confirmed by the nurse manager of the Wing Song Way Neighborhood on 09/21/2016 at 1:28 PM, who secured the cart at this time. An interview with the Nurse Manager of the Wing Song Way Neighborhood on 09/21/2016 at 1:28 PM, confirmed that the cart was unsecured and that medication carts should be secured when unattended. An interview with Registered Nurse A (RN A) at 09/21/2016 1:36 PM revealed that the cart was unlocked about five minutes and RN A had left the unit to go upstairs to fax a document. RN A confirmed that the cart should had been secured prior to RN A's leaving the cart. A record review of the facility's Medication Guidelines/Preparation/Administration Policy dated revised 5/91,7/92, 12/94, 1/95, 6/97, 3/07, 1/09, 12/10; revealed the following: The medication room/cart MUST be closed and locked at all times except when medications are being prepared by the Nurse.",2020-09-01
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 any evidence that the Resident 210 had been back to a dentist since 04/07/2015. A follow-up interview with the DON on 09/21/2016 1:15 PM confirmed that the standard of care is that dental services should be offered at least annually to those who want the services. The DON further confirmed that there was no evidence available concerning whether or not the facility had asked, the resident or the POA, if the resident wanted to receive dental services.",2020-09-01
30,DOUGLAS COUNTY HEALTH CENTER,285019,4102 WOOLWORTH AVENUE,OMAHA,NE,68105,2017-11-14,371,F,0,1,VVNM11,"Licensure Reference Number 175 NAC 2-006.11E Based on observation, record review and interview; the facility dietary staff failed to utilize hair restraints in the facility kitchen. This had the potential to affect 219 residents that ate food prepared in the facility kitchen, and failed to maintain serving temperature of cool food used for medication administration for Resident 235. The facility census was 226. Findings are: [NAME] Record review of the Nebraska Food Code dated (MONTH) (YEAR) section 2-402.11 revealed: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service or single use articles. Observation on 11/13/2017 between 10:10 AM and 10:30 AM revealed Cook A had a mustache without a hair restraint in place over the mustache during the preparation of meat for roast. Dietary Aide (DA) B was present in the kitchen and had a beard and mustache with no hair restraint in place over the beard or mustache. DA C was present in the kitchen and had a mustache with no hair restraint in place over the mustache. Interview on 11/13/2017 4:16:31 PM with the Dietary Supervisor confirmed that Cook A and DA ' s B and C should have worn beard and mustache hair restraints while in the kitchen. Record review of a facility policy on Employee Appearance dated 1/26/17 revealed that sideburns, mustaches and beards are to be trimmed. All beards must be covered with an approved mask. Record review of a list of residents that take nothing by mouth dated 11/14/17 revealed that there were a total of 7 residents in the facility that did not eat any food prepared in the facility kitchen. B. Record review of the facility policy of Safe Food Handling dated revision 2/14/17 revealed: D. Holding and Service 1. Hot food must be held at 135 degrees Fahrenheit (F) or above, and cold food at 41 degrees F or colder. 6. When serving cold food, fill wells with ice, and cover food whenever possible to maintain temperature. Observation on 11/13/17 at 9:23 AM during medication pass, it was noted after providing medications to Resident 235, that the yogurt that was used to administer medications was 60 degrees F. Interview with Staff Member D, on 11/13/17 at 9:23 AM, revealed that Resident 235 was the only resident that yogurt was used to administer medications. Staff Member D revealed that the yogurt was taken from the unit refrigerator at 7 AM that morning, and was placed on top of the medication cart for use. Staff Member D confirmed that the yogurt was not placed in ice wells when not in use. Staff Member D confirmed that the temperature at the time of administration, at 9:23 PM was 60 degrees as tested with thermometer. Interview with Unit Manager [NAME] on 11/13/17 at 9:23 AM confirmed that the yogurt was served at a temperature higher than the facility policy of 41 degree or less. Interview with the facility Dietary Manager on 11/13/17 at 12:29 AM confirmed that yogurt was to be served at 41 degree or less and that it was to be kept on ice if out of the refrigerator waiting to be served to maintain the temperature. The dietary manager confirmed that safe food handling policy was not followed.",2020-09-01
31,EASTMONT TOWERS,285036,6315 O STREET,LINCOLN,NE,68510,2017-03-30,371,F,0,1,GDOK11,"LICENSURE REFERENCE 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure a Food Service Provider washed hands in a manner to prevent potential for food born illness and failed to ensure frozen foods were stored in a sanitary manor. These failures had the potential to affect all of the resident's residing in the facility. The facility census was 9. Findings are [NAME] A review of the Facility's HANDWASHING POLICY AND PR[NAME]EDURE initated 2/1/17 revealed the procedure included use a clean paper towel to dry hands and use a paper towel to turn off water. An observation on 3/28/17 at 10:45 AM of Chef-A preparing fresh vegetables revealed the Chef washed hands at appropriate times throughout the preparation. Observation of the Chef's handwashing technique revealed hands were washed the appropriate amount of time. The Cook was noted to: obtain paper towels, turn off the water faucets, and then with the same paper towels dried hands and arms possibly recontaminating hands. The Chef returned to the task of cutting/prepping the vegetables using bare hands. Observations on 03/30/2017 from 8:05 AM to 8:20 AM of Chef-A during food preparation (prep) revealed the Chef washed hands at appropriate times, paper towels were obtained and used to turn the water faucets were turned off. Chef-A then dried hands using the same paper towels. The Chef preformed handwashing in the same manner three times during the food prep observation. An interview on 03/30/2017 at 08:22 AM with Chef-A revealed the Chef was knowledgeable of need for proper handwashing at the proper times while preparing food items. The Cook confirmed using the paper towel to turn off the faucets prior to drying hands and reported that clean paper towels should be used to dry hands if the towels had been first used to turn off the water faucets. B. An observation on 03/30/2017 at 8:25 AM in the Facility's large walk in freezer revealed a gallon sized plastic container of ice cream on the floor under the food storage shelving unit. The Food Service Director (FSD) collected the container and further observation of the container revealed it had been opened and approximately 1/2 of the contents was gone. The container was not marked with the date the ice cream was opened and the remaining product was covered with ice crystals. The FSD placed the unmarked ice cream container into the trash. Further observation in the freezer revealed 5 individually wrapped ice cream sandwiches and an individual styrofoam container of ice cream, on the floor under the shelving unit. The floor of the freezer also contained several areas of visible debris. An interview on 03/30/2017 at 8:30 AM with the FSD revealed routine audits were completed in the kitchen and dietary staff were aware of the need to clean the floor of the walk in freezer. The FSD confirmed the identification of ice cream products on the floor of the freezer and the lack of marking the container with the date it was opened.",2020-09-01
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,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,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 3-30-17, Staff D visited with the Family about why the resident had been left in incontinent urine for 15 minutes on 4-30-17 when the Family arrived that day. However, Staff D did not say anything about the why this had occurred on other days, or the other 2 concerns the Family had addressed on the grievance how those were being addressed. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the Grievance Log was absent of a grievance for Resident 603. The DON also confirmed the DON was not aware of any grievance that had been filed by any member of Resident 603's family that had not been yet listed on the Grievance Log. The DON also denied knowledge of a grievance that had been personally handed to Staff D the end of (MONTH) by the Family. On 05-04-17 the DON provided a copy of a grievance form on Resident 603 dated 03-30-17 initiated by the Family. Documentation of Facility Follow-Up and Resolution of Grievance/Complaint sections of the form were completed by SS-E (Social Service) dated 04-10-17. Documentation on the grievance addressed the resident being left to sit in incontinent urine on 3-30-17 and an intervention if it should occur in the future. The documentation revealed the reason the resident did not get the medications for 7 days was due to the doctor not getting back to facility's request. The documentation did not reveal a resolution to ensure it would not happen again or to explain why this was acceptable. The documentation did not have when the Family was notified of the information about the medications. The ADM (Administrator) dated the form 05-01-17. Interview on 05-04-17 at 08:30 AM with the ADM revealed the ADM received the grievance form on 05-01-17 and could not explain why it took so long for the ADM to receive it even though the SS dated the form as completed on 04-10-17. The ADM revealed the ADM called the Family and reached a voicemail and left a message 05-01-17. Interview on 05-04-17 at 8:42 with SS-E revealed the facility process for grievances was to respond back to the person who filed the grievance within 1 week with a resolution. The ADM usually also responded back to the person who filed the grievance. SS-E provided the Homestead Care Handbook with the grievance process wrote in it which revealed All grievances/complaints received from Residents, Representatives and Families are addressed. All grievances will be investigated and a response given to the complainant within 5 working days. If longer than 5 days is required, the complainant will be notified. Interview on 05-04-17 at 9:48 AM with SS-F revealed the SS felt the grievance was resolved by Staff D so SS-F completed the form and notified the Family of the resolution. SS-F denied documenting the conversation with the Family of the grievance resolution on the grievance form, Progress Notes, or anywhere else. SS-F denied recalling the details of the conversation.",2020-09-01
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 even if the resident would have wanted to have tried to transfer. Resident 603 revealed Staff B from the evening shift entered the bathroom while passing fresh water pitchers and emptied the old water in the sink and found the resident on the shower chair. Staff B asked the resident what the resident was doing in the shower then went and informed the charge nurse and they returned and transferred the resident into the wheelchair. Resident 603 denied any physical injury from the incident. Observation on 04-26-17 at 10:20 AM revealed the resident shower was in the bathroom of the resident's room. The shower chair was a permanently fixed chair to the wall and not a chair with wheels. The only call light in the bathroom was across the room by the toilet. Review of the facility investigation report revealed on 04-08-17 at approximately 2:00 PM a shower was given to Resident 603. The resident was dressed followed by the wound treatment to the left leg by the Staff [NAME] The resident was left sitting on the shower chair to allow the [MEDICATION NAME] to dry before the resident was transferred back into the wheelchair. The call cord was not long enough to reach the resident in the shower. Staff A left the resident to go give report to the oncoming shift. Staff A revealed (gender) believed report was told to the oncoming shift of Resident 603 being left in the shower. The oncoming nurse, Staff C, denied being told Resident 603 was in the shower. The resident was taken out of the shower at 4:45 PM when Staff B found the resident when Staff B emptied a water pitcher. Review of the Progress Notes revealed no documentation of the incident. On 04-08-17 at 9:35 PM it was documented a general overall skilled assessment of the resident which revealed resident had no visible sores noted. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the incident had occurred and the staff involved were disciplined. The resident was left unattended on the shower chair in the resident's bathroom without a call light for 2 hours and 45 minutes.",2020-09-01
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 has not established advanced directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline this assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer and the resident's decision to accept or decline. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directives. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of Resident #330's Admission Baseline Care Plan and current care plan revealed no code status is care planned. Review of Resident #330's Summary of Care Document printed 5/9/18 at 2:13 PM, revealed : Current Code Status DNR Review of Resident #330's Patient Demographics printed on 5/9/2018 revealed Documents on File Advanced Directives Discharge & Transfer -- Altitude Discharge Plan of Care",2020-09-01
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
38,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2018-05-22,584,E,1,1,HJ5H11,"> Licensure Reference Number NAC 12-006.18A(1) Based on observation and interview, the facility failed to ensure the bath house was free from non jagged corners on the shower wall and a black substance on the shower floor and wall that had the potential to affect 60 residents on the 100 and 200 halls. The facility census was 131. Findings are: Observation of the 100 and 200 wing bath house on 5/22/18 at 8:00AM and a second observation on 5/22/18 at 11:00AM revealed a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge. Environmental tour with the Adminstrator and Maintenance Man on 5/22/18 at 11:00 AM revealed a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge. Interview with the Administrator on 5/22/18 at 2:30PM comfrmed that there was a black substance in between the shower floor and wall and the edge of the shower wall had a jagged edge",2020-09-01
39,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2018-05-22,656,E,0,1,HJ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews and interviews; the facility failed to develop care plans to address, A) activities and oral intake status for Resident 73, B) activities for Resident 90. Resident sample size was 31. Facility census was 131. Findings are: [NAME] Review of Resident 73's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 4-4-18 revealed total dependence for dressing and extensive assist for personal hygiene. Review of Resident 73's current Physician order [REDACTED]. Review of a Nutrition Note dated 5-6-18 revealed Resident 73 was on Tube Feeding at at 50 cc/hour and was to have no food by mouth with all nutrition via the feeding tube. Review of Resident 73's Care Plan last revised 5-14-18 noted the resident has tube feeding, but has ok for ice chips and now ok for 10 bites of pureed food with extra gravy one time daily. Review of Resident 73's Care Plan for activities last revised 5-14-18 revealed a problem start date of 1-19-2018. The first approach for the problem was dated 5-14-18. Interview with RN J (Registered Nurse) on 5-22-18 at 1423 05/22/18 the care plan interventions for Resident 73's activity needs dated 1-19-18 could not be located. B. On 05/16/18 at 01:08 PM Observation of Resident 90 revealed the resident was not engaged in activities. Review of Resident 90's Resident Face Sheet revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/21/18 at 9:46 AM Observation of Resident 90 revealed the resident was in bed in room with music playing. On 05/22/18 at 11:47 AM Observation of Resident 90 revealed the resident was in bed in room with music playing. On 05/22/18 at 01:48 PM Interview with the Activity Director revealed that the Activity Director stated read the newspaper and books to Resident 90 in room. Record review of Resident 90's care plan revealed that the facility failed to Care Plan Activities. On 05/22/18 at 02:53 PM Interview with Nurse Consultant A confirmed that activities had not been care planned for Resident 90.",2020-09-01
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,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
42,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2018-05-22,755,E,0,1,HJ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.10A2 Based on observation, record review and interview, the facility failed to administer medications through an Enteral Tube (is used to feed patients who cannot attain an adequate oral intake from food and/or oral nutrition supplements, or who cannot eat/drink safely) per facility policy. This was the observation for one sample resident (Resident 73). This had the potential to affect 4 residents (Residents 90, 61, 37 and 73) at the facility. Census: 153 Residents. Sample size 73 Residents. Observation on 5/22/18 from 8:33 AM until 9:10 AM RN-G (Registered Nurse) set up medications for Resident 73 to be given through an Enteral Tube. The medications were Calcium [MEDICATION NAME] (a dietary supplement used when the amount of calcium taken in the diet is not enough). [MEDICATION NAME] (a medication used to treat diabetes insipidus, betwetting, [DIAGNOSES REDACTED] A, von Willebrand diseae, and high blood urea levels). Docu Liquid (medication used to treat occasional constipation). [MEDICATION NAME] (a medication used for pain control, to help prevent or control [MEDICAL CONDITION], or as a mood stabilizer). [MEDICATION NAME] (is used to treat certain conditions where there is too much acid in the stomach. It is used to treat gastric and [DIAGNOSES REDACTED] ulcers, erosive esophagitis). [MEDICATION NAME] (is a class of drugs call steroids. [MEDICATION NAME] prevents the release of substances in the body that cause inflammation). Levetiracetam (is an anti-epileptic drug used to treat partial onset [MEDICAL CONDITION] in people with [MEDICAL CONDITION]). [MEDICATION NAME] (used to treat occasional constipation). [MEDICATION NAME] (is used to treat intestinal and stomach ulcers, [MEDICAL CONDITION] reflux disease (GERD) and conditions where your stomach makes too much acid). Vitamin D 1000Units (is a supplement that helps your body absorb calcium and phosphorous). RN-G took the listed medications to the bedside of Resident 73. RN-G was observed to check the placement of the Enteral Tube and check for residual. RN-G drew up each medication individually and administered each medication into the Enteral Tube using the syringe and plunger. Record review Administering Medications through an Enteral Tube (Revised (MONTH) 2012) 22. Reattach syringe (without plunger) to the end of the tubing 23. Administer medication by gravity flow. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. Open the clamp and deliver medication slowly. Clamp tube (or begin flush) before the tubing drains completely. 24. If administering more than one medication, flush with 5ml (or prescribed amount) warm sterile water between medications. Interview on 5/22/18 at 9:12 AM with RN-H stated was not sure if RN-G gave the medications correctly through the Enteral Tube, but would get a copy of the Policy and Procedure for the Surveyor.",2020-09-01
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,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
45,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2018-05-22,867,E,0,1,HJ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.07C (2) Based on observations, interviews, and record reviews, the facility failed to Develop and implement a plan to correct and maintain compliance regarding repeat federal and State deficiencies pertaining to housekeeping and maintenance. The concerns identified had the potential to effect 66 residents. The facility census was 131. Record reviews of past re-certification survey deficiency statements dated 5-25-17 revealed the facility was cited for failures regarding the ventilation motors in resident rooms, and broken and stained caulking in resident bathroom areas. Observations and interviews conducted during the current survey from 5-16-18 to 5-22-18 revealed vents were not working in rooms [ROOM NUMBER] bathrooms. The 100 and 200 wing bath house observation revealed a black substance in between the shower floor and wall and the edge of the shower had a jagged edge. These observations were confirmed with Maintenance and the Administrator. Interview with the Administrator on 5-22-18 at 1554 revealed resident bathing area for the 100 and 200 hallways was not identified as a possible area to focus on for Quality Assurance. Record review of the facility Quality Assurance and Performance Improvement revised 5-2017 revealed the QAPI Committee oversees the quality and effectiveness of the facility operations and systems to meet the needs of the residents; to monitor and analyze facility key performance indicators to identify improvement opportunities.",2020-09-01
46,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2018-05-22,923,F,0,1,HJ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure the vent fans were working in bathrooms for room [ROOM NUMBER], 402, and 410. Facility Sample size was 31. Facility census was 131. Findings are: Observation of bathrooms in rooms [ROOM NUMBER] revealed that the vent fans were not working. On 05/22/18 at 10:59 AM During the Environmental tour the Administrator and Maintenance Man confirmed that the vent fans in rooms [ROOM NUMBER], were not working. On 05/22/18 at 1:59 PM an interview with the Administrator confirmed that the vent fans in rooms [ROOM NUMBER] were not working.",2020-09-01
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
48,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2017-05-25,253,E,1,1,18U611,"> Licensure Reference Number(s) 175 NAC12-006.18B and 175 NAC 12-006.18A(1) Based on observation, interview, and record review; the facility failed to ensure two mechanical sit to stand lifts (a mechanism used to assist residents to transfer from one surface to another) were clean. This failure had the potential to affect 10 of 15 sampled residents (Residents 71, 92, 150, 109, 158, 194, 145, 169, 44, and 152) who required use of a lift for transfers. The facility also failed to ensure; 1) Eight resident rooms (306, 103, 102, 314, 216, 301, 318, and 410) had tiles with stained or broken caulking in the bath rooms; and 2) Rooms 219, 400, 306, and 410 were free from lingering odors . Findings are [NAME] An observation on 5/24/17 at 10:12 AM revealed Nursing Assistant (NA)-E using a disposable wipe to wipe the handles, upper bars, and knee rest, of a mechanical sit to stand type lift (a devices used to assist residents during transfers from one surface to another). The NA did not wipe the foot plate, lower bracing, or wheels of the lift. Further observation revealed the wheels of the lift had evidence of hair and other foreign materials wrapped around them, the foot plate and lower bracing contained visible dust and debris. An interview on 5/24/17 at 10:14 AM with NA-E revealed the NA did not clean the lower surfaces of the lift. The NA was unaware of a cleaning schedule which included all of the lifts surfaces. An interview on 5/24/17 at 10:15 AM with Registered Nurse (RN)-F revealed the mechanical lift should be cleaned after each resident use. The RN observed the lift and confirmed the lower areas of the lift were soiled and in need of cleaning. An interview on 05/25/2017 at 11:39 AM with Licensed Practical Nurse (LPN)-G revealed the area of the facility (Station 3) had two mechanical sit to stand type lifts in use, and that both of the lifts had the same concerns related to sanitation. The LPN reported that other areas of the facility had their own equipment, including mechanical lifts. Review of a facility Census roster dated 5/24/17 revealed fifteen residents who required use of a sit/stand lift for transfer assist. Ten of the fifteen residents resided on Station 3, (Residents 71, 92, 150, 109, 158, 194, 145, 169, 44, and 152). A review of the facility policy titled CLEANING AND DISINFECTION OF RESIDENT CARE ITEMS AND EQUIPMENT dated/revised (MONTH) 2014 revealed reusable resident care equipment would be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection between resident use. B. Observation of Room 514 on 5/18/17 at 9:22 AM revealed the bathroom smelled of urine . Observation of the bathroom in [RM #]6 on 5/22/17 at 10:26 AM revealed stained caulking around the toilet. Observation of the bathroom in Room 103 on 5/22/17 at 9:58 AM revealed cracked caulking around the base of the toilet. Observation of the bathroom in Room 102 on 5/18/17 at 9:18 AM revealed cracked caulking around the base of the toilet. Observation of the bathroom in Room 219 on 5/22/17 at 11:23 AM revealed a urine odor. Interview with a resident in Room 400 on 5/23/17 at 7:39 AM revealed the bathroom had an odor especially on warm days. During an environmental tour on 5/24/17 beginning at 1:00 PM, interview with the Maintenance Supervisor (MS) revealed the caulking needed replaced in the bathrooms of rooms 314, 216, 301, 318, 410. Further interview during the environmental tour on 05/24/2017 at 2:04 PM with the MS revealed odors were acknowledged in the bathrooms of 306, 219, and 410. The MS further reported the odors smelled of urine. Interview with the Housekeeping Supervisor on 05/25/2017 at 10:50 AM revealed the odors have not been alleviated with cleaning or the use of odor eliminator products.",2020-09-01
49,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2017-05-25,258,E,1,1,18U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.18A (3) Based on observations and interview, the facility failed to replace loud bathroom ventilation motors to promote comfortable sound levels in rooms [ROOM NUMBER]. The facility census was 131. Findings are: Observation of the bathroom in room [ROOM NUMBER] on 05/18/2017 at 9:18 AM revealed a noisy bathroom ventilation fan . Interview with a resident living in room [ROOM NUMBER] on 5/18/17 at 9:22 AM revealed the bathroom vent is so loud that the resident has to turn on the radio in the room in order to not hear it. Observation of the bathroom in room [ROOM NUMBER] on 05/22/2017 at 02:44 PM revealed a noisy bathroom ventilation fan. Observation of the bathroom in room [ROOM NUMBER] on 05/22/2017 at 09:58 AM revealed a noisy bathroom ventilation fan that could be heard in room with the bathroom door shut. Observation of bathrooms during the Environmental Tour with the Maintenance Supervisor on 5/24/2017 between 1:00 PM and 3:30 PM revealed all of Station One vents were loud. Interview with the Maintenance Supervisor on 5/24/2017 between 1:00 PM and 3:30 PM confirmed the vents were loud still loud despite having been taken out and cleaned.",2020-09-01
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,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 187 something else to hold in order to assist Resident 187 with wearing and keeping the glasses on. Interview with the unit manager/Registered Nurse (RN) F on 05/25/2017 at 12:22 PM revealed there was no problem on the care plan addressing Resident 187's impaired vision or interventions to aide in the wearing of the eye glasses but that it is noted on the Resident Assignment sheet that Resident 187 was to wear glasses.",2020-09-01
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 toileting, and obtain labs as ordered. The CP did not include an individualized toileting plan or interventions to prevent or improve incontinence status. A review of the electronic medical record for Resident 194 revealed a document titled DISCHARGE & TRANSFER-MEDICARE DISCHARGE PLANNING MEETING dated 10/25/16. The document revealed the resident required physical assist from 1-2 people for toileting, without a documented goal related to the concern. The section of the document titled BOWEL/BLADDER MANAGEMENT indicated Resident 194's previous level of bowel/bladder control and management was continent (able to control) of bowel and bladder. The documentation was incomplete and did not include information related to the resident's current level or goals and interventions related to toileting concerns. An interview on 05/23/2017 at 9:58 AM with Nursing Assistant (NA)-H revealed Resident 194: required assistance from 2 staff for transfers using a sit-stand lift (mechanical device used to move residents from one surface to another), was incontinent of bowel and bladder, was able to let staff know of need to use the bathroom, was toileted with staff assistance every 2 hours and as needed. An interview on 05/24/2017 at 8:41 AM with Registered Nurse (RN)-J, revealed Resident 194 was incontinent while receiving Medicare Services and residing on the Skilled Unit of the facility, 10/21/16-1/7/17, but was not on a toileting program. The RN reported that a Bowel and Bladder Voiding Diary was not completed upon admission for the resident. An interview on 05/24/2017 at 10:45 AM with RN Unit Manager-F revealed a bowel and bladder (B & B), three day diary/observation had not been completed for Resident #194 since moving to Unit 3 on 1/8/17. The RN confirmed the resident's CP did not include individualized interventions related to toileting/incontinence issues. A review of an undated facility document titled BOWEL AN BLADDER GUIDELINE revealed: all residents have a B & B observation completed on admission, quarterly, change in condition, and in the instance of a change in continence; if B&B observation shows resident is both continent and incontinent of either bladder or bowel, a 3 day tracking/voiding diary shall be initiated; Care Plan needs to include individualized toileting schedule/program or reason one is not appropriate; the facility should observe that incontinent residents have pericare completed at least every 2 hours. B. An observation on 5/23/17 at 10:02 AM of NA-H and NA-I assisting Resident 194 with toileting needs revealed a sit stand lift (a mechanical device used to move residents from one surface to another) was used to transfer the resident from a wheel chair to the bathroom and toilet with no concerns identified. NA-I was noted to apply gloves prior to assisting the resident to lower pants and remove a soiled brief. Soiled gloves were not removed prior to NA-I assisting NA-H to manipulate and reposition the mechanical lift and lower Resident 194 onto the toilet. Privacy was provided and when Resident 194 indicated completion of elimination needs, the lift was used to bring the resident to a standing position. NA-I was observed to use disposable wipes to cleanse the resident's genital area, and a different wipe was used to complete back pericare. NA-I then applied a clean brief for the resident and assisted NA-H to move the lift out into the resident's room. Resident 194 was lowered into a wheel chair in order to remove wet trousers and apply a clean pair. Neither NAs were noted to change gloves or sanitize hands throughout the provision of care for Resident 194. Interviews on 5/23/17 at 10:15 AM with NA-H and NA-I revealed the NAs did not remove soiled gloves prior to making contact with items considered clean or sanitize their hands, during the provision of toileting and incontinence care for Resident 194. A review of Lab Reports for Resident 194 revealed urine specimans tested positive for symptoms of urinary tract infection on 1/13/17 and 2/7/17. A review of the Basic Nursing Assistant Training Manual, 4th Edition dated 2009 revealed to prevent the potential for cross contamination, gloves were to be removed and hands sanitized following the completion of pericare and before touching clean clothing items. C. 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 severely impaired cognition, required extensive assist with toileting, and was always incontinent of bowel and bladder. Review of Resident 187's (MONTH) Medication Administration Record [REDACTED]. Observation of incontinent care on 05/23/2017 at 10:40 AM revealed Nursing Assistants (NAs) R, S, and T assisting Resident 187. NA S put on gloves, removed the dirty brief and providing hygiene to Resident 187's buttocks as Resident 187 was having an incontinent stool. NA S continued to wipe away the stool from Resident 187 four additional times and then assisted Resident 187 over to Resident 187's back. NA S did not remove gloves and proceeded to provide care to Resident 187's vaginal area while wearing the same gloves. Interview with NA S and Registered Nurse (RN) U on 5/23/17 at 10:55 AM revealed RN U agreed that NA S did not change gloves after providing care for incontinent stool. Review of the facility's undated Peri-Care Competency Checklist revealed staff should use a tissue/disposable peri-wipe and remove any stool that is present, then remove gloves and sanitize hands before proceeding with perineal care.",2020-09-01
53,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2017-05-25,323,E,0,1,18U611,"Licensure Reference Number: 175 NAC 12-006.18E5 Based on observations and interviews, the facility failed to safely store chemicals in its Memory Unit (Station 4), which had the potential to affect 4 residents out of 19 residents. The facility census was 131 . Findings are: Observation on 5/17/2017 at 1:30 PM revealed an unlabeled spray bottle with a purple liquid on the counter in the dining room of Station 4. A container of disposable bleach wipes were noted in an unsecured cupboard under the sink in the same dining room. Observation on 5/23/2017 at 10:42 AM with RN AA revealed a container of Dispatch with Bleach sanitizing wipes were unsecured in a cupboard under the sink in the dining room of Station 4. Interview with RN AA during this observation confirmed the wipes were unsecured . Interview with Housekeeper Z on 5/23/17 at 10:25 AM revealed residents are allowed in the dining room unsupervised at times. Interview with the Nurse Consultant on 5/25/17 at 4:30 PM revealed there were 4 residents that wandered and rummaged on Station 4.",2020-09-01
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,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 for dx of unspecified dementia without behavior disturbance-started on 11/16/16, Seroquel an antipsychotic medicine (changes the actions of chemicals in the brain-used to treat schizophrenia and bipolar disorder) 25 mg four times a day started on 3/24/17, and Trazodone (an antidepressant) 100 mg daily started on 8/26/16. A review of pharmacist monthly reviews for Resident 163 revealed documentation that 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. Review of Resident #163's medical record revealed no documented evidence of AIMS Testing (Abnormal Involuntary Movement Scale which aids in the early detection of movement disorders related to the use of antipsychotic medications as well as providing a method for on-going surveillance). An interview on 05/25/2017 at 3:49 PM with RN (Registered Nurse)-L revealed no AIMS testing had been completed for Resident 163. A review of a Drug Interaction Report obtained from Drugs.com revealed taking Trazodone, Seroquel, and Citalopram had the potential for a major negative drug interaction. Use of the medications together have the potential to cause severe side effects. An interview on 05/25/2017 at 2:11 PM interview with Pharmacist-D revealed the medications prescribed for Resident 163 had not been reviewed for possible negative drug interactions. The Pharmacist reported the lack of AIMS testing for Resident 163 had not been identified as an irregularity. A review of a facility policy titled MEDICATION THERAPY, revised (MONTH) 2007, revealed all medication orders will be supported by appropriate care processes and practices. Resident medications will be reviewed, assisted by the Consultant Pharmacist, upon admission and periodically to identify whether postential or suspected side effects are present.",2020-09-01
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's room, laid the machine directly onto Resident 104's bedside table, picked up the glucometer and tested Resident 104's blood, again laying the glucometer down directly onto Resident 104's bedside table. LPN V then gathered all supplies, left the room and laid the glucometer on top of the medication cart. LPN V then removed another disposable sani cloth and wrapped it in the same fashion as before, laying the machine back on top of the cart with only the top of the machine in contact with the disinfecting wipe. LPN V again failed to make any effort to wipe down the machine with the cloth before wrapping it. LPN V then removed the sani wipe off of the 1st glucometer used labeled PRN 2 and reported the machine needed to air dry now. LPN V disposed of the wipe never wiping down the machine and never touching the underside of the machine. This was observed at 11:46 AM on the same date. At 11:48 AM (on 5/24/17) LPN V proceeded to remove another glucometer machine from the cart labeled PRN 1 and laid it on top of the medication cart. LPN V gathered the supplies and took the machine labeled PRN 1 into Resident 31's room and laid the glucometer directly on top of Resident 31's bedside table. LPN V then picked up the machine and used it to test Resident 31's blood, gathered the supplies and went back to the medication cart, laying the glucometer back on top of the medication cart. LPN V then removed another sani cloth and wrapped this glucometer in the same fashion and laid it back down directly on top of the medication cart. At 11:51 am (on 5/24/17) LPN V picked up the first glucometer (labeled PRN 2) that was now dry and took it to Resident 197's room, laid it on the bedside table before picking it up again to and used it to test Resident 197's blood. LPN V then laid the glucometer back onto Resident 197's bedside table before taking it back out to set it on top of the medication cart. Interview with LPN V on 5/24/17 at 11:58 AM revealed LPN V would proceed to take off the disposable wipes from the machines and replace the glucometers back into the medication cart in the same manner as before, without wiping down any of the surfaces with the sani cloth. Interview with the Director of Nursing (DON) on 5/24/17 at 1:48 PM revealed the policy was not followed for cleaning the machine. Review of the facility's undated policy for Maintenance of Assure Platinum Blood Glucose Monitoring System revealed, Cleaning and Disinfecting guidelines: Remove wipe from container, wipe all sides and end of machine. Allow machine to sit for 10 minutes after using wipe to totally disinfect the machine before using the machine again. It is critical that the meter be completely dry before testing a resident's glucose level. B. An observation on 5/23/17 at 10:02 AM of staff assisting Resident 194 with toileting needs revealed Nursing Assistant (NA)-H and NA-I applied gloves prior to assisting the resident to remove a soiled brief. Further observation revealed NA-I did not remove soiled gloves prior to having contact with/touching clean items. Interviews on 5/23/17 at 10:15 AM with NA-I revealed the staff member did not remove soiled gloves prior to making contact with items considered clean, during the provision of toileting and incontinence care for Resident 194. A review of a facility policy titled PERSONAL PROTECTIVE EQUIPMENT-GLOVES, revised (MONTH) 2009, revealed gloves were to be worn when touching body fluids and excretions. Gloves should be used for one resident contact and then discarded. C. An observation on 5/24/2017 at 10:29 AM of staff providing cares for Resident 98, revealed: Nursing Assistant (NA)-M washed hands prior to and following the provision of care for 7 seconds each time; NA-N was noted to wash hands for 10 seconds prior to providing needed assist Interviews on 5/24/17 at10:35 AM with NA-M and NA-N revealed the Nursing Assistants were knowledgeable of need for recommended 20 seconds for effective handwashing. Both NA-M and NA-N confirmed they did not wash hands for the recommended 20 seconds. A review of the facility policy titled HANDWASHING/HAND HYGIENE, revised (MONTH) 2008, revealed Appropriate ten (10) to fifteen (15) second handwashing or sanitation via an alcohol based hand rub was to be completed before and after direct contact with residents. The policy did not include the most current CDC (Center for Disease Control) recommendation of 20 seconds for handwashing. D. An observation on 5/23/17 at 10:02 AM of staff providing transfer/toileting assistance for Resident 194 revealed: a sit to stand type lift (a reusable mechanical device used to transfer residents from one surface to another) was obtained from a soiled utility area on Station 3, by Nursing Assistant (NA)-H; the lift was visibly soiled with a dried black colored substance noted to the base/foot rest of the lift, a dry crusty substance and debris were noted to the wheels and locking mechanism of the lifts wheels; and the lift was not cleaned/sanitized prior to entering Resident 194's room. Following the use of the lift to transfer Res 194, NA-H removed the lift from the resident's room and proceeded down the hallway, the lift was intercepted by NA-O who positioned the lift next to the wall. NA-O left the lift momentarily and returned taking the lift into resident room [ROOM NUMBER], without sign of sanitation. An interview on 5/23/17 at 10:20 AM with NA-H confirmed the NA did not sanitize the sit to stand lift prior to, or after use with Resident 194. An interview on 5/23/17 at 10:28 AM with NA-O revealed the NA did not sanitized the lift prior to using the equipment to transfer Resident 158, in room [ROOM NUMBER]. A review of the facility policy titled CLEANING AND DISINFECTION OF RESIDENT CARE ITEMS AND EQUIPMENT dated/revised (MONTH) 2014 revealed reusable Resident care equipment would be cleaned and disinfected according to current CDC recommendations for disinfection between resident use.",2020-09-01
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
58,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,550,E,1,1,UZYC11,"> Licensure Reference Number 175 NAC 12-006.05(6) Based on Observation, record review and interview the facility failed to ensure residents dignity and respect were maintained at all times. This affected 6 residents, residents (274, 54, 70, 96, and 82). The facility census was 123. Findings are: [NAME] Record review of Quality of Life- Dignity Policy dated 10/2009 revealed staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or cares. An Observation on 09/23/19 at 12:05 PM revealed restorative aide- H asking resident 274 if (gender) needed help removing bib. NA (nursing assistant) G and Restorative aide H talking over a table of residents (274, 54, 70, and 82) called the residents Feeders. Referring to residents that needed help with eating. An interview on 09/30/19 at 3:46PM with DON and CSC (Clinical Service Coordinator) revealed staff should not be referring to residents that sit at an assist table as feeders and the discussion of calling clothing protectors bibs/ crumb catchers had not been reviewed but will be looked at.",2020-09-01
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 other day. Record review of bathing log notes that resident only received baths on 02/23/19 and 02/25/19. Next bath was 7 days later on 03/5/19. Next bath was 3 days later on 03/09/19. Following bath was 3 days later on 03/13/19. Resident was admitted to hospital on [DATE] for bowel obstruction. 9 days later a bath was completed on 03/23/19. An interview on 09/26/19 with DON and CSC ( Clinical Service Coordinator) confirmed that facility has been short a bath aide and residents have missed scheduled bath days and may only receive 1 bath a week during those short staffing times. C. An interview on 09/23/19 at 10:40 AM with Resident 10 revealed that (gender) prefers to have female care givers perform perineal cares (the cleaning of genital areas) and not male care givers. Record Review of Care Plan dated 07/31/19 revealed no documentation of Resident 10's choice of no male care givers. Record Review of Progress note dated 9/13/19 revealed resident does not want a male care giver. An interview on 09/24/19 @ 4:25PM with DON stated Resident 10 has gone back and forth with allowing male staff to assist with cares. But the unit it's typically staffed with at least 1 female staff member. An interview on 09/25/19 at 2:30PM with NA (Nursing assistant) I revealed Resident 10 requests to not have male staff help with perineal care. Record review of green binder called (Resident 10's book) revealed a list of Resident 10's care preferences; specifically states resident requested no male care givers. Facility has informed Resident 10 that they cannot accommodate this request. Facility stated they would provide 1 female and 1 male caregiver, if 2 female care takers are not available. Resident 10 has the right to refuse care, the reason that cares are not completed will be documented in green binder. An interview on 09/26/19 at 3:00PM with DON and Clinical Services Coordinator revealed the facility did not understand that they need to provide residents with gender specific caregivers per resident preferences and that facility assessment would need to reflect gender specific caregivers ( no males) as admission denial criteria. Record Review of Facility Assessment not dated revealed under section Guidelines for Conducting the Assessment; For example, if the facility decides to admit resident with care needs who were previously not admitted , such as resident on ventilators the facility assessment would be be reviewed and updated to address how the facility staff, resources, physical environment, etc,. Meet the needs of those resident and any areas requiring attention, such as any training or supplies required to provide care. On page 5 of The Facility Assessment under Ethnic, Cultural or religious factors 1.6 revealed a resident/patients ethnic, cultural, or religious factors, or personal resident preferences, that might potentially affect the care provided to residents.",2020-09-01
60,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,565,E,1,1,UZYC11,"> Licensure Reference Number 175NAC 12-006.06B Based on record review and interview the facility failed to ensure that residents and other persons filling out a grievance (complaint) were informed of the findings of the investigation and the corrective actions taken by the facility within 3 working days. This had the potential to affect all residents of the facility. The facility census was 123. Findings are: Record review of the facility policy titled Resident/Family Grievances dated 1/22/19 step 7 revealed: The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions taken to correct any identified problems. Such report will be made orally by the Grievance Official, administrator, or his or her designee, within 3 working days of filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident upon their request, and a copy will be filed in the Social Services department. Interview on 9/24/19 at 1:40 PM in the facility activity room with Resident 121 and Resident 77 confirmed that they did not know who the facility Grievance Officer was and confirmed that residents do not receive a follow up report for filed grievances. Record review of the facility grievances revealed no documentation that the report of findings was provided to the person filing the grievance. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that the facility is missing documentation for grievances. B. Record review of an email dated 09/16/19 at 10:17 AM revealed an email was sent to SSD (Social Services Director) J from Staff member K regarding Resident 58's missing under garment. It had been missing for several weeks, the front desk personnel was unsure if the resident had reported the loss to the right person. Inquired if the SSD knew of the missing item. A hand written note on the form revealed that SSD was looking in laundry for the missing item. Record review of the Policy for Grievances dated 01/22/19 revealed; any resident, his or her representative, family or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of, or missing property. The administrator had appointed a Grievance Official to be the contact person for the residents, their representatives, other interested family members or advocates. Upon receipt of a grievance and or complaint a designated individual will investigate and submit a written report of the findings to the Grievance official. The Grievance Official will submit the report to the appropriate leadership team member and appropriate actions will be taken to ensure appropriate resolution. The resident or representative will be informed on the findings of the investigation and the actions taken to correct the identified problems with in 3 working days of the filing of the grievance. The facility will follow state law in accordance with any reports of abuse and neglect and take appropriate steps to ensure the degree of residents safety. An interview on 09/24/19 01:04 PM with the Administrator confirmed; that the staff was not currently using the grievance form. If a grievance was presented it would be emailed to Staff Member K and then the email would be forwarded to the appropriate department and would be addressed. A reply to the correction would go to the Grievance Officer. The department would follow up with the person who filed the grievance. The facility had 3 days to complete the process and have a resolution for the resident or family. An interview on 09/24/19 02:31 PM with Resident 58 reported that no one had come to discuss the missing item with them and there had been no follow up on the residents missing item. Resident 58 reported the missing item to several people with no resolution. Resident 58 reported there was not a Resident Belonging Tracking document filled out on admission. Interview with the Administrator on 09/24/19 03:05 PM confirmed; that the resolution for the missing item for Resident 58's garment was beyond the 3 day resolution per the facility policy. The Administrator reported that the facility does not call in missing items they just replace them. Record review of Resident Belonging Tracking Procedure dated 1/5/15 revealed; that an inventory sheet would be provided the resident and family to fill out to identify all of the belongings upon admission. The instructions were to complete the inventory sheet in its entirety and sign and date. Include all items, clothing, dentures, glasses, watches, jewelry, picture, etc. All clothing items were to be labeled even if the family intended to launder. It was recommended the Resident bring 5 days worth of items. All clothing needed to be marked or labeled regardless of who did the laundry. The original goes to the UM mail box, a copy will be placed in a 3 ring binder in the labeling room. This facility shall not be liable for the loss of or the damage to personal property, unless it ha been placed on the facilities aforementioned secured area for safe keeping of money and valuables. Plea be aware of this policy and take precautions necessary to protect valuables per homestead personal property and missing property handbook. ' Record review of Resident 58 Resident Belonging Inventory revealed that the inventory document was not filled out. An interview on 09/24/19 02:40 PM with the DON(Director of Nurses) confirmed; that the inventory sheet had not been done and that it was nurses responsibility to complete the document. The DON confirmed that there had been a PIP in place for this and that the Administrator had started this prior to the DON starting. Additional information provided from the facility revealed : a Missing Item Policy not dated, the policy revealed; it was the responsibilty of the nursing home to establish and maintain a written inventoy of residents property, add to teh inventory list upon request, and provide a copy to the resident/resident representative.",2020-09-01
61,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,583,F,1,1,UZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on record review, interview and observations the facility failed to protect resident privacy by posting photos/videos of residents on a social media site for 2 residents (Resident 45 and 86), the facility failed to ensure that a resident was draped during personal cares for 1 resident (Resident 58), and the facility failed to protect residents privacy by having the EMR (Electronic Medical Records) open to public view, this had the potential to affect all residents past and present. The facility census was 123. Findings are: [NAME] Record review of a report dated 05/24/19 revealed Resident 45 was admitted on [DATE]. Resident 45 [DIAGNOSES REDACTED]. Assist level is total dependence for all activities of daily living. Record review of Quarterly MDS dated [DATE] revealed; Section G 0110 Functional status Resident 45 required extensive 2 person assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. BIMS ( Brief Interview for Mental Status) was 0 of 15 indicating severe impaiment. Section I 8000 revealed; TODD's paralysis (post epileptic), Diabetes, Parkinson, encephalopath, dysphasia and [MEDICAL CONDITION] following cerebral infarct. Record review of a report dated 05/24/19 revealed; an anonymous reporter had notified the Administrator that a staff member had posted videos and photos of residents making fun of them on snap chat. It was found that NA (Nursing Assistant) L had posted the photos. The Administrator had confirmed the 2 resident in the photos were Resident 45 and 86. The Administrator and CSC (Clinical Services Coordinator) had called NA L, who had become agitated with the questions. On 05/31/19 NA L's employment was terminated. The conclusion was that NA L violated the facility policy of Abuse, Neglect and Exploitation. The facility action was to terminate NA [MI] The facility notified APS (Adult Protective Services), DHHS (Department of Health and Human Services), and the NA registry. Record review of the Policy for Homestead personal cellular phones revealed; while on duty to use a cell phone was prohibited. Since this policy was overly abused the facility was no longer allowing cell phones in the building. Employees were not to carry cellular phones on them in person while at work. Managers were to use cell phones for business purposes only. Record review of the Policy for Social Networking Media Policy signed and dated by NA L on 04/24/19 revealed; Photos of the facility/company or residents were not to be used or posted on any site. Photographs of other employees could only be posted with permission of the employee and may not identify the employer. Please refer to resident privacy and HIPPA (Health Insurance Portability and Accountability Act- is United States legislation that provides data privacy and security provisions for safeguarding medical information) policy for further guidance. Record review of a document signed by NA L dated 9 revealed; NA L had been given a copy of the reporting requirements for elder abuse and neglect. Record review of a document signed by NA L dated 9 confirmed; that NA L had read the HIPAA/Privacy Policy. Record review of Nebraska Central Registry Check Request revealed; NA L had no records found for APS (Adult Protective Services) or CPS (Child Protective Services). Record review of Public health Licensure Unit Certification of Licensure revealed; no disciplinary action taken against this license. Record An observation with the CSC on 09/25/19 at 3:50PM of a video that had been posted to a social media site of Resident 45, the facility was able to identify that the resident in the video was Resident 45. The film showed the employee prior to the resident filmed. An interview on 9 at 3:50 PM with the CSC confirmed; that the facility identified the employee who had posted the video because they had filmed themselves prior to the filming the resident. The CSC reported that the employee would not answer questions and employee had been terminated post investigation. B Record review of investigation document initiated on 05/24/19 and completed on 05/30/19 revealed; that Resident 86 was admitted on [DATE]. Primary [DIAGNOSES REDACTED]. BIMS score was 7/of 15 indicating severe cognitive impairment. Record review of a photo posted to the social media site provided by the facility revealed; Resident 86 was seated in a wheelchair with a cover and had laughing emoji's with my life help, help, help. The post was dated 9. NA L's name was posted and the photo was posted 14 hours ago. Record review of Resident 86's MDS Quarterly dated 05/29/19 revealed; Section G 0110 Resident 86 was extensive assist with 2 person for Bed mobility, transfers, dressing, and toileting, was one assist for eating and locomotion, the MDS revealed; resident 86 did not ambulate was able to surface to surface transfers with assistance. Section I 4800 revealed; dx of dementia, I 5700 anxiety, C. An observation on 09/25/19 at 10:23 AM of Perineal care for Resident 58. Resident 58's pants were pulled down to the residents ankles and the resident was exposed (no blanket covered the resident) the brief was removed and the resident had been incontinent. Perineal care was completed. Resident 58 requested to be covered. The NM (Nurse Manager) had to exit room to ask staff to get a cover. The bed spread was on the floor between the wall and bed. There was not sheet located on the bed. An interview on 09/30/19 03:30 PM with the DON confirmed; that staff should have linen in the room prior to the start of cares. Record review of Perineal Care Policy dated 9 revealed; Fold the bed spread toward the foot of the bed, Fold the sheet down to the lower part of the body and cover the torso with a sheet, raise the gown or lower the pajamas, and avoid unnecessary exposure of the resident's body. D) Observation on 9/24/19 at 7:47 AM revealed the 200 hall medication cart computer was left unattended with the screen unlocked and displaying resident information. Observation on 9/24/19 at 7:48 AM revealed LPN-A (Licensed Practical Nurse) returned to the 200 hall medication cart and was preparing to administer a resident's medications. Observation on 9/24/19 at 7:50 AM revealed the 200 hall medication cart was left unattended with the screen unlocked and displaying resident information. Interview on 9/24/19 at 7:51 AM with LPN-A revealed the computer with access to resident medical records should have been secured when left unattended. E) Observation on 9/26/19 at 7:13 AM revealed the 200 hall medication cart computer was left unattended with the screen unlocked and displaying resident information. Interview on 9/26/19 at 7:15 AM with LPN-B revealed the computer screen should not have been unlocked and displaying resident information when unattended. Interview on 9/26/19 at 11:17 AM with CSC (Clinical Services Coordinator) revealed the expectation for securing resident medical information was to secure the computer and ensure resident information is not displayed when the computer would be left unattended.",2020-09-01
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,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 written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 87 revealed no documentation of facility measures to protect the resident from resident to resident abuse. B. 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. Resident 326 and friend went to HyVee pharmacy to get instructions. The pharmacist reported that the bagged medications were not the Resident 326's medications. The Reporter told APS that the medications belonged to Resident 333. The caller reported that the facility was called, spoke to SSD asked that the medication be brought back to the facility. The caller reported that the facility staff was to go the pharmacy and pick up the medications. Record review revealed; no facility self-report of misappropriation of medication for Resident 333 that were sent home with Resident 326. Record review of Resident 326's medications revealed; [MEDICATION NAME] 10 mg (milligrams) tablet one daily 0800 Fish oil 1000 mg 120mg-180mg daily 0800 [MEDICATION NAME] 0.4 mg daily 8PM [MEDICATION NAME] 88 mcg daily 0500 [MEDICATION NAME] 3.4/5.4 gram 1 packet daily 0800 [MEDICATION NAME] 40 mg BID (Twice a day) 0730/3:30PM [MEDICATION NAME] (Vitamin B6) 25 mg 1 tab 0800 [MEDICATION NAME] XL 25mg 1 tab daily 0800 Vitamin D 3 1 tablet daily 0800 [MEDICATION NAME] 1 gr QID (four times a day) 0800/1200/4:00P/8:00P Record review of Resident 333 medications revealed; [MEDICATION NAME] 200mg 1 tablet once a day at 0800 ASA 81 mg daily 0800 [MEDICATION NAME] 150 mg once a day at the 1st of the month 0800 [MEDICATION NAME] Fiber Singles BID Multivitamin with minerals 1 tab daily Pantoprazole 1 tab once a day 0800 Potassium chloride 10 MEQ (Millaequivalent) 1 cap daily 0800 Requip 4 mg BID 0800/8:00PM [MEDICATION NAME] 100mg 1 tablet daily 0800 [MEDICATION NAME] HFA 160-4.5 Mcg 2 puffs Rinse after use- 0800/8:00PM Mag oxide 400 mg 1 tab TID 0800/1:00PM /6:00PM [MEDICATION NAME]-[MEDICATION NAME] 5/325mg 1 tab QID 0800/1200/4:00PM/8:00PM An interview on 09/25/19 at 03:05PM with the CSC confirmed; that Resident 326 was sent home with another residents medications. Both Resident 326 and 333 had medications bagged for home and the nurse grabbed the wrong bag of medications. The CSC reported that the nurse on duty was to have disciplinary action by the Unit Manager and there was no documentation that the discipline had been completed. The nurse manager was sent to Hy Vee and retrieved the medications and the residents correct medications were delivered to the resident at the place of discharge. The Unit Manager was no longer employed. The nurse who gave the medications to Resident 326 was no longer employed. The CSC confirmed; that the facility had not reported the incident.",2020-09-01
64,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,609,G,1,0,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 resident abuse resulting in injury was investigated for 1 resident (Resident 87) and the facility failed to ensure that misappropriation of resident property was investigated for 1 resident (Resident 86). Based on record review and interview, the facility failed to ensure incident investigations were submitted to the state agency within 5 working days. This affected 5 residents (Residents 14, 40, 69, 86, and 87) of 10 residents reviewed. The facility census was 123. Findings are: A) 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 facility policy titled Abuse Investigations dated (MONTH) 2014 revealed the Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Step 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, with five (5) working days of the reported incident. Interview with the Clinical Services Consultant (CSC) on 9/30/19 at 11:07 AM confirmed that a state report was not completed or submitted for the resident to resident altercation that resulted in a [MEDICAL CONDITION] pinky finger for resident 87. B) Record review of the Progress note for Resident 86 dated 5/26/19 10:19 PM 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. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that if an item is reported as stolen, it is reported right away. If an item is missing, the facility looks for it to try and find it first. The Administrator confirmed that the facility was unable to provide documentation showing that an investigation was completed and submitted to the state agency within 5 working days. C) Review of Abuse/Neglect Investigation Report Form dated 5/30/19 revealed that on 5/25/19 Resident 14 was walking by Resident 40 when Resident 40 reached out and hit Resident 14 on the arm. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/30/19 at 8:23 AM with the DON (Director of Nursing) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days. D) Review of Abuse/Neglect Investigation Report Form dated 6/12/19 revealed that on 6/7/19 Resident 69 reported NA-C (Nurse Aide) pushed Resident 69 into a wheelchair while being assisted to the bathroom. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/24/19 at 3:24 PM with CSC (Clinical Services Coordinator) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days.",2020-09-01
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 relative to incidents of abuse. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that if an item is reported as stolen, it is reported right away. If an item is missing, the facility looks for it to try and find it first. The Administrator confirmed that the facility was unable to provide documentation showing that an investigation was completed and submitted to the state agency within 5 working days. B) 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 (Resident 87). 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 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 relative to incidents of abuse. Interview with the Clinical Services Consultant (CSC) on 9/30/19 at 11:07 AM confirmed that a state report was not completed or submitted for the resident to resident altercation that resulted in a [MEDICAL CONDITION] pinky finger for resident 87. The CSC confirmed that no notes or emails were located regarding the incident or an investigation.",2020-09-01
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,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 [REDACTED]. The CSC verified that Resident 77 was diagnosed with [REDACTED]. B. Record review of PASARR for Resident 116 dated 11/16/15 revealed; no SMI (Serious Mental Illness), no history of mental disorders, No behaviors, No concentration/task related problems, no adaptation to change, no mental health problems, and no significant disruption in life. Resident 116 had a primary [DIAGNOSES REDACTED]. Record review of Psychiatric Services dated 4/12/19 revealed; dx of [MEDICAL CONDITION] Major neurocognitive disorder, HX of [MEDICAL CONDITION]/anxiety with development of cognitive deficits. The Provider was asked to see due to agitation period of yelling out Resident 116 was noted to be confused but was calm during exam. Medications were increased [MEDICATION NAME] to 200mg TID (3 times daily) better overall. The medications prescribed for Resident 116 were [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for [MEDICAL CONDITION] per chart. Record review of Care plan dated with a start date of 10/02/2018 Category: [MEDICAL CONDITION] Drug Use Resident 116 was at risk for adverse consequences R/T receiving antidepressant medication [MEDICATION NAME] and antipsychotic medication [MEDICATION NAME] for treatment of [REDACTED]. Care Plan dated with a start date of 07/03/2018 revealed that Resident 116 had behaviors of calling out help me frequently. [DIAGNOSES REDACTED]. On [MEDICATION NAME] for [MEDICAL CONDITION]. An interview on 09/24/19 03:36 PM CSC Q confirmed; the PASARR received from the facility that discharged Resident 116 did not reflect the residents current [DIAGNOSES REDACTED]. Record review of Resident 116 Annual MDS dated 9 revealed; Section A 1500 Prescreening and Resident Review was answered no, Level II 1510, 1550 had not been marked. Section I 4800 Non-Alzheimer's Dementia Section I 5300 [MEDICAL CONDITION] Section I 5900 [MEDICAL CONDITION] Section O No special therapies.",2020-09-01
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,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,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,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 wash cloth. LPN D put a glove on the right hand and squeezed the Silver [MEDICATION NAME] 1% cream from the tube directly onto the glove and then applied the cream to the 4th left toe wound. LPN D removed the glove from the right hand and discarded it. No hand washing was performed. LPN D applied a band aid to the resident's left 4th toe to cover the wound. LPN D gathered the cream and the soiled wash cloths and exited the resident room and walked to the soiled room on the 100 hall. LPN D entered the soiled room and then exited holding the cream container. LPN D walked to the 200 nurse station and started to chart on the computer at the nurse's station. Interview on 9/25/19 at 4:14 PM with the Clinical Services Consultant (CSC) confirmed that staff should use a q tip or something else to get the cream or ointment from the container to apply to the wound and not apply the cream or ointment to a glove for application. B. Record review of the physician Referral Form dated 8/29/19 revealed that Resident 21 had a 0.2 centimeter decubitus ulcer on the 4th digit of the left foot. Record review of the facility policy titled Skin Assessments and Pressure Ulcers/Skin Breakdown-Clinical Protocol dated (MONTH) (YEAR) revealed step 3a: Weekly skin assessments will be completed by the nurse and documented in the EHR (electronic health record). Record review of the facility Weekly Skin Assessment (a tool used to thoroughly document the assessment of a wound) revealed a section to document any skin issues present, a section directing the nurse to document the wound size (length x width X depth) for any skin issue present, and a section to document the character of the wound bed. The Weekly Skin Assessment also contained a section to describe the following: odor, pain, color, drainage, and surrounding tissue. Record review of the facility Weekly Skin assessment dated [DATE] for Resident 21 identified the pressure ulcer on the 4th digit (toe) of the left foot. The Weekly Skin Assessment contained no documentation of the wound size, character, or descriptions of the wound. Record review of the facility Weekly Skin assessment dated [DATE] for Resident 21 identified the pressure ulcer on the 4th digit (toe) of the left foot. The Weekly Skin Assessment contained no documentation of the wound size, character, or descriptions of the wound. Record review of the facility Weekly Skin assessment dated [DATE] for Resident 21 identified the pressure ulcer on the 4th digit (toe) of the left foot. The Weekly Skin Assessment contained no documentation of the wound size, character, or descriptions of the wound. Interview on 9/25/19 at 4:14 PM with the Clinical Services Consultant (CSC) confirmed that weekly skin assessments are completed for follow up of resident wounds and that the weekly skin assessment should contain a description and measurements of the wound. Interview with the Director of Nursing (DON) on 9/26/19 at 10:44 AM confirmed that Resident 21 had a pressure ulcer identified on the facility Nurses Weekly Skin assessment dated [DATE] and that the assessment did not include documentation of the wound size as directed by the assessment. The DON confirmed that the facility Nurses Weekly Skin Assessments dated 9/9/19 and 9/16/19 identified the resident pressure ulcer and did not include documentation of the wound size as directed on the assessment.",2020-09-01
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 development of a comprehensive plan of care) Quarterly dated 9: Section C- revealed; Resident 45 was moderately impaired both short and long term memory. Section [NAME] revealed; No behaviors Section G revealed; Resident 45 required extensive assist with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Section H revealed; Resident 45 was always incontinent bowel and bladder. Section J Falls revealed; Resident 45 had falls since admission. Section O revealed; Resident 45 had not been in therapy. Section P revealed; resident 45 did not have alarms. B. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 6 revealed that the resident is a current tobacco user with the potential for smoking related injury. Interventions on the care plan included that a Smoking Observation (an assessment to identify resident safety and interventions for smoking safety) be performed upon admit, quarterly, and as needed. Record review of the Electronic Health Record for Resident 6 revealed the completion of the Facility Smoking Safety Observation on 8/6/19. No other Smoking Safety Observations assessments were documented in the resident record. The Smoking Safety Observation dated 8/6/19 confirmed that Resident 6 is allowed for supervised group smoking only, including smoking apron and staff to light cigarette. Record review of the Resident 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) for Resident 6 confirmed that the resident was admitted to the facility on [DATE]. Observation on 9/24/19 at 3:32 PM revealed that Resident 6 walked out into the facility courtyard. Certified Nursing Assistant (CNA) M handed a smoking apron (a protective cover to shield against hot ashes and dropped cigarettes) to Resident 6 and the resident put it on without assistance. CNA M handed a cigarette to Resident 6 and lit the cigarette for the resident. Interview with Resident 6 on 9/26/19 at 8:55 AM in the Lancaster dining room of the facility revealed that the resident came to the facility to live in (MONTH) of this year. Resident 6 confirmed that the resident was allowed to smoke from the time of admission to the facility. Observation on 9/26/19 at 9:47 AM in the facility courtyard revealed that Resident 6 was handed a smoking apron and a cigarette. CNA N then handed a cigarette lighter to Resident 6. Resident 6 lit the cigarette and then handed the lighter to CNA N. Interview on 9/26/19 at 9:47 AM with CNA N in the facility courtyard confirmed that Resident 6 lit his own cigarette and that the resident gave the lighter back right away. Interview on 9/26/19 at 10:44 AM with the Director of Nursing (DON) confirmed that Resident 6 was admitted to the facility on [DATE] and that the first and only Smoking Safety Observation completed for the resident was on 8/6/19. The DON confirmed that the facility Smoking Policy dated 8/17/19 directed that smoking risk observations are to be performed upon admission. The DON confirmed that the Smoking Safety Observation identified that Resident 6 required group supervised smoking only including a smoking apron and for staff to light the cigarette.",2020-09-01
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 request was in the resident record. Interview on 9/30/19 at 1:53 PM with the Clinical Services Consultant (CSC) confirmed that Resident 17 had a current order for the antipsychotic [MEDICATION NAME] that was started on 11/14/16. The CSC confirmed that the gradual dose reduction request on 6/30/19 was not addressed and documented by the physician and that there was no documentation of a GDR attempt in the past year addressed by the physician. The CSC confirmed that a GDR must be attempted annually after the first year after starting an antipsychotic medication.",2020-09-01
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 of 70/30 insulin to Resident 62. LPN-D confirmed the physician's orders [REDACTED].",2020-09-01
75,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,761,E,1,1,UZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure insulin (a medication used to treat diabetes mellitus) was dated when opened This had the potential to affect 2 residents (Resident 34, and 277). The facility failed to provide safe storage of drugs and biologicals as medications were left unlocked and unattended, and medications were left on top of the medication carts. This had the potential to affect all the residents on the 100, 200, 300, 400, and 500 halls. The facility failed to ensure a vial of insulin was labeled updated with the current administration information for 1 resident (Resident 62 and 79). The facility census was 123. Findings are: [NAME] An observation 9 at 07:10 AM Medication administration RN V prepared medications for administration for Resident 79. 1. Acidophilus 500 Million per 2 caps per day (from a stock medication bottle)-take 2 capsules per gastric tube 2. Vitamin B -1 tablet 100mg daily gastric tube 3. Vitamin C 1000mg daily 4. Folic Acid 1 mg daily every afternoon (on the card) - in the EMAR (Electronic Medical Record) the order reflected that the medication was to be given at 0700AM. 5. Modafnil 100mg 1 tab in am. 6. Ocean Nasal Spray 0.65% amount 2 sprays per nasal - The nasal spray was given 2 sprays per nostril. Record review of an order dated 06/13/18 revealed; a standing order that read, (MONTH) change the time of daily medications for compliance with taking medications, to avoid interaction with other medications unless contraindicated by manufacturer or specific time ordered by physician. Order dated 6/13/18 revealed that the medication Folic Acid 1mg was to be given in the afternoon. An interview with the DON on 09/25/19 confirmed that the labels were not the same, there was a standing order to change the times of the medication administration times. B. An observation on 09/2/519 at 12:50 PM of medication administration for Resident 227 revealed; the Humalog Pen was opened and used and not dated with an opened date. An interview on 09/2/519 at 12:52 PM with RN W confirmed; that the Humalog insulin pen was not dated and was opened. C. An observation on 09/30/19 at 09:30AM of 3 cups of liquid with spoons in it on the top of the cart, also on the top of the cart were Medication of Azelastine HCL nasal spray and Breo Ellipta inhaler that were Resident 120's. No staff was present medications were unsecured. An interview with MA (Medication Aide X) on 09/30/19 at 09:40 AM confirmed; that the medications in the cup were [MEDICATION NAME] that were premixed prior to administration and the medications belonged to Resident 69, 120, and 324. The MA revealed that medication on the cart were not secured. C) Observation on 9/25/19 at 2:26 PM of 200 hall treatment cart revealed there were 2 boxes containing multi-dose vials of [MEDICATION NAME] 70/30 bound together with a rubber band. One box contained an unopened vial and one box was opened and contained a partially used vial. The open and partially used vial was labeled by the facility pharmacy with instructions to administer 11 units before breakfast. The unopened vial was labeled with instructions to administer 13 units before breakfast. Interview on 9/25/19 at 2:36 PM with the DON (Director of Nursing) confirmed the label on the partially used vial did not match the current order. Review of Resident 62's Physician order [REDACTED]. Review of Storage of Medications policy revise (MONTH) 2007 revealed drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. D) Observation on 9/25/19 at 4:50 PM of the 100 hall medication cart revealed Resident 34's [MEDICATION NAME] inhaler (a medication to keep the airway relaxed and open) did not have an open date documented on the inhaler or on the box. Interview on 9/25/19 at 4:50 PM with the DON confirmed the inhaler did not have an open date documented. E) Observation on 9/25/19 at 4:20 PM of 600 hall medication cart revealed Resident 373's Toujeo insulin (a long acting insulin (a medication to lower the blood sugar level)) did not have an open date documented on the pen. Interview on 9/25/19 at 4:20 PM with the DON confirmed the insulin pen did not have an open date documented. Review of Storage of Medications policy revised (MONTH) 2007 revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. F) Observation on 9/26/19 at 7:13 AM of the 200 hall medication cart revealed the cart was unattended and unlocked. Interview on 9/26/19 at 7:15 AM with LPN-B confirmed the medication cart was left unlocked while unattended. LPN-B revealed the expectation was for the medication cart to be locked when unattended. Interview on 9/26/19 at 11:17 AM with CSC (Clinical Services Coordinator) revealed the expectation for securing the medication cart was for the medication cart to be locked when unattended. Review of Storage of Medications policy revised (MONTH) 2007 revealed compartments containing drugs and biologicals shall be locked when not in use, and carts used to transport such items shall not be left unattended if open or other potentially available to others.",2020-09-01
76,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,802,F,1,1,UZYC11,"> Licensure Reference Number 175 NAC 12-006.04D Based on Observation, interview and record review the facility fails to ensure sufficient dietary staffing to provide meals to residents. This had the potential to affect 121 residents that receive food from the facility kitchens. The facility census was 123. Findings are: Observation on 09/24/19 at 12:00 - 1:00PM revealed first food to leave kitchen was unit 1 - 2 room trays at 12:05 PM; Scheduled meal time 11:25PM. Station 4 cart left kitchen at 12:14 PM, meal time 11:45AM. Lincoln dining room cart left at 12:23PM; First tray served at 12:25 PM- last tray served at 12:34PM. Lancaster cart left kitchen at 12:44 PM, meal time 12:00PM. Station 3 meal trays left kitchen at 12:48 PM, Meal time 12:15 PM An interview on 09/24/19 at 10:40AM with DM ( Dietary Manager) revealed current dietary staff consists of 3 aides on day and 1 cook, evenings 4 aides and 1 cook. DM states she is the only cook so she is currently filling the positions of Dietary Manager and cook. An interview on 09/24/19 at 12:35PM with Residents 14 and 42 revealed the lunch meal is scheduled to be served at 11:45AM; frequently meal are not served until 12:30PM or later.",2020-09-01
77,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,812,E,1,0,UZYC11,"> Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview the facility failed to ensure all hair was enclosed in hairnets, complete proper hand hygiene to prevent the spread of food borne illness, to maintain a clean kitchen and to follow facility policy after employee injury. This had the potential to affect all residents that consume food prepared in the facility kitchen. The facility census as 123. Findings are: [NAME] Record review of The Nebraska Food Code dated (MONTH) 2012 Section 2-402.11 revealed the following related to Hair Restraints effectiveness: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair that are designed and worn to effectively keep their hair from contracting exposed food, clean equipment, utensils and linens and unwrapped single service and singe use articles. Observation on 09/24/19 at 10:10 AM revealed DA (Dietary Aide) S and T and DM (Dietary Manager) had hair exposed outside of hairnets. Observation on 09/24/19 at 10:48AM revealed DA - S had hair outside of hairnet while working in kitchen. Observation on 09/24/19 at 11:05 AM revealed SP (speech pathologist) U was in kitchen without a hairnet covering hair. An interview on 09/24/19 at 4:40 PM with DM (Dietary Manager) revealed (gender) was not aware that all hair needed to be enclosed in hairnet. B. Record review of Policy titled Handwashing/Hand Hygiene dated 04/2012 revealed the following steps: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow he handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least Fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: 5 c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); 5 f. Before and after eating or handling food (hand washing with soap and water); 5 g. Before and after assisting a resident with personal care; 5 k. Before and after assisting a resident with toileting (hand washing with soap and water); 5 o. After handling soiled or used linens, dressing, bedpans, catheters, and urinals; 5 p. After handling soiled equipment or utensils; 5 r. After removing gloves RA (Restorative Aide) H assisted Resident 274 to unlock wheelchair breaks and move out of the dining room. RA- H then preformed hand washing for 9 seconds then continued to help residents eat. Observation on 09/24/19 at 10:28AM revealed DM washed hands for 11 seconds. Observation on 09/24/19 at 10:45-10:48AM revealed DM started food processor and walked away leaving food processor running, DM washed hands for 11 seconds. Observation on 09/24/19 at 11:55 AM revealed TA (Tray Aide) R washed hands for 8 second after preparing desserts. Observation on 09/24/19 at 11:58AM revealed TA-R preformed hand hygiene for 8 seconds after preparing food in the kitchen. C. Observation on 09/23/19 from 7:40-8:00AM revealed a white substance on the wall behind ice machine. Mixer was dirty with white yellow dried on substance. Observation on 09/23/19 at 9:18[NAME]M revealed dishwasher component box was covered in a fuzzy gray substance. Observation on 09/24/19 at 9:25 AM kitchen floors covered in grease, very slippery. Observation on 09/24/19 at 11:01 AM revealed cob webs on lights above stove, crumbs around toaster and steam table had dried yellow substances to lids and table. An interview on 09/24/19 at 4:40 PM with DM (Dietary Manager) confirmed the kitchen should be clean and free from dried on food particles. D. Record review of Policy titled Accidents Causing Breaks in Skin in Nutritional Service Area not dated revealed the following: Nutritional Service personnel should wear gloves after performing hand washing to provide a barrier between hands and food during food preparation or service as appropriate. In the event a food service worker is cut, sliced or nicked on hand or finger the following should be completed. 1. Immediately stop preparing, cooking food and go to hand washing sink. 2. Cover open are with paper towel and apply light pressure to stop the bleeding. 3. Determine if stich or other type of closure is necessary for the wound. 4. Wash hands using antibacterial soap. 5. If closure of wound is not needed, apply bandage, finger cot or finger stall to the open area. 6. Apply gloves prior to restarting your work flow. The bandage finger cots or finger stalls represent a potential physical hazard when worn by a food employee during food preparation. 7. Any food product that was in contact with blood or body fluid must be discarded. 8. The work service area must be cleaned with bleach wipe if blood or body fluid were present following instruction on the bleach wipe container. Observation on 09/24/19 at 10:58AM revealed DM was cutting open frozen packages of broccoli with large a kitchen knife. I Surveyor noticed red color through glove to left hand middle finger. DM did not notice, informed DM of cut. DM stated she did not think knife had went through the glove. DM instructed to removed gloves and wash hands; assess cut.DM removed gloves and washed hands and applied band aide to middle finger on left hand. DM returned to broccoli in pan with knife, DM stated I don't think anything was contaminated. Instructed DM to discard pan with broccoli and knife and start over with new equipment and broccoli. An interview on 09/24/19 at 11:59 AM with DM revealed any time an incident happens in the kitchen a report is completed and they are to seek assistance from nursing if injury is severe. DM stated (gender) would write up incident report after lunch services.",2020-09-01
78,HOMESTEAD REHABILITATION CENTER,285049,4735 SOUTH 54TH STREET,LINCOLN,NE,68516,2019-09-30,880,E,1,1,UZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.117D Based on observation, record review, and interview the facility failed to ensure that handwashing was performed after glove removal during resident cares and wound cares for 4 residents (Residents 21, 10, 77 and 86). This had the potential to cause cross contamination between dirty and clean areas. The facility failed to ensure that handwashing to prevent the potential for cross contamination occurred during activities of daily living (ADLs). This had the potential to affect 2 residents (Residents 10 and 38). The facility census was 123. Findings are: Record review of the facility policy titled Handwashing/Hand Hygiene dated (MONTH) 2012 revealed the following steps: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow he handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least Fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: 5 c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); 5 g. Before and after assisting a resident with personal care; 5 o. After handling soiled or used linens, dressing, bedpans, catheters, and urinals; 5 p. After handling soiled equipment or utensils; 5 r. After removing gloves [NAME] Observation on 9/25/19 at 7:34 AM revealed that nursing assistant I (NA I), certified nursing assistant O (CNA O), and Registered Nurse P (RN P) entered the room of Resident 86. NA I entered the resident bathroom and turned the water on in the sink. NA I placed soap on NA I hands and immediately placed the hands under the running water while scrubbing the hands under the running water for 15 seconds. NA I dried the hands and turned the water off with a new paper towel and put on gloves. NA I talked to Resident 86 and explained the cares that would be provided to the resident. NA I removed the gloves and obtained a trash bag and placed it at the foot of the resident bed. NA I entered the resident bathroom and put soap on the hands and scrubbed the hands under running water for 5 seconds and dried the hands. NA I put on new gloves. NA I obtained a disposable wipe and wiped the perineal area (the genitals and anal area) turning the disposable wipe after each wipe. NA I removed and discarded the gloves and put new gloves on with no handwashing performed. NA I obtained a new disposable wipe and completed washing of the resident front perineal area. NA I removed the gloves and put on new gloves with no handwashing performed. NA I repositioned Resident 86 onto the resident's right side and removed the resident brief from the resident buttocks. NA I wiped the resident anal area from front to back and then disposed of the wipe and removed the gloves. NA I put on new gloves with no handwashing performed. NA I applied skin protectant lotion to the resident anal area and buttocks. NA I removed the gloves and put on new gloves with no handwashing performed. NA I placed a new brief underneath the resident's buttocks and secured the brief on the resident. NA I removed the gloves and put on new gloves with no handwashing performed. CNA O removed gloves from CNA O's hands and put on new gloves with no handwashing performed. NA I dressed the resident putting elastic hose on both resident legs and then placed the soiled soaker pad from under the resident into the trash bag at the foot of bed. NA I removed NA I's gloves and put on new gloves with no handwashing performed and put pants on the resident. NA I untied and removed the gown from Resident 86 and put a shirt on the resident. NA I placed the resident gown in the trash bag at the foot of the resident's bed and removed the gloves. NA I put on new gloves with no handwashing performed. NA I placed a lift sling underneath the resident. CNA O removed the gloves from CNA O's hands and no handwashing was performed. NA I placed shoes on the resident's feet. NA I positioned the total body lift (a mechanical device used to lift and transfer residents from one surface to another) and connected the lift straps to the lift. NA I informed Resident 86 of the transfer to the resident's wheelchair from the bed. The resident was transferred from the bed into the wheelchair by NA I and CNA O. NA I moved the mechanical lift away from the resident wheelchair and removed the gloves. NA I performed handwashing for 3 seconds scrubbing with soap under running water. RN P placed a sweater on Resident 86 and placed a lap blanket over the resident's legs and lap. NA I put on gloves and applied denture adhesive to the resident's upper and lower dentures. NA I placed the lower denture in the resident's mouth and then placed the upper denture in the resident's mouth. NA I removed the gloves and performed soap handwashing under running water for 3 seconds and dried the hands and put on new gloves. NA I wet a wash cloth and cleaned Resident 27's face. NA I patted the resident face dry with a dry cloth and then removed the gloves and put on new gloves with no handwashing performed. B. Observation of wound care on 9/25/19 at 1:13 PM in Resident 21's room. LPN D entered the resident room and removed the band aid from the resident's left 4th toe. LPN D performed handwashing with soap in the bathroom sink and obtained a wash cloth soaked 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 wash cloth. LPN D put a glove on the right hand of LPN D and squeezed the Silver [MEDICATION NAME] 1% cream (a topical antibiotic used on skin wounds to prevent infection) from the tube directly onto the glove and then applied the cream to the 4th left toe wound of the resident. LPN D removed the glove from the right hand and discarded it. No handwashing was performed. LPN D applied a band aid to the resident's left 4th toe to cover the wound. LPN D gathered the Silver [MEDICATION NAME] 1% cream and the soiled wash cloths and exited the resident room and walked to the soiled room on the 100 hall. LPN D entered the soiled room and then exited holding the Silver [MEDICATION NAME] 1% cream container. LPN D walked to the 200 nurse station and started to chart on the computer at the nurse's station. No handwashing was performed. Interview with the Director of Nursing (DON) on 9/26/19 at 10:44 AM confirmed that hand washing is to be performed by staff each time after glove removal. Interview with on 9/26/19 at 10:57 AM the facility Infection Control Coordinator U (ICC U) confirmed that the facility hand washing procedure directed staff to scrub the hands with soap for a minimum of 15 seconds over the sink and not scrub under running water before rinsing the soap off. ICC U confirmed that staff are to complete hand washing each time gloves are removed. C. Observations of Resident 77's wound care on 9/24/19 from 7:17 AM until 7:45 AM with LPN-T (Licensed Practical Nurse) and NA-I (Nurse Assistant) revealed the following: -LPN-T donned gloves to provide cares to resident's legs and feet, -LPN-T removed gloves and washed hands less than 10 seconds -LPN-T donned gloves and provided ordered cream to resident legs -NA-I removed gloves but failed to wash or sanitize hands and left resident room -LPN-T removed gloves but failed to wash or sanitize hands -NA-I applied gloves after reentering the room but failed to wash or sanitize hands -LPN-T applied gloves and provided ordered lotion to residents legs -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and washed area on back of left leg, and applied a [MEDICATION NAME] boarder (a versatile all-in-one bordered foam dressing, that minimizes patient pain and trauma to the wound and surrounding skin at removal while reducing the risk of maceration (occurs when skin is in contact with moisture for too long, skin looks lighter in color and wrinkly, it may feel soft, wet or soggy to touch) -NA-I removed gloves and washed hands less than 10 seconds and exited the resident room -LPN-T removed gloves and washed hands less than 10 seconds -LPN-T applied gloves and sterilized (cleansed with alcohol pad) scissors and proceeded to cut Interdry roll (fabric is a moisture-wicking antimicrobial silver that effectively manages complications associated with skin folds) -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and placed the cut Interdry in abdomen folds -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and cleansed the basin -LPN-T removed gloves but failed to wash or sanitize hands, removed trash and the linen bag -LPN-T left the resident room and obtained a container of chlorox wipes (a disinfecting wipe used to remove germs, and bacteria) -LPN-T applied gloves and wiped off the scissors and basin with chlorox wipes -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T applied gloves and put the basin in a plastic bag -LPN-T removed gloves but failed to wash or sanitize hands -LPN-T put gloves in trash bag, box of gloves in the bathroom, and washed hands less than 10 seconds -LPN-T left resident room During an interview on 9/25/19 at 7:48 AM, LPN-U (Licensed Practical Nurse) verified that NA-I and LPN-T should have washed or sanitized hands before starting resident cares, before putting on clean gloves and after removing soiled gloves. D. The CDC (Center for Disease Control and Prevention) Campaign 4 Moments of Hand Hygiene (MONTH) 15, (YEAR). Hand hygiene should be performed before gloves are removed from the glove box (non-sterile) or package (sterile) to prevent contamination of the box or package and to ensure hands are clean under the gloves. If possible, leave the gloves in their original box or package until they are donned (applied). Gloves that touch anything unclean (e.g. surfaces, objects, face, pockets) are contaminated and become a means for spreading micro-organisms. Record review of the facility policy titled Handwashing/Hand Hygiene dated (MONTH) 2012 revealed the following steps: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow he handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least Fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: 5 c. Before and after direct resident care (for which hand hygiene is indicated by acceptable professional practice); 5 f. Before and after eating or handling food (hand washing with soap and water); 5 g. Before and after assisting a resident with personal care; 5 k. Before and after assisting a resident with toileting (hand washing with soap and water); 5 o. After handling soiled or used linens, dressing, bedpans, catheters, and urinals; 5 p. After handling soiled equipment or utensils; 5 r. After removing gloves Record review of Resident 10's MDS (Minimum Data Set) (dated 9/16/19 revealed resident is always incontinent of bowel and bladder; no current bowel program. Observation on 09/23/19 at 10:50AM revealed LPN ( Licensed Practical Nurse) A arrived to resident room knocked on door, entered room, did not perform hand hygiene, applied gloves, asked resident to spread her legs to view private area, nurse stated area on labia is red and raw, resident then asked bottom to be looked at, resident turned on side, bowel movement present nurse preformed perineal care and removed gloves, no hand hygiene preformed, new gloves applied; bottom area assessed no red area noted. Bed pad was removed and placed on floor not in a bag. New pad was placed under resident. Nurse then went into restroom to get trash bag for soiled bed pad, removed gloves and took bed pad trash bag out of room, leaving bowel movement and wipes in trash with soiled gloves. Nurse did not perform hand hygiene before leaving residents room. Record Review of TAR (Treatment Administration Record) dated 07/16/2019 revealed an order to treat wounds to Resident 10's bilateral lower legs: lotion to all areas (other than open areas) daily. Record review of TAR dated 08/13/2019 revealed the following order wound care order: wash bilateral legs daily and apply [MEDICATION NAME] (topical antibiotic used to prevent infections or treat burns) ointment to open areas, apply ABD's (Abdominal pads) (used to cover large wound areas), gauze wrap and tub grip (a comfortable skin friendly tubular support bandage that easily contours to body) on Mondays, Wednesdays, and Fridays. Observation on 09/25/19 from 10:25 AM - 11:03 AM revealed LPN (Licensed Practical Nurse) T washed hands for 20 seconds, applied new gloves, removed towel covering resident's legs, removed gloves, and applied new gloves. Opened cream tube, placed cap from tube on bed face down. Removed ointment from tube with Q-tip applied to areas on left leg and right leg, removed gloves. Preformed hand hygiene for 20 seconds. Applied new Gloves, lotion applied to remaining areas. LPN -T washed hands for 12 seconds. Gloves applied, ABD's were applied to legs. Bilateral legs wrapped with gauze starting at top of leg working down. Tearing tape during procedure contaminating entire roll of tape. Hand washing completed for 20 seconds. Nylons applied to resident's feet/ legs. NA (Nursing Assistant) I entered room washed hands for 3 seconds, removed gloves from pant leg pocket and applied them, assisted in applying tub grip. NA-I removed gloves. Applied new gloves again from pant pocket. NA Reese washed hands for 8 seconds. ICC (Infection Control Coordinator) U assisted with holding residents legs, then washed hands for 8 seconds. An interview on 09/26/19 at 2:30 PM with DON confirmed hand hygiene should be performed for 15-20 seconds following facility policy and gloves should not be carried in staff pockets and used. E. An observation on 09/25/19 at 10:23 AM of Perineal care for Resident 58 - NA [NAME] performed Hand Hygiene from 10:33:12 to10:33: 27 (15 seconds). The wheel chair pedals were removed from the wheelchair. Resident 58 was transferred with one person assist and a gait belt to the bed via pivot transfer. NA [NAME] gloves were donned gloves while Resident 58 was able to get into the bed from the bed side without assistance. Resident 58's pants were pulled down to the residents ankles and the resident was exposed (no blanket covered the resident) the brief was removed and the resident had been incontinent. Perineal care was completed. Gloves doffed and hand hygiene was performed with hand sanitizer, gloves donned bed pan was placed per resident request. NA [NAME] removed the gloves. Resident 58 requested to be covered. The NM (Nurse Manager) had to exit room to ask staff to get a cover. The resident asked for privacy and was given privacy. NA [NAME] performed hand hygiene from 10:45:07-10:45:17 (8 seconds). NA [NAME] donned gloves and perineal care was completed. NA [NAME] performed hand hygiene from10:51:59-10:52:05 (6 seconds). An interview on 09/25/19 11:01 AM with NA [NAME] confirmed; that hand hygiene, lathering of the hands should be for 20 seconds. Hand washing policy dated (MONTH) 2012 revealed; that Employees must wash hands for 20 seconds using antimicrobial or non antimicrobial soap and water.",2020-09-01
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,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,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,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
83,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,242,D,0,1,LLQX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (4) Based on record review and interviews, the facility failed to ensure resident choices for bathing were followed for Resident 182 and Resident 222. The facility Census was 128. Findings are: [NAME] Interview with Resident 182 on 05/31/2017 at 03:04 PM revealed Resident 222 had not been offered a bath since being admitted to the facility 6 days prior on 5/25/2017. Interview on 06/05/2017 at 11:05 PM with the Assistant Director of Nursing (ADON)-D revealed the nursing staff ask the residents on admission about their bathing preferences and forward the preference sheets to ADON-D. ADON-D places the resident on the bath schedule with the use of the sheet. Interview on 06/05/2017 at 12:58 PM with the Director of Nursing (DON) revealed Resident 222 should be placed on the bath schedule based on personal preference. Review of facility form titled Bath Preferences dated 5/25/2017 revealed Resident 222 prefers 2 baths per week on Tuesday and Friday in the morning and prefers a shower. Review of the bath schedule dated as updated on 6/2 revealed Resident 222 is scheduled for Tuesday and Thursday and does not specify that Resident 222 prefers it in the morning. Review of the facility documentation of baths located under tasks in the electronic medical record revealed Resident 222 had received one bath since admission on Thursday, 6/1/2017 at 2:29 PM. Interview with the DON on 6/6/2017 at 1:30 PM revealed Resident 222 is not scheduled for baths on her preferred schedule. Findings are: B. Record review of Resident 182's Admission Record dated 6/6/17 revealed that Resident 182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident 182 on 6/1/17 at 8:50 AM revealed that his choice of bathing was a shower, 2 x a week and to be performed by the male musing assistant, in the evening. Resident 182 revealed that he had not been receiving his shower 2 x week. Resident 182 revealed that the male who performs his showered had changed shifts, and after that he did not receive a shower. Record review of Resident 182's comprehensive care plan revealed that the facility identified a Self Care Performance Deficit. The plan of care for Resident 182 included interventions that follow: Resident 182 requires extensive staff participation with personal hygiene, dated 1/17/17 Resident 182 is dependent on staff to provide a bath as necessary, dated 1/17/17 Record review of the facility bathing schedule revealed that Resident 182 was to receive shower two times per week in the evening on Sunday and Wednesday. Record review of the facility documentation of bathing received by resident revealed that Resident 182 had bathing performed on the following dates, for the month of May; 5/10,5/17,5/21,5/28,5/31. There was no record of bathing for the month of June. Interview with Nursing Assistant (NA) G on 6/6/17 at 8:44 AM confirmed that the schedule performed had changed from evening shift to day shift. NA G confirmed that the duties of the shower for Resident 182 had been changed to other staff. Interview with Assistant Director of Nursing (ADON) D confirmed that Resident 182's choices of bathing had not been met, that Resident 182 had not been provided shower 2 x week for (MONTH) or June. ADON D confirmed that the facility had made staffing changes and had not provided care as per Resident 182's plan of care.",2020-09-01
84,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,253,D,0,1,LLQX11,"Licensure Reference Number 175 NAC 12-006.18A Based on observations and interviews, the facility failed to ensure the cleanliness of rooms and ventilation systems in 4 resident rooms (103,104,201, 203) of 88 resident rooms. The facility identified the resident census at 128. The findings are: An observation conducted on 5/31/17 at 10:37 AM of the bathroom in room 104 revealed a puddle of liquid on the floor with rust colored stains on the flooring and a urine odor. An observation conducted on 5/31/17 at 10:35 AM of the bathroom in room 103 revealed a buildup of tan fluffy material resembling dust on the vent to the ventilation system. An observation conducted on 5/31/17 at 10:43 AM of the bathroom in room 201 revealed cobwebs were hanging from the ceiling above the sink and from the ventilation system vent. An observation conducted on 6/1/17 at 9:12 AM of room 203 revealed an unpainted drywall patch with a buildup of wall sanding dust on the wall and chair rail. An environmental tour conducted on 6/6/17 from 8:10 AM to 8:27 AM with the facility Administrator revealed the following: -Room 103 bathroom had cobwebs and dust buildup on the ventilation system vent. - Room 104 bathroom had a puddle of liquid on the floor around the toilet with rust stains and a small red tablet resembling a pill was dissolving in the liquid which had developed a red stain on the floor. -Room 104 bathroom had a urine odor. -Room 201 bathroom had cobwebs on the ceiling and ventilation system vent. -Room 203 had a buildup of white dust from sanding drywall patch on the wall and chair rail. The Administrator confirmed the above findings during the tour.",2020-09-01
85,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,315,D,0,1,LLQX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 Based on observations, interviews, and record reviews; the facility failed to evaluate incontinence and implement a toileting program for 1 resident (Resident 119) of 3 residents sampled. The facility identified the census at 128. The findings are: A review of Resident 119's Admission Record dated 6-5-2017 revealed Resident 119 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An observation conducted on 5/31/17 at 10:37 AM of Resident 119's bathroom revealed a urine odor in the bathroom with puddles of liquid that resembled urine on the floor surrounding the toilet. An observation conducted on 5/31/17 at 2:17 PM revealed Resident 119 had a urine odor about them. An observation conducted on 6/5/17 at 7:31 AM revealed Resident 119 sitting on the side of the bed with a urine odor about them. Resident 119's bathroom was observed to have a urine odor, puddles of liquid that resembled urine surrounding the toilet, and a sticky floor. An interview conducted on 6/5/17 at 12:32 PM with Nursing Assistant (NA) C revealed that Resident 119 was independent with dressing, toileting, and hygiene. NA C reported that Resident 119 was occasionally incontinent of urine and would turn on their call light when they needed a new incontinence brief. NA C also reported that the resident would often miss the toilet when urinating. An observation conducted on 6/5/17 at 3:38 PM of Resident 119's bathroom revealed a urine odor and a sticky floor. An observation conducted on 6/6/17 at 9:44 AM revealed Resident 119 sitting in their recliner with a urine odor about them. Resident 119's bathroom was observed to have a puddle that resembled urine on the floor next to the toilet. A review of Resident 119's Comprehensive Care Plans dated 11/23/15 and 2/7/17 revealed that Resident 119 was occasionally incontinent of urine and nursing staff were to complete an Incontinence Data Collection Tool quarterly and as needed. A review of Resident 119's medical record revealed a Quarterly Data Collection Tool dated 6/3/16 that indicated Resident was continent and was not on a bladder retraining program. A review of Resident 119's medical record revealed a Quarterly Data Collection Tool dated 11/3/16 that indicated Resident was usually incontinent and was not on a bladder retraining program. A review of Resident 119's Annual Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 11/17/16 revealed that Resident 119 was occasionally incontinent of urine and was not on a toileting plan. A review of the facility's Urinary Incontinence-Clinical Protocol dated (MONTH) 2013 Monitoring: 1. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. a. This should include documentation of a resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications to treat incontinence. An interview conducted on 6/5/17 at 3:49 PM with the Director of Nursing (DON) revealed the expectation was that incontinence was to be evaluated at onset for medical or physical cause of incontinence. An interview conducted on 6/6/17 at 8:55 AM with The DON revealed that the Quarterly Data Collection Tool was the only tool that the facility used to evaluate incontinence on a quarterly basis. The DON reported they were not sure if there were any completed on Resident 119 since (MONTH) (YEAR). An interview conducted on 6/6/17 at 10:27 AM with the DON revealed that their was not a quarterly evaluation completed on Resident 119 since (MONTH) (YEAR) and they were not sure when or why the tool was not being completed. The DON reported the facility's system for the evaluation and treatment of [REDACTED].",2020-09-01
86,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,323,E,0,1,LLQX11,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18E3a Based on observation and interview the facility failed to maintain water temperatures in a manner to prevent potential burns in 17 resident rooms (315, 317, 401, 403, 404, 405, 104,101,204,100,105,203, 112,201,209,103, and 208). Findings are: The facility policy for Water Temperatures, Safety of dated revised (MONTH) 2010 revealed that: Tap water in the facility shall be kept within a temperature range to prevent scaling of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more that 108 degrees Fahrenheit, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Observations on 5/31/17 at 10:20 AM thru 10:55 AM the following rooms were found to have the following temperatures: Room 315 - 127.7 degrees Fahrenheit Room 317 - 129.7 degrees Fahrenheit Room 401 - 131.5 degrees Fahrenheit Room 403 - 136.7 degrees Fahrenheit Room 404 - 139.2 degrees Fahrenheit Room 405 - 133.2 degrees Fahrenheit Room 104 - 134.2 degrees Fahrenheit Room 101 - 134.8 degrees Fahrenheit Room 204 - 132.2 degrees Fahrenheit Room 100 - 125.0 degrees Fahrenheit Room 105 - 133.6 degrees Fahrenheit Room 203 - 138.5 degrees Fahrenheit Room 112 - 136.9 degrees Fahrenheit Room 201 - 137.1 degrees Fahrenheit Room 209 - 129.6 degrees Fahrenheit Room 103 - 133.0 degrees Fahrenheit Room 208 - 127.2 degrees Fahrenheit Interview with Resident 166 on 5/31/17 at 10:40 AM revealed that the water temperature from the handwashing fixtures was too hot, Resident 166 stated that, is careful not put a hand under the hot water, until cold was added. Interview with Resident 111 confirmed that the water temperature from the handwashing fixtures was hot but that has not been burned, knows to add cold water to wash hands. Interview with Resident 172 confirmed that the water temperature from the handwashing fixtures was in need of being regulated with the cold before using. Record review of Maintenance Logs for the facility revealed that daily temperature checks were being performed in random rooms at random times and that the facility record revealed temperatures of a range of 102-108 on 5/31/17 at 9 AM. Observation on 5/31/17 at 10:50 AM in room 404 with the facility Administrator and Maintained Supervisor revealed that the water temperature from the handwashing fixtures was 133.8 degrees Fahrenheit, with facility and surveyor thermometers. Observation on 5/31/17 at 10:49 AM in room 405 B with the facility Administrator and Maintenance Supervisor revealed that the water temperature from the handwashing fixtures was 133.2 Interview with the facility Administrator confirmed that the water temperatures in resident rooms 315, 317, 401, 403, 404, 405, 104,101,204,100,105,203, 112,201,209,103,and 208, was not in a temperature range to prevent scalding of residents. The facility administrator confirmed that water temperatures feel excessive to the touch.",2020-09-01
87,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,329,D,0,1,LLQX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on interviews and record reviews, the facility failed to identify current behaviors and implement non-pharmacological interventions prior to administering an as needed psychoactive medication for 1 resident (Resident 152) of 5 residents sampled. The facility identified the census at 128. The findings are: A review of Resident 152's Admission Record dated 6/6/17 revealed Resident 152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 152's Medication Administration Record [REDACTED]. According to documentation on the MAR indicated [REDACTED]. A review of Resident 152's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed there were no behaviors or non-pharmacological interventions documented for the days and times that the as needed [MEDICATION NAME] was administered. A review of Resident 152's Medical Record revealed no behaviors or non-pharmacological interventions were documented in the progress notes for the days and times that the as needed [MEDICATION NAME] was administered except for the dose given on 5/19/17 at 10:05 PM. A review of Resident 152's Comprehensive Care Plan for [MEDICAL CONDITION] medication use dated 1/27/17 revealed an intervention for staff to administer the medications as ordered by the physician, document the occurrence of target behaviors symptoms, and document the effectiveness of the medications administered. An interview conducted on 6/5/17 at 1:57 PM with Licensed Practical Nurse (LPN) [NAME] revealed that their procedure for administering an as needed psychoactive medication was to attempt 3 non-pharmacological interventions prior to giving the medication and to document in the progress notes the behaviors, interventions attempted, medication given, and effectiveness of the medication. An interview conducted on 6/5/17 at 2:15 PM with Registered Nurse (RN) F revealed that their procedure for administering an as needed was to find out what was wrong, attempt activities, and document in notes after the medication is given what activities were done, what medication was given, and the effectiveness of the medication. An interview conducted on 6/5/17 at 3:49 PM with the Director of Nursing (DON) revealed that the expectation for administration of an as needed psychoactive medication was that the staff were to try non-pharmacological interventions prior to administration and the behaviors, interventions, medication effectiveness were to be documented on the Behavior/Intervention Monthly Flow Record. The DON reported that prior to their start at the facility the documentation was supposed to be done in the progress noted, but that the nursing staff had received education in (MONTH) to document on the Flow Record.",2020-09-01
88,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,332,D,0,1,LLQX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observation of 26 medications administered revealed 3 errors resulting in an error rate of 11.53 %. The errors affected 2 (Resident 219 and 224) of 4 sampled residents. The facility staff identified a census of 128. Findings are: [NAME] Record review of Resident 219's Medication Administration Record [REDACTED]. The directions to give the Potassium was that it was to be given with food and a full glass of water. The directions for the [MEDICATION NAME] (anti hypertension medication) 75 milligrams (mg) daily was that the medication was to be held if Resident 219's systolic (top number of a blood pressure) was less than 110 and to call the physician. Observation on 6-05-2017 at 7:08 AM of the medication administration for Resident 219 revealed Medication Assistant (MA) A prepared Resident 219's medication and administered them to Resident 219 with a half a cup of water and no food. Resident 219 stated after taking the medications it's not good to give me medications on an empty stomach. No blood pressure was observed to have been obtained prior to giving the [MEDICATION NAME] medication. On 6-5-2017 at 7:23 AM an interview was conducted with MA [NAME] During the interview, review of Resident 219's MAR for (MONTH) (YEAR) was reviewed. When asked if Resident 219's blood pressure was obtained prior to giving the [MEDICATION NAME] or was the Potassium given with food, MA A stated no. B. Record review of Resident 224's MAR for (MONTH) (YEAR) revealed Resident 224 had orders for medications that included Potassium Chloride (supplement) 20 meq to be given daily. The directions to give the Potassium was that it was to be given with food and a full glass of water. Observation on 6-05-2017 at 7:25 AM revealed MA B prepared and administered Resident 224's medications with water and no food. On 6-05-2017 at 7:33 AM an interview was conducted with MA B. MA B confirmed during the interview Resident 224's potassium was not administered with food as directed.",2020-09-01
89,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-06-06,333,D,0,1,LLQX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation record review and interview; the facility staff failed to ensure 1 (Resident 219) of 9 residents reviewed was free of significant medication errors. 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]. Observation on 6-5-2017 at 7:08 AM of the medication administration for Resident 219 revealed Certified Medication Assistant (CMA) A prepared Resident 219's medication and administered them to Resident 219 with a half a cup of water and no food. Resident 219 stated after taking the medications it's not good to give me medications on an empty stomach. No blood pressure was observed to have been obtained prior to giving the [MEDICATION NAME] medication. On 6-5-2017 at 7:23 AM an interview was conducted with CMA [NAME] During the interview, review of Resident 219's MAR for (MONTH) (YEAR) was reviewed. When asked if Resident 219's blood pressure was obtained prior to giving the [MEDICATION NAME], CMA A stated no. Record review of Resident 219's MAR for (MONTH) (YEAR) revealed on 5-19-2017 Resident 219's [MEDICATION NAME] medication was signed of as being given with a recorded blood pressure of 106/62. On 6-6-2017 at 7:58 AM an interview was conducted with the facility Pharmacist. During the interview review of Resident 219's order for the [MEDICATION NAME] was reviewed. When asked if the medication was given outside of the physicians orders would that be a significant error, the Pharmacist stated yes.",2020-09-01
90,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-06-06,580,D,1,0,GX5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12- C3a(6) Based on record review and interview; the facility staff failed to notify the practitioner of refusal of medications for 1 (Resident 45) of 5 sampled residents. The facility staff identified a census of 127. Findings are: Record review of Resident 45's Medication Administration Record [REDACTED] -[MEDICATION NAME], 5 units at bed time, refused 16 times in May. -[MEDICATION NAME] (antihypertensive medication) 20 milligrams (mg), 1 time a day, refused 21 times in May. -[MEDICATION NAME] (antidepressant medication) 15 mg at bed time, refused 10 times in May. -[MEDICATION NAME] (antibiotic medication) 875 mg , 2 times a day for 10 days, refused 5 times in may. -Carvedilol (antihypertensive medication) 3.125 mg, 2 times a day, refused 19 times in May. -Eliquis (anticoagulant medication) 5 mg, 2 times a day, refused 4 times, medication was started on 5-21-2018. -[MEDICATION NAME] (medication used for pain control) 100 mg, 2 times a day, refused 21 times. -Pantoprazole (medication used to decrease stomach acid) 40 mg, 2 times a day, refused 20 times. -Senna Plus (medication used for bowels), 1 tablet every day, refused 20 times. Review of Resident 45's medical record revealed there was no evidence the facility had followed up with the practitioner regarding Resident 45 refusing the medications at the time of the refusals. On 6-06-2018 at 2:47 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not being able to provide evidence Resident 45's practitioner had been notified of the refusals of taking the medications at the time of occurrence.",2020-09-01
91,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-06-06,686,D,1,0,GX5K11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to implement interventions to prevent pressure ulcers for 1 (Resident 43) of 5 sampled residents. The facility staff identified a census of 127. Findings are: [NAME] Record review of Resident 43's Comprehensive Care Plan (CCP) dated 3-01-2018 revealed Resident 43 was high risk or the development of a pressure ulcer and currently had a pressure ulcer. The goal identified on Resident 43's CCP was not have have any complications related to the pressure ulcer. Interventions identified on Resident 43's CCP included applying a pressure relieving cushion to the wheelchair, a special mattress to the bed and to off load ( remove pressure) both heels when in bed every shift and as needed. Observation on 6-05-2018 at 10:43 AM revealed Resident 43 was in bed and Resident 43's heels were pressing into the mattress. Observation on 6-06-2018 at 6:40 AM resident 43 was in bed with the heels on the mattress. Observation on 6-06-2018 at 8:40 AM revealed Resident 43 heels were on the mattress. Observation on 6-06-2018 at 9:12 AM with Licensed Practical Nurse (LPN) A revealed Resident 43's heels were resting on the mattress. On 6-06-2018 at 10:25 AM a interview was conducted with LPN [NAME] During the interview, review of Resident 43's CCP was completed with LPN [NAME] LPN A confirmed Resident 43's heels should have been off loaded and were not. B. Record review of a Physician/Prescriber orders sheet dated 5-23-2018 revealed Resident 43's practitioner had order the facility provide a Trapeze ( Devices that is placed over the bed so that a person is able to pull self up) for the bed so Resident 43 could better reposition self. Observation on 6-5-18 at 2:12 PM revealed Resident 43 was in bed and did not have a trapeze bar in place. Observation on 6-06-2018 at 8:40 AM revealed Resident 43 was in bed and there was not a trapeze bar in place. Observation on 6-06-2018 at 10:16 AM with LPN A revealed Resident 43 was in bed and did not have the trapeze bar in place. A interview was conducted on 6-06-2018 at 10:16 AM with LPN [NAME] During the interview LPN A confirmed Resident 43 did not have the trapeze bar in place for Resident 43 to use.",2020-09-01
92,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-06-26,609,D,1,0,49DM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an elopement (leaving a secure area without staff knowledge or supervision) to the state agency for Resident 4. The facility census was 131. Findings are: Interview on 6/26/2018 at 8:30 AM with the Director of Nursing (DON) revealed on 5/6/2018 Resident 4 left the building when a visitor left. Resident 4's Wanderguard braclet (a device used to alert staff a vulnerable resident is leaving a secured area) did activate the alarm however the visitor turned off the alarm and Resident 4 left the building. Review of the facility incident tracking assessment dated [DATE] revealed Resident 4 had gone outside to go home to check on the horses. The resident was confused and only oriented to person at the time staff were called to assist Resident 4. Review of the facility reports and investigations for the past 4 months revealed no report of the elopement (leaving a secure area without staff knowledge or supervision) was present for Resident 4. Review of the undated facility policy titled Abuse Investigations defines essential services as those necessary to safeguard the person including proper supervision of the vulnerable adult. Review of the undated facility policy titled Abuse Investigation revealed if there is a reason to suspect or believe conditions are present that could result in neglect the incident should be reported to the state agency immediately and an investigation completed. Interview with the DON on 6/26/2018 revealed no report was filed for Resident 4's elopement on 5/6/2018.",2020-09-01
93,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-06-26,610,D,1,0,49DM11,> Based on record review and interview the facility failed to submit a completed investigation to the state agency within 5 working days for 2 residents (Residents 1 and 5) and failed to complete an investigation of an elopement (leaving a secure area without staff knowledge or supervision) for Resident 4. The facility census was 131. Findings are: [NAME] Review of the facility policy revealed the facility will conduct an investigation of all incidents involving the potential or allegation of abuse or neglect and submit a written report of the results of all abuse investigations to the state agency in 5 working days of the reported incident. Review of facility investigation related to an unwitnessed fall for Resident 1 revealed a fall occurred in the morning of 6/5/2018 and Resident 1 received a laceration to the head and was sent to the hospital for treatment. The facility completed an investigation and submitted it to the state agency 6 day later on 6/13/2018. Review of the facility investigation revealed Resident 1 fell a second time in the evening of 6/5/2018 and went to the hospital for treatment as remained at the hospital until 6/6/2018 Review of the facility investigation revealed it was submitted to the state agency 6 days later on 6/13/2018. Interview on 6/26/3028 at 8:45 with the Social Services Director revealed both investigations were submitted late. B. Review of a facility report for Resident 5 revealed a facsimile (fax) confirmation sheet attached to the investigation indicated the status of the fax to be S-OK. Review of the fax cover sheet revealed that S-OK means stop communication Interview on 6/26/2018 at 8:45 AM with the Director of Nursing revealed that the confirmation sheet would indicate that the fax did not go to the state agency. C. Review of the facility investigations for the past 4 months revealed that no investigation was completed or submitted to the state agency regarding an elopement for Resident 4. Interview on 6/26/2018 at 10:30 AM with the Director of Nursing revealed that an investigation was not completed or submitted to the state agency.,2020-09-01
94,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-06-26,812,E,1,0,49DM11,"> Licensure Reference Number: 175 NAC 12-006.11C Based on observation, record review and interview, the facility failed to ensure the ice scoop was not stored in the ice chest to prevent the potential for foodborne illness. This had the potential to effect 14 residents that were provided ice from the ice chest. The facility census was 131. Findings are: Observation on 6/25/2018 revealed Nursing Assistant (NA)-A obtained a Styrofoam cup from the ice cart and opened the lid of the cooler. NA-A reached into the cooler and picked up the scoop from on top of the ice. NA-A obtained a scoop of ice from the cooler and placed the scoop back into the ice. NA-A gave the ice to Resident 7. Review of the facility policy dated 10/30/2017 titled IC208 Ice Chests revealed scoops are to be kept in the scoop holder that is attached to each ice chest. Interview on 6/26/2018 at 9:35 AM with the Dietary Manager revealed the scoop should not be left in the ice chest. Interview on 6/26/2018 at 11:00 with the Social Services Director revealed 14 resident reside on the designated unit and receive ice from the ice chest.",2020-09-01
95,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-07-30,554,D,1,0,N7DY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observation, record review and interview the facility staff failed to assess a resident for self-administration of medication for 1 (Resident 3) of 1 sampled resident. The facility staff identified a census of 133. The findings are: During an observation of wound care on 7/29/19 at 02:36 PM for Resident 3 revealed Resident 3's husband removed an inhaler from his pocket and handed it to Resident 3. Resident 3 administered 2 puffs of the inhaler. Record review of current physician orders for (MONTH) 2019 revealed an order for [REDACTED]. Record review of Resident 3's medical record revealed no evidence that Resident 3 was assessed for self-administration of medication. Review of the facility policy for self-administration of medications revealed that if a resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the residents' cognitive, physical, and visual ability to carry out this responsibility during the care planning process and there is a prescriber's order to self-administer. Interview conducted on 7/29/19 at 03:06 PM confirmed that Resident 3 did not have an order to self-administer medications and did not have an assessment for self-administration of medications.",2020-09-01
96,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-08-27,689,D,1,0,GSSL11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observation, record review and interview; the facility staff failed to implement assessed intervention for fall prevention for 1 (Resident 3) of 5 sampled residents. The facility staff identified a census of 140. Findings are: Record review of Resident 3's Comprehensive Care Plan (CCP) updated on 4-24-2018 revealed the facility staff identified Resident 3 was at risk for falls. Interventions identified on Resident 3's CCP to prevent potential falls included ensuring belongings were within reach, call light reminder sign and to ensure Resident 3's call light was within reach. Observation on 8-26-2019 at 2:20 PM revealed Resident 3 was placed next to the bed after using the bathroom. Resident 3's call light was not in reach of the resident. Observation on 8-26-2019 at 3:00 PM with Social Services (SS) [NAME] During the observation SS A confirmed Resident 3's call light was not within reach of Resident 3 and should have been.",2020-09-01
97,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,580,D,1,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview: the facility failed to notify the physician of the presence of a pressure ulcer (a localized injury to the skin/underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and /or friction) to obtain treatment orders at the time of admission to promote healing of a pressure ulcer for 1 (Resident 105) of 5 residents reviewed with pressure ulcers. The facility census was 126. Findings are: Record review of a facility Policy and Procedure for Skin and Wound Management standard dated revised (MONTH) (YEAR) revealed the following policies: - A resident having pressure sores receives necessary treatment and services to promote healing and prevent infection: Pressure Ulcer Skin Condition: - Initial identification of a new pressure ulcer will include an assessment and measurement of the wound. Documentation of findings, assessment results and notification of the physician and family will be made in the residents clinical record. Treatment: - The treatment plan will be specific for each individual resident as directed by the physician. Appropriate treatment will address length, width, depth, odor, drainage, pain, wound bed and surrounding skin. Evidence of slough, necrotic tissue or infection should be communicated to the physician and treated accordingly. Record review of Resident 105's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/18 revealed that Resident 105 was admitted to the facility on [DATE] with 1 unhealed pressure sore that was unstageable due to coverage of the wound bed by slough (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and /or eschar) and/or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissues that has lost its usual physical properties and biological activity. Eschar may be lose or firmly adhered to the wound.) The MDS identified that the pressure ulcer was covered by Eschar. Record review of a Braden Scale ( a risk assessment for pressure ulcers) dated 8/4/18 identified that Resident 105 was at high risk for the development of pressure sores with a score of 15. A score of 20 and below was considered to be high risk. Record review of a nursing Admission Summary Progress Note dated 8/2/18 identified that Resident 105 had a pressure ulcer to the heft heel that measured 4 centimeters (cm) by 1.4 cm. Record review of Resident 105's Skin Assessments revealed the following measurements and description of Resident 105's pressure ulcer to the left heel: - 8/3/18: left heel pressure 4 cm x 1.4 cm unstageable, black dry/eschar to left heel - 8/10/18 left heel pressure 4 cm x 1 cm, black dry eschar/scab to left heel - 8/18/18 left heel not identified on the skin assessment, identified no alteration in skin integrity - 8/23/18: left heel pressure 1.4 x 1.3 0.3 cm, stage 3, Wound has about 50 percent eschar to the wound bed, recommend alginate AG with 4 by 4 bordered gauze, change q (every) 3 days and prn (as needed) soiled or dislodged dressing. - 9/1/18: left heel pressure 1.1 x. 75 x .2 - 9/8/18: left heel pressure, no measurements documented. Observation on 09/12/18 at 08:00 AM with the Wound Care Registered Nurse (RN) confirmed the presence of a pressure ulcer to the left heel. The Wound Care RN confirmed that the wound was open and not covered by eschar. Record review of Resident 105's discharge orders from the hospital and admission orders [REDACTED]. The treatment wound care orders only covered treatments to bilateral lower leg stasis ulcers and did not address treatment of [REDACTED]. Record review of Resident 105's Physician orders [REDACTED]. Cover wound bed with Alginate Silver (a medication used to treat pressure ulcers) and apply bordered gauze. Change every 3 days and as needed for soiled or dislodged dressing. Record review of Resident 105's (MONTH) (YEAR) Treatment Sheets revealed that treatments to the left heel pressure ulcer were not started until 8/27/18, a total of 24 days after admission when the left heel ulcer was first identified on 8/2/18. Interview on 09/13/18 at 09:41 AM with the RN Wound Nurse confirmed that there were no treatment orders for the treatment of [REDACTED]. The RN Wound Nurse confirmed that Resident 105's admission Nursing Assessment Progress Note documentation dated 8/3/18 identified the presence of a left heel ulcer and that treatment orders should have been obtained at the time of admission. Interview on 09/13/18 at 01:05 PM with the Director of Nursing (DON) confirmed that there were no treatments provided or ordered for Resident 105's left heel pressure ulcer until 8/27/18. The DON confirmed that the hospital did not send treatment orders for the left heel wound and there was no follow up with the physician regarding the treatment of [REDACTED]. The facility DON was unable to provide evidence that the physician had been notified of the presence of a heel at the time of admission. The DON confirmed that he expectation would be to notify the physician and obtain treatment orders and that this was not done.",2020-09-01
98,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,623,E,0,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify residents representatives and the ombudsman in writing of resident transfers for 5 (Residents 15, 94, 90, 80, 104) of 6 residents reviewed for hospitalization . The facility census was 126. Findings are: [NAME] Review of Resident 15's progress note revealed on 9/1/2018 Resident 15 Change of Condition Note revealed the resident has a change of condition and was transferred to the hospital for evaluation and treatment. Review of Resident 15's scanned documents revealed no documentation regarding notification in writing to the Resident 15's representative or the State Ombudsman regarding the reason for Resident 15's transfer. 09/13/18 10:40 AM Interview with the director of nursing(DON) revealed they do not send a letter to the family or resident regarding reason for the transfer and they do not notify the State Ombudsman. Review of the facility policy dated (MONTH) (YEAR) titled Bed-holds and Returns revealed; prior to transfer written information will be given to the residents and the resident representatives that explains in detail including the details of the transfer using the Notice of Transfer. B. Review of Resident 80's progress notes revealed Resident 80 was admitted to the hospital on [DATE]. Review of Resident 80's scanned documents revealed no evidence of notification to Resident 80, the family representative or the State Ombudsman in writing of the reason for Resident 80's transfer to the hospital. Interview on 09/13/18 at 11:01 AM with the (DON) revealed the facility has not been using the Notice of Transfer referenced in the facility policy. C. Review of Resident 90's progress notes revealed Resident 90 was admitted to the hospital on [DATE]. Interview on 09/13/18 at 10:40 AM with the DON revealed families are verbally notified of transfer and the reason for the transfer. The State Ombudsman is not notified. D. Review of Resident 94's progress notes revealed Resident 94 was transferred to the hospital on [DATE]. Review of Resident 90's scanned documents revealed no evidence of notification to Resident 80 or the family representative or the State Ombudsman in writing of the reason for Resident 80's transfer to the hospital Interview 9/13/2018 at 10:49 AM with the Social Services Director revealed transfers are not reviewed with the State Ombudsman. E. Review of Resident 104's progress notes revealed Resident 104 was transferred to the hospital on [DATE]. Review of Resident 90's scanned documents revealed no evidence of notification to Resident 80 or the family representative or the State Ombudsman in writing of the reason for Resident 80's transfer to the hospital Interview on 09/13/18 at 11:00 PM with the DON revealed no letter was provided to the family or resident regarding the reason for transfer. The ombudsman was not notified of transfers.",2020-09-01
99,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,625,E,0,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify residents of the right to hold a bed during hospitalization at the time of transfer for 5 of 6 residents (Resident's 15, 94, 90, 80, and 104). The facility census was 126. Findings are: [NAME] Review of Resident 15's progress note revealed on 9/1/2018 at 18:22 a Change of Condition Note revealed the resident has a change of condition and was transferred to the hospital for evaluation and treatment. Review of Resident 15's Bed hold revealed Resident 15 was issued a Bed hold notice on return to the facility. Review of the policy dated (MONTH) (YEAR) titled Bed-holds and Returns Prior to a transfer revealed written information will be given to the residents and the resident representatives that explains in detail: - The rights and limitations of the resident regarding bed-holds. - The reserve bed payment policy as indicated by the state plan - The facility per diem rate required to hold a bed or to hold a bed beyond the state bed-hold period. Interview on 9/13/2018 at 10:45 AM with the Business office manager revealed the only time bed hold are completed are on admission or readmission from the hospital. B. Review of Resident 80's progress notes revealed Resident 80 was admitted to the hospital on [DATE]. Review of resident scanned documents revealed the only bed hold was signed on admission. No bed hold located in the medical record for admission o 8/10/2018. Interview 9/13/2018 at 10:49 AM with the Social Services Director revealed bed holds are completed by the Business Office Manager. C. Review of resident 90's progress notes revealed resident 90 was admitted to the hospital on [DATE]. Review of Resident 90's scanned documents a Bed Hold was issued on 7/13/2018 on Resident 90's return to the facility. Interview on 9/13/2018 at 10:45 AM with the Business office manager revealed the Business office manager was not aware of the requirement to provide the bed hold on transfer to the hospital. D. Review of Resident 94's progress notes revealed Resident 94 was transferred to the hospital on [DATE]. Review of Resident 94's scanned document titled bed hold revealed it was issued on 7/24/2018 when resident 94 was readmitted to the facility. 09/13/18 11:00 PM DON Confirmed no bed hold was obtained when resident transferred to the hospital or followed up on and no letter was provided to the family or resident regarding the reason for transfer. The ombudsman was not notified of transfers. E. Review of Resident 104's progress notes revealed Resident 104 was transferred to the hospital on [DATE]. Review of Resident 104's scanned document titled Bed hold revealed no bed hold was issued to the resident on transfer to the hospital or during the hospitalization . 09/13/18 11:00 AM DON revealed no bed hold was provided when resident was transferred to the hospital.",2020-09-01
100,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,656,D,1,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record review and interview, the facility staff failed to implement a CCP (Comprehensive Care Plan) to reflectthe current status of smoking for 1 (Resident 75) of 2 sampled residents. The facility staff identified the census of 126. Findings are: Record review of Smoking assessment dated [DATE] for Resident 75 revealed that Resident 75 required physical assist to smoking area destination due to uneven terrain and low vision. Record review of the CCP dated 02/21/2018 for Resident 75 revealed that the current status of smoking was not identified on the CCP until 09/12/2018. Interview conducted on 09/12/2018 at 10:30 AM with the Director of Nursing confirmed that the CCP was not updated with Resident 75's smoking status until 09/12/2018.",2020-09-01
101,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,657,D,1,1,XOYL11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview the facility staff failed to revise the CCP (Comprehensive Care Plan) to reflect current status of smoking for 1 (Resident 27) of 2 sampled residents. Facility staff identified a census of 126. The findings are: Record review of Smoking assessment dated [DATE] for Resident 27 revealed that Resident 27 was unsafe to smoke independently and propel self to designated area safely. Patient required supervision to complete smoking task. Record review of behavior note dated 7/19/2018 revealed that Resident 27 was let out of the building by another resident and staff found Resident 27 outside smoking with 2 other residents. Record review of behavior note dated 9/11/2018 revealed that Resident 27 was in the courtyard smoking by self. Record Review of the CCP dated 8/31/2017 revealed that Resident 27 desired to smoke while at a smoke free campus. The goal was that Resident 27 would demonstrate compliance with non-smoking campus policies. There were no updates to the CCP reflecting Resident 27's non-compliance with the smoking policy. Interview with the Director of Nursing on 09/13/2018 at 02:45 PM confirmed that the CCP had not been updated to reflect Resident 27's non-compliance with the smoking policy.,2020-09-01
102,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,686,D,1,1,XOYL11,"**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 obtain treatment orders at the time of admission to promote healing of a pressure ulcer (a localized injury to the skin/underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and /or friction) for 1 (Resident 105) of 5 residents reviewed with pressure ulcers. The facility census was 126. Findings are: Record review of a facility Policy and Procedure for Skin and Wound Management standard dated revised (MONTH) (YEAR) revealed the following policies: - A resident having pressure sores receives necessary treatment and services to promote healing and prevent infection: Pressure Ulcer Skin Condition: - Initial identification of a new pressure ulcer will include an assessment and measurement of the wound. Documentation of findings, assessment results and notification of the physician and family will be made in the residents clinical record. Treatment: - The treatment plan will be specific for each individual resident as directed by the physician. Appropriate treatment will address length, width, depth, odor, drainage, pain, wound bed and surrounding skin. Evidence of slough (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and /or eschar), necrotic tissue or infection should be communicated to the physician and treated accordingly. Record review of Resident 105's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/18 revealed that Resident 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 105's MDS identified the presence of 1 unhealed pressure sore that was unstageable due to coverage of the wound bed by slough and/or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissues that has lost its usual physical properties and biological activity. Eschar may be lose or firmly adhered to the wound.) The MDS identified that the pressure ulcer was covered by Eschar. Resident 105 was identified as moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 11 and required extensive assistance of 2 staff for bed mobility, transfers and mobility on and off the unit. Record review of a Braden Scale ( a risk assessment for pressure ulcers) dated 8/4/18 identified that Resident 105 was at high risk for the development of pressure sores with a score of 15. A score of 20 and below was considered to be high risk. Record review of a nursing Admission Summary Progress Note dated 8/2/18 identified that Resident 105 had a pressure ulcer to the heft heel that measured 4 centimeters (cm) by 1.4 cm. Record review of Resident 105's Skin Assessments revealed the following measurements and description of Resident 105's pressure ulcer to the left heel: - 8/3/18: left heel pressure 4 cm x 1.4 cm unstageable, black dry/eschar to left heel - 8/10/18 left heel pressure 4 cm x 1 cm, black dry eschar/scab to left heel - 8/18/18 left heel not identified on the skin assessment, identified no alteration in skin integrity - 8/23/18: left heel pressure 1.4 x 1.3 0.3 cm, stage 3, Wound has about 50 percent eschar to the wound bed, recommend alginate AG with 4 by 4 bordered gauze, change q (every) 3 days and prn (as needed) soiled or dislodged dressing. - 9/1/18: left heel pressure 1.1 x. 75 x .2 - 9/8/18: left heel pressure, no measurements documented. Observation on 09/12/18 at 08:00 AM with the Wound Care Registered Nurse (RN) confirmed the presence of a pressure ulcer to the left heel. The Wound Care RN confirmed that the wound was open and not covered by eschar. Record review of Resident 105's discharge orders from the hospital and admission orders [REDACTED]. The treatment wound care orders only covered treatments to bilateral lower leg stasis ulcers and did not address treatment of [REDACTED]. Record review of Resident 105's Physician orders [REDACTED]. Cover wound bed with Alginate Silver (a medication used to treat pressure ulcers) and apply bordered gauze. Change every 3 days and as needed for soiled or dislodged dressing. Record review of Resident 105's (MONTH) (YEAR) Treatment Sheets revealed that treatments to the left heel pressure ulcer were not started until 8/27/18, a total of 24 days after admission when the left heel ulcer was first identified on 8/2/18. Interview on 09/13/18 at 09:41 AM with the RN Wound Nurse confirmed that there were no treatment orders for the treatment of [REDACTED]. The RN Wound Nurse confirmed that Resident 105's admission Nursing Assessment Progress Note documentation dated 8/3/18 identified the presence of a left heel ulcer and that treatment orders should have been obtained at the time of admission. Interview on 09/13/18 at 01:05 PM with the Director of Nursing (DON) confirmed that there were no treatments provided or ordered for Resident 105's left heel pressure ulcer until 8/27/18. The DON confirmed that the hospital did not send treatment orders for the left heel wound and there was no follow up with the physician regarding the treatment of [REDACTED].",2020-09-01
103,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,689,D,0,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on record review, observation, and interview; the facility staff failed to provide assistance and supervision for residents identified at risk for smoking and failed to ensure accuracy of assessments for smoking ability for 2 (Resident 75 and 27) of 2 sampled residents. The facility staff identified census of 126. Findings are: Review of facility smoking policy dated 2/2018 revealed: a purpose to maintain the highest level of safety for all residents To uphold a non-smoking facility. All residents must be off ground when smoking A smoking assessment will be completed on all residents desiring to smoke and will identify resident's level of independence and ability to smoke safely. [NAME] Observation on 09/12/2018 at 08:35 AM revealed Resident 75 was smoking in the facility parking lot. Observation on 09/12/2018 at 03:00 PM revealed Resident 75 was sitting in the driveway of the facility smoking. Record review of Smoking assessment dated [DATE] for Resident 75 revealed that Resident 75 requires physical assist to smoking area destination due to uneven terrain and low vision (pt legally blind). Interview with Resident 75 on 09/10/2018 at 02:36 PM revealed that Resident 75 is a smoker and knows that the policy is to leave the premises to smoke, but it is difficult due to being legally blind. An interview conducted with the Assistant Director of Nursing (ADON) G on 09/12/2018 at 03:00 PM confirmed that Resident 75 was in the facility parking lot smoking and that the policy is for the residents to leave the premises to smoke. An interview conducted on 09/12/2018 at 10:30 AM with the Director of Nursing (DON) revealed that the facility is a non-smoking facility and if a resident smokes the resident is required to leave the premises. DON confirmed that the residents were smoking in the facility parking lot. B. Record review of Smoking assessment dated [DATE] for Resident 27 revealed that Resident 27 is unsafe to smoke independently and propel self to designated area safely. Patient requires supervision to complete smoking task. Record review of behavior note dated 7/19/2018 revealed that Resident 27 was let out of the building by another resident and staff found Resident 27 outside smoking with 2 other residents. Record review of behavior note dated 9/11/2018 revealed that Resident 27 was in the courtyard smoking by self. Interview conducted with the DON and Social Service Director confirmed that Resident 27 was assessed as an unsafe smoker and that Resident 27 did go outside without supervision to smoke.",2020-09-01
104,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,758,D,0,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 of 5 residents reviewed (Resident 94) did not receive an as needed psychoactive medication for more than 14 days without a physician rationale. Findings are: Review of Resident 94's Physician orders [REDACTED]. Review of Resident 94's Physician orders [REDACTED]. Review of the monthly Pharmacy Review notes revealed in (MONTH) (YEAR) the Pharmacist documented a letter was not back from the physician regarding Resident 94 being on two as needed medications for Anxiety and the prescribed time for discontinuing the medication being over 14 days. Review of Resident 94's Electronic Medical Record revealed no documentation from Resident 94's healthcare provider regarding the rationale for use of the medications for over 14 days or the need for two medications for the same [DIAGNOSES REDACTED]. Interview on 09/17/18 at 10:01 AM with Assistant Director of Nursing (ADON)-F revealed ADON-F was unable to locate letter regarding [MEDICATION NAME] and [MEDICATION NAME] in Resident 94's medical record.",2020-09-01
105,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,759,D,0,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observation of 25 medication administered revealed 4 errors for 3 Residents ( 4, 21 and 79) resulting in an error rate of 16%. The facility staff identified a census of 126. Findings are: [NAME] Record review of Resident 4's Medication Administration Record [REDACTED]. Observation on 9-11-18 at 3:50 PM revealed Licensed Practical Nurse (LPN) A administered the [MEDICATION NAME] and Potassium chloride with water and no food. On 9-11-18 3:57 PM a interview was conducted with LPN [NAME] During the interview LPN A confirmed the [MEDICATION NAME] was given late and the potassium Chloride was not given with food as ordered. B. Record review of a Order Summary Report sheet printed on 9-12-18 revealed Resident 21 had ordered for medications that included Breo Ellipta (medication to help with breathing) , 1 inhalation in the morning. According to the directions Resident 21 was to rinse the mouth after taking the Breo Ellipta. Observation on 9-12-18 at 9:22 AM revealed LPN B administered medications to Resident 21 that included the Breo Ellipta. LPN B instructed Resident 21 to swish with water and swallow. According to www.breo.com instructions for use of Breo Ellipta is to rinse the mouth with water without swallowing after using BREO ELLIPT[NAME] On 9-12-18 at 9:28 AM an interview was conducted with LPN B. During the interview, LPN B confirmed Resident 21 was instructed to rinse the mouth and swallow. C. Record review of a Order Summary Report sheet printed on 9-12-18 revealed Resident 79 had orders for medications that included Potassium Chloride 20 meq to be give 2 times a day. Observation on 9-12-18 at 9:30 AM revealed LPN B prepared Resident 79's medications that included the Potassium Chloride. LPN was observed to crush all of Resident 79's medication. Further observations revealed the label contained directions that the Potassium Chloride was not to be crushed. On 9-12-18 at 10:05 AM an interview was conducted with LPN B. During the interview, LPN B confirmed the Potassium Chloride was crushed and should not have been.",2020-09-01
106,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,804,F,0,1,XOYL11,"LICENSURE REFERENCE NUMBER 174 NAC 12-006.11D Based on observation and interview the facility failed to ensure food temperatures were maintained to prevent the potential for food borne illness and ensue the palatability of the food. This had the potential to effect 125 of 126 residents who ate food from the kitchen. The facility staff identified a census of 126. Observation on 8-12-18 at 8:56 am revealed the facility nursing staff had completed serving the last resident room tray. The Dietary Services Manager (DSM) removed a test food tray for evaluation. Following is the temperatures and tasting of the test tray food obtained by the DSM: - Regular oatmeal was 118.6 degrees, the oat meal was pasty tasting and stuck to the teeth. -The regular egg and cheese Omelet temperature was 123.1 degrees, was chewy and bland. -Pureed oat meal temperature was 103.9 degrees was pasty and bland. -Pureed eggs, temperature was 113.2 degrees, bland and grainy tasting. -Pureed bread temperature was 102.9 degrees, thick pasty that stuck to the roof of the mouth and teeth. On 9-12-18 at 8:56 AM the DSM confirmed the food was cold, bland, with some food items sticking to the teeth and roof of the mouth.",2020-09-01
107,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,812,D,0,1,XOYL11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to obtained food temperatures before and after meal services and failed to date food items prepared in the facility for resident use to prevent potential food borne illness. The had the potential to effect 125 of 126 resident who ate food from the kitchen. The facility staff identified a census of 126. Findings are: [NAME] Observations on 8-12-18 at 1:35 PM with the Dietary Services Manager (DSM) revealed 11 ham and cheese sandwiches that were undated, 4 peanut butter and jelly sandwiches that were undated and a container of cucumber salad with cream like dressing that was undated. B. Record review of of the facility Service Line Checklist sheets provided by the facility DSM revealed the following information: -9-2-18 revealed breakfast and lunch food temperatures were not obtained and recorded. -9-3-18 revealed breakfast and lunch services food temperatures were not obtained and recorded. -9-4-18 revealed breakfast and lunch service food temperatures were not obtained and recorded. -9-8-18 revealed breakfast and lunch service food temperature was not obtained and recorded. -9-9-18 revealed breakfast and lunch service food temperature was not obtained and recorded. -9-11-18 revealed breakfast and lunch service food tempts was not obtained and recorded. On 9-12-18 at 1:35 PM an interview was conducted with the DSM. During the interview the DSM confirmed the ham and cheese sandwiches were not dated when prepared and the peanut and jelly sandwiches were not dated when prepared. The DSM further confirmed food temperatures were not obtained and recorded and should have been. 09/12/18 7:25 AM [NAME] DSM, is certified, Easter D RN also is an employee at facility. Steam table not functional. Kitchen staff using 2 portable type steam tables, and using crock pot to try and keep food temps up. Crock pots have hot liquid, however, unable to submurge 3 containers in hot waters. Omelet 178.Oat Meal 164.3, folded omelet 193.2. Pureed oat meal 163.3, eggs a 155.9 toast 156.4, scrambled eggs 156.6. 9-12-18 Room trays 8-12-17 starting at 7:40 AM , 2nd batch of eggs 157.7, 2nd batch of oat meal 152.7. DSM uses thermometer, cleans and places it into pocket. 8-12-18 7:50 AM needed another batch eggs, DSM takes thermometer out of pocket and temps foods. 8-12-18 8:20 AM needed more omelet, folded type , DSM takes thermometer out of pocket and tempts eggs. Test tray 9-12-18 8:45 AM taken to 100 hall. DSM, RD Ester last tray served at 8:56 AM. Testing meal test tray Oatmeal 118.6, luke warm, pasty, sticks to teeth , omelets 123.1 chewy and bland tasting, Pureed oatmeal 103.9 pasty, bland sticks to the roof of the mouth and teeth. Pureed eggs 113.2 bland, not hot, somewhat grainny tasting, purred bread 102.9 pasty, sticks to roof of mouth and teeth, difficult to swallow. DSM [NAME] confirmed findings on 8-12-18 at 9:07 AM. 8-12-18 1:35 PM lunch meal completed Erica DA doing dishes washes hands from dirty to clean, good tech, Temp of tuna slad in refrigerator reveal 38.9 after DSM took thermometer out of pocket. Cucumber salad 47 degrees, was made just prior to lunch service per DSM. D SM throw away. Reviewed temp logs confirmed was not being completed for each meal. Observation og refrigerator revealed 11 ham and cheese sandwiches undated, PBJ 4 undated, DSM reported should be dated with put into refrigerator and was not, and food temperatures were not obtained and recorded. Initial observation of the kitchen on 09/10/2018 at 09:30 AM revealed: A bulk sugar container was dirty and not covered with particles of food in the sugar. Cans of Oranges, Pineapple, Bush Beans and Hunts Ketchup in dry storage area were not dated. Interview with Dietary Manager 09/10/2018 at 09:45 AM confirmed that the sugar container was dirty and not covered and that the cans were not dated and should have been.",2020-09-01
108,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,880,E,0,1,XOYL11,"Licensure Reference Number: 175 NAC 12-006.17D Based on observation, record review and interviews, the facility to failed to ensure hand hygiene was completed when changing gloves, failed to utilize a clean barrier for supplies during pressure ulcer treatments for 4 of 4 residents( 94,90,97,105), and failed to complete hand hygiene during personal cares for resident 22. The facility census was 126. Findings are: [NAME] Observation on 9/11/2018 at 8:23 AM of the wound nurse completing Resident 97's treatment to his pressure sore. The wound nurse performed hand hygiene on entering Resident 97's room and donned gloves. Assisted Resident 97 to expose the wound. The wound nurse then removed the old dressing and picked up the bottle of wound cleaner and sprayed wound cleaner on Resident 97's wound and wiped with a gauze pad removed from the dresser. No clean barrier was placed on the table under supplies to ensure a clean surface. Wound Nurse removed gloves and applied new gloves without performing hand hygiene. Clean dressing was retrieved from bare bedside table top and placed on Resident 97's wound. Review of the facility policy dated 10/2010 titled Wound Care revealed the following steps in the procedure: -Use disposable cloth to establish a clean field on resident's over bed table. -Place items to be used during procedure on the clean field. -Put on gloves. -Loosen tape and remove dressing. -Pull gloves over dressing and discard into appropriate receptacle. -Wash and dry hands thoroughly. -Put on gloves. -Apply clean dressing as ordered. -Discard Disposable items. -Wash and dry hands thoroughly. -Wipe over bed table. -Clean reusable supplies with alcohol and return to the treatment cart. -Disposable supplies cannot be returned to the cart. B. Interview on 9/11/2018 at 8:40 AM with the Wound Nurse revealed Resident 90 had large pressure wound with a large amount of drainage. Observation on 9/11/2018 at 8:45 AM of wound care revealed the Wound nurse entered Resident 90's room and placed the dressing supplies on bare over-bed table with no clean barrier cloth. The Wound nurse then completed hand hygiene and put gloves on. The Wound nurse then removed the old dressing and cleansed Resident 90's wound without changing gloves. Wound nurse handled package of cotton tip applicators with the same gloves as used to remove old dressing and removed two cotton tipped applicators and proceeded to clean the wound base. The Wound nurse then removed gloves and put on a clean pair of gloves without performing hand hygiene. The wound was packed and covered as ordered. The Wound Nurse secured the dressing and then reached into the pocket of uniform and retrieved a pen to mark the date and time on the dressing, placing the pin back into the same pocket. Wound nurse then removed trash and washed hands. Wound nurse exited room and with an ungloved hand reached into the pocket and retrieved the pen and placed it on the top of the treatment cart. Wound nurse then took trash to dispose of in the main trash and returned to the treatment cart. At the treatment cart the Wound Nurse picked up the pen with an ungloved hand and without cleaning the pen placed it inside the clean treatment cart. Interview on 9/13/2018 with the Director of nursing revealed the wound nurse should not place supplies in Resident 90's room without them on a barrier and should not have placed the pen on or in the cart without cleaning the pen. Hand hygiene should always be completed when changing gloves and gloves should be changed when going from removing a dressing and placing a new dressing. C. Observation on 9/11/2018 at 9:00 AM of the Wound Nurse changing Resident 94's dressing on a pressure wound on Resident 94's right heel. The Wound Nurse removed supplies from the treatment cart including the pen used on a previous Resident without cleaning it. A package of disposable gauze pads and scissors were removed from the treatment cart. On entering the room, the Wound Nurse placed the supplies on Resident 94's over bed table and completed hand hygiene. The Wound nurse applied gloves and gathered the supplies from the over bed table and placed them on the end of Resident 94's bed near Resident 94's feet with no protective barrier. The Wound nurse removed Resident 94's socks and removed Resident 94's dressing on the Right heel wound. Without changing gloves the Wound nurse cleaned the area with wound cleanser from the treatment cart and reached into the container of gauze pads to dry the wound. The Wound nurse changed gloves without cleansing hands and applied the clean dressing prior to removing supplies from the end of the Resident 94's bed and placed them on the floor. The Wound Nurse then disposed of the old dressing and cleansed hands. The Wound nurse then picked up the supplies from the floor and placed them on top of the treatment cart. Trash was disposed of and on returning the Wound nurse placed the items back into the treatment cart without cleaning the non-disposable equipment and placing the disposable supplies into the cart. Interview on 9/13/2018 at 2:45 PM with the Director of nursing revealed the wound nurse should not place supplies in Resident 90's room without them on a barrier or on the floor and should not have placed the pen on or in the cart without cleaning the pen. Hand hygiene should always be completed when changing gloves and gloves should be changed when going from removing a dressing and placing a new dressing. D. Observation on 09/12/18 between 8:00 AM and 8:15 AM revealed the Registered Nurse (RN) Wound Care Nurse entered Resident 105's room with 2 enclosed packages of dressings and a pair of scissors. Resident 105 was seated in a recliner with the foot rest in the up position. The RN Wound Nurse placed the packages of supplies directly on the floor with no clean barrier beneath. The RN Wound Nurse proceeded to wash hands, donned clean gloves and performed a dressing change and treatment to a pressure ulcer on Resident 105's left heel. Interview on 09/13/18 at 02:41 PM with the Director of Nursing (DON) confirmed that the wound care supplies should not have been placed directly onto the floor and that the floor was considered to be a dirty surface. The DON confirmed that the supplies should have been placed on a clean barrier on a bedside table. E. Observation of Nursing Assistant (NA) C on 09/12/2018 at 08:30 AM during personal care of Resident 22 revealed the following: NA C put gloves on when entering Resident 22 room. NA C removed brief from resident and placed the dirty brief on the floor, then opened a new brief and placed the brief on the resident, put on the residents pants and shirt, and then transferred the resident to her wheelchair. At no time during the observation did NA C remove gloves or wash hands. Review of the Handwashing/Hand Hygiene Policy Statement dated (MONTH) 2012 revealed that employees must wash their hands for at least 15 seconds before and after direct resident contact and assisting a resident with personal care. Interview with Assistant Director of Nursing (ADON) who was present during personal care on 09/12/2018 at 08:45 AM confirmed that NA C did not wash hands or remove gloves, and NA C placed dirty brief on the floor in Resident 22's room.",2020-09-01
109,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2018-09-17,921,E,1,1,XOYL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(1) Based on observation and interview, the facility staff failed to ensure that walls were free of gouges and holes, concrete sidewalks and parking area were free from large cracks and holes and failed to ensure the ventilation system was not dirty in resident rooms. Findings are: Observation during the Environmental tour on 09/13/2018 between 02:55 PM and 03:24 PM with the Maintenance Director (MD) revealed the following: room [ROOM NUMBER]B had a large hole in the wall behind the bed room [ROOM NUMBER] had gouges in the wall behind the bed room [ROOM NUMBER]A had gouges on exterior bathroom door and vent in bathroom was dirty room [ROOM NUMBER]B had paint chipped wall behind the toilet and no threshold room [ROOM NUMBER]B vent in bathroom was dirty with lint room [ROOM NUMBER]A vent in bathroom was dirty room [ROOM NUMBER]B vent in bathroom was dirty room [ROOM NUMBER]B vent in bathroom was dirty Large chunks of concrete missing from the edge of the side walk Large holes in the parking lot Interview with the MD on 09/13/2018 at 03:24 PM confirmed the areas of concern had not been identified prior to environmental tour and needed to be repaired.",2020-09-01
110,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-09-23,609,D,1,0,IVTR11,"> LICENSURE REFERENCE NUMBER 175 NACC 12-006.02(8) Based on record review and interviews the facility staff failed to report an allegation of abuse with 2 hours for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 139. The findings are: Review of the only witness statement signed by the Life Enrichment Director and dated (MONTH) 29, 2019 revealed at approximately 1615 PM the Life Enrichment Director entered the memory support area and saw Resident 1 attempting to put a female residents hand down the front of Resident 1's pants. No contact was made due to Life Enrichment Director intervening and separating the residents. Review of the facility reported investigations revealed no evidence the observed incident was reported to the required state agency Interview with the Life Enrichment Director conducted on 09/23/2019 at 01:30 PM revealed the Life Enrichment Director was assisting residents back to the Memory support area and saw Resident 1 attempt to put a female residents hand down the front of Resident 1's pants. Life Enrichment Director separated the residents and no contact was made. She reported the incident to the Director of Nursing. Interview with the Director of Nursing on 09/23/2019 at 03:09PM confirmed the incident had not been reported to the required State Agency.",2020-09-01
111,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,584,E,0,1,WIY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A(1) Based on observation and interview; the facility failed to ensure that residents dining experience was homelike as evidenced by meals served on trays to the 12 Residents who eat their meals in the Memory Unit Dining Room and failed to ensure the environment was maintained in a clean, safe and comfortable manner. The facility staff identified a census of 134. The findings are: [NAME] Dining An observation on 12/04/19 at 08:07 AM of residents eating in the dining room on the Memory Unit revealed residents were served their breakfast plates on serving trays. An observation on 12/04/19 at 12:16 PM of residents eating in the dining room on the Memory Unit revealed residents were served their lunch plates on serving trays and the plates were not removed from the trays. An observation on 12/05/19 at 07:50 AM of residents eating in the dining room on the Memory Unit revealed breakfast plates were left on serving trays. An interview conducted on 12/05/19 at 07:55 AM with Certified Medication Aide K revealed there is no reason for leaving the plates on the trays and confirmed that it was not homelike. An interview conducted on 12/05/19 at 08:00 AM with the Director of Nursing confirmed there was no reason for the plates being left on the serving trays and that it was not homelike. B. On 12/10/19 between 7:47 AM and 8:50 AM a tour of the facility with the Maintenance Man and the Infection Control Nurse revealed the following infomation: -The wheel chair by room [ROOM NUMBER] was scuffed on the arms and had food debris on the wheelchair. -Near room [ROOM NUMBER] a wheelchair was scuffed and had food debris on it. -The resident lifts near 509 were covered in debris and rust. -The lift near the Physicial therapy office was dirty and had chipped paint, - A wheel chair near room [ROOM NUMBER] was visibly soiled. - A lift near room [ROOM NUMBER] was visibly soiled with debris and had chipped paint. - Walls are scuffed near nurses station near room [ROOM NUMBER], the wall was scuffed near room [ROOM NUMBER], The lifts are visibly soiled with human skin cells, food debris and possibly rust and had chipped paint near room [ROOM NUMBER]. - A wheel chair was soiled with debris near room [ROOM NUMBER] and the lift near room [ROOM NUMBER] has food debris and had chipped paint. On 12/10/19 between 7:47 AM and 8:50 AM during the environmental tour the Maintenance Man and Infection control nurse confirmed the findings and both agreed that the items required repair. Finding Are: C. Environment 12/04/19 room [ROOM NUMBER] : 10:AM Water temp in bathroom sink, 129.5F Rechecked 12/5/19 at 8:45AM 129.5F Rechecked with Maintenance Mg at 9:45AM 130.2F Maintenance Mg agreed too High. Will decrease temperature and Rechecked at 2:00PM 117.5F 12/4/19 room [ROOM NUMBER] : Water temp in bathroom sink 125.8 F. Rechecked 12/5/19 at 9:45 AM 129.8F Rechecked at 2PM 116.5F 12/5/19 room [ROOM NUMBER] 8:00AM Water temp. 129.5F Rechecked 12/5/19 at 9:45 AM 129.9F Rechecked at 2PM 116.5F 12/5/19 2:30PM Interview with Maintenance Manager confirmed that the water temperature are checked daily in each hall and bath house at least 5 rooms each. Reviewing the month of (MONTH) and (MONTH) does not show any high temperatures . 12/09/19 1:20 PM Observation on 12/9/19 at 1:20PM with ADM( facility administrator ) and Housekeeping Lead, revealed the following environmental concerns in resident rooms and facility space. room [ROOM NUMBER] room [ROOM NUMBER] both rooms have dirty walls ,floors sticky, room [ROOM NUMBER] the floor tile is tore at door entrance room [ROOM NUMBER] Room smells, the toilet has a toilet seat that doesn't fit Resident complains that is hurts to set on. room [ROOM NUMBER] Bathroom dirty, floors sticky room [ROOM NUMBER] Carpet in Room by window is stained with liquid from tube feeding. room [ROOM NUMBER] No drain over floor drain, in shower in bathroom room [ROOM NUMBER] Bed A wall over bed is stained with something red? Bed B holes in wall behind bed. room [ROOM NUMBER] Holes in wall behind door. The bathroom for visitors near station 2 , walls are dirty and edge above floor trim full of dust. room [ROOM NUMBER] Drywall is missing from the ceiling over the window. Window blind does not function Interview on 12/9/19 at 1:20PM with the ADM and Housekeeping Lead confirmed the observation and that those things needed to be corrected and addressed.",2020-09-01
112,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,656,D,0,1,WIY511,"Licensure Reference Number 175 NAC 12-006.09C Based on interview and record review, the facility failed to notify the physician of abnormal blood pressure readings for 1 (Resident 23) of 5 residents reviewed. The facility had a census of 134. The findings are: A review of Resident 23's (MONTH) and (MONTH) 2019 Medication Administration Records revealed the following high blood pressure readings: 161/117, 156/99, 170/92, 160/91, 156/96, 173/82, 166/104, 166/104, 166/104, 174/104, 178/92, 156/93, 186/90. A review of Resident 23's Progress Notes revealed no documentation Resident 23's physician was updated regarding high blood pressure readings. A review of Resident 23's Comprehensive Care Plan (a document outlining how to care for a resident) dated 8/6/2019 revealed an intervention to notify physician of any abnormal vital sign (VS) readings. In an interview on 12/11/19 at 8:33 AM, the Director of Nursing confirmed Resident 23's physician was not notified of any high blood pressure readings.",2020-09-01
113,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,676,D,0,1,WIY511,"Licensure Reference Number 175 NAC 12-006.09D1 Based on interview and record review, the facility failed to provide restorative services for 1 (Resident 56) of 27 sampled residents. The facility had a census of 134. The findings are: A review of a discharge summary from Physical Therapy for Resident 56 dated 11/29/19 revealed a discharge recommendation of Restorative Nursing/Maintenance Program. A review of a document titled Therapy Communication Restorative Nursing Program revealed instructions for Resident 56's Restorative Program were written by physical therapy on 11/30/19. A review of the Facility Assessment updated on 7/20/19 revealed a staffing plan of two restorative nurse aides on day shift, 7 days a week. In an interview on 12/04/19 at 9:52 AM, Resident 56 reported being told Resident 56 would be receiving restorative services, but had not started yet. In an interview on 12/10/19 at 11:49 AM, Restorative Aide (RA)-H reported Resident 56 hadn't started restorative services yet. RA-H reported the reason restorative services were not getting done with Resident 56 was because RA-H gets moved to working the floor when there is a CNA (Certified Nursing Assistant) call-in. RA-H stated that the goal was to do restorative services with Resident 56 three times a week, but RA-H was only working as a Restorative Aide approximately one day a week due to the facility being short-staffed. RA-H reported making an appointment to start restorative services with Resident 56 the following day (12/11/19) at 10:00 AM. In an interview on 12/10/19 at 11:55 AM, Resident 56 reported still not receiving restorative services, but Restorative Aide H had scheduled an appointment for restorative services the following day (12/11/19) at 10:00 AM. In an interview on 12/11/19 at 11:03 AM, Resident 56 reported RA-H came to Resident 56's room that morning and informed Resident 56 that RA-H could not do restorative services with Resident 56 due to getting pulled to work on the floor. In an interview on 12/11/19 at 1:39 PM, RA-H confirmed RA-H was not working as a restorative aide today, but as a CNA, so had to cancel the restorative appointment RA-H made with Resident 56.",2020-09-01
114,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,686,D,0,1,WIY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on record review and interview the facility failed to document a weekly assessment of wounds on toes for 1(Resident 237) of 1 sampled resident. The facility staff identified a census of 134. The findings are: Record review of admission/readmission assessment dated [DATE] for Resident 237 revealed the following: Right Ankle eschar (dead tissue found in a full thickness wound), Right heel eschar, Right toes eschar, Sacrum pressure, and Right Lower Extremity. Review of the (MONTH) TAR and (MONTH) TAR for Resident 237 revealed no documentation of treatment to right toes eschar. Review of the weekly skin alteration form dated 8/31/19 for Resident 237 revealed no documentation of the wounds to the toes. Review of the weekly skin alateration form dated 9/7/19 for resident 237 revealed no documentation of any wounds. On 12/10/19 at 07:06 AM an interview was conducted with the DON (Director of Nursing) which confirmed that the resident was re-admitted to the facility on [DATE] with areas to her toes. The DON further confirmed that the resident did not return with orders to treat toes and there was no further documentation on the weekly skin alterations of the areas to the toes.",2020-09-01
115,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,695,D,0,1,WIY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6 Based on observation, interview, and record review, the facility failed to provide oxygen in accordance with physician orders [REDACTED]. The facility had a census of 134. The findings are: A review of Resident 36's physician's orders [REDACTED]. An observation on 12/10/19 at 10:48 AM revealed Resident 36 wearing a nasal cannula hooked to an oxygen concentrator delivering oxygen at 3.5 liters per minute. In an interview on 12/10/19 at 11:44 AM Registered Nurse (RN)-L confirmed Resident 36's oxygen was set at 3.5 liters per minute. RN-L checked Resident 36's oxygen order and confirmed the oxygen was supposed to be set at 2.5 liters per minute.",2020-09-01
116,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,725,E,0,1,WIY511,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on record review and interview; the facility failed to ensure sufficient staff were available for a restorative program. The facility staff identified 27 residents receiving restorative care. The findings are: Record review of the Facility Assessment updated on 7/20/19 revealed a staffing plan as follows: Licensed Nurses providing direct Care 12 (6 Days, 6 Nights) Nurse Aids (2 restorative, 2 bath aides day shifts 7 days a week) 35 (14Days, 12Evenings, 7Nights) Other nursing personel (Infection, Wound, 2 Assistant Director of Nursing, Director of Nursing. Review of daily staffing schedule as worked for 30 days revealed that 2 restorative aides were not scheduled daily. 1 restorative aide was scheduled 13 times in 30 days. On 12/11/19 at 11:22 AM an interview with ADON A/ Restorative Coordinator confirmed that if an aide is needed for transportation or there is a staffing crisis, the restorative aide is assigned were needed and that restorative care does not get completed when the restorative aide is re-assigned or not scheduled.",2020-09-01
117,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,757,D,0,1,WIY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to ensure vital signs were obtained in accordance with physician orders [REDACTED]. The facility had a census of 134. The findings are: A review of Resident 23's (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. A review of Resident 23's (MONTH) and (MONTH) 2019 MAR indicated [REDACTED] 11/3 (evening dose), 11/5 (evening dose), 11/7 (morning dose), 11/8 (morning and evening dose), 11/16 (evening dose), 11/17 (morning and evening dose), 11/18 (morning dose), 11/19 (evening dose), 11/21 (morning and evening dose), 11/30 (evening dose), 12/1 (evening dose), 12/3 (evening dose), 12/5 (morning and evening dose), 12/6 (morning and evening dose). In an interview on 12/11/19 at 7:50 AM, Registered Nurse G confirmed a blood pressure and pulse were not recorded as ordered by Resident 23's physician on the dates listed above.",2020-09-01
118,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,758,D,0,1,WIY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a stop date was obtained for a PRN (as needed) [MEDICAL CONDITION] medication for 1 (Resident 118) of 5 residents reviewed. The facility had a census of 134. The findings are: A review of Resident 118's (MONTH) and (MONTH) 2019 MAR (Medication Administration Record) revealed a PRN order for [MEDICATION NAME] (an anti-anxiety medication) with a start date of 10/3/19. There was no stop date listed on the order. A review of Resident 118's (MONTH) and (MONTH) 2019 MAR indicated [REDACTED]. A review of Resident 118's Electronic Health Record revealed no documentation from the prescriber of a rationale for continued use of PRN [MEDICATION NAME]. In an interview on 12/11/19 at 12:01 PM, the DON (Director of Nursing) confirmed no stop date was listed for the PRN [MEDICATION NAME] order for Resident 118 nor was there a documented rationale for continuation of the PRN [MEDICATION NAME] past 14 days in Resident 118's medical record prior to 12/11/19. The DON stated documentation for continued use was obtained from the prescriber on 12/11/19.",2020-09-01
119,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,759,D,0,1,WIY511,"**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 ensure a medication error rate of less than 5%. The medication error rate was 8%. There were 2 medication errors out of 25 medications observed. This practice affected 2 (Residents 37 and 54) of 13 residents observed receiving medications. The facility had a census of 134. The findings are: [NAME] A review of Resident 54's (MONTH) 2019 MAR (Medication Administration Record) revealed an order for [REDACTED]. An observation on 12/11/19 at 9:36 AM of medication administration by Licensed Practical Nurse (LPN)-J to Resident 54 revealed LPN-J pouring [MEDICATION NAME] Liquid into a medication cup while holding the cup in the air at eye level. Further observation on 12/11/19 at 9:38 AM revealed an amount over 15mL (approximately 17mL) of [MEDICATION NAME] Liquid had been poured into the medication cup for Resident 54. An observation and interview on 12/11/19 at 9:38 AM with LPN-J confirmed too much [MEDICATION NAME] Liquid had been poured into the medication cup for Resident 54. B. A review of Resident 37's (MONTH) 2019 MAR indicated [REDACTED]. Further instruction on the order indicated to, use with toothbrush during oral cares. An observation on 12/11/19 at 9:47 AM of medication administration by LPN-J to Resident 37 revealed LPN-J instructed Resident 37 to swish with the [MEDICATION NAME] and handed it to Resident 37. Resident 37 put [MEDICATION NAME] in mouth and then swallowed it. In an interview on 12/11/19 at 3:00 PM, the Director of Nursing confirmed the [MEDICATION NAME] Solution should have been applied to Resident 37's toothbrush and that LPN-J made an error.",2020-09-01
120,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,761,D,0,1,WIY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12E3 & 12-006.12E7 Based on observation, interview, and record review, the facility failed to ensure medications were stored in the original pharmacy containers for 3 (Residents 79, 116, and 385) of 3 sampled residents and failed to ensure insulin pens were dated when opened for 4 (Residents 14, 69, 113, and 131) of 4 sampled residents. The facility had a census of 134. The findings are: [NAME] An observation on 12/11/19 at 9:17 AM revealed Licensed Practical Nurse (LPN)-I administering medications to Resident 385 from the top drawer of the medication cart that were already in a medication cup. An observation on 12/11/19 at 9:19 AM of the 100 Hall medication cart revealed 2 medication cups of medications in the top drawer of the medication cart for Residents 79 and 116. In an interview on 12/11/19 at 11:09 AM, Registered Nurse (RN)-G, confirmed medications should be prepared just prior to administration and staff should not be removing medications from original containers ahead of time. A review of an udated facility policy titled, Storage of Medication, revealed the following: -The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia. Medications are kept in these containers in a controlled environment. B. An observation on 12/11/19 at 1:41 PM with RN-F of 400 Hall medication cart revealed a [MEDICATION NAME] Pen with no open date belonging to Resident 14, a Humalog Insulin Pen with no open date belonging to Resident 131, and a Tresiba Insulin Pen win no open date belonging to Resident 69. RN-F confirmed the insulin pens had been used and did not have an open date. C. On 12/11/19 at 01:47 PM an observation of Medication Cart 1 with the DON (Director of Nursing) revealed a [MEDICATION NAME] Insulin Pen belonging to Resident 113 had no open date. The DON confirmed the pen was opened and had been used and there was no open date.",2020-09-01
121,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,812,F,0,1,WIY511,"Liscensure Reference number 12- C Based on observation and interview the faility failed to ensure that a thermometer was in place in the refrigerator and failed to ensure one staff member had adequate coverage of facilal hair. This had the potential to affect 133 residents that eat food in the facility . The facility census was 134 Findings are: Kitchen 12/04/19 07:04 AM Observation with Assistant Dietician manager B . One,Refrigerator in kitchen did not have a thermometer in it to determine the temperatures. all other Refrigerators did have thermometers. temps were at 41 F. Staff member B confirmed that the refrigerator did not have a thermometer inside to check temperature. Staff member B did have facial hair that was exposed, it was confirmed that he should have facial hair covered while working in the kitchen 12/5/19 Interview with Dietician : Dietian is in building 2 to 3 times per week. She confirmed that Staff member B needs to have facial hair covered and that themometer needs to be in place to check temperatures daily.",2020-09-01
122,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2019-12-11,908,F,0,1,WIY511,"Licensure Reference Number 175 NAC 12_006.18B Based on observation and interview, the facility failed to ensure that equipment was serviceable. The staff identified a census of 134. Findings are: An observation of the facility boiler room on 12/10/19 between 7:47 AM and 8:50 AM revealed a pool of water next to the boiler. An interview on 12/10/19 between 7:47 AM and 8:50 AM with the Maintenance Director confirmed that the boiler was not operational.",2020-09-01
123,AZRIA HEALTH MONTCLAIR,285054,2525 SOUTH 135TH AVENUE,OMAHA,NE,68144,2017-12-28,609,D,1,0,S8MH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.02 (8) Based on record reviews and interviews, the facility failed to report allegations of abuse for 1 resident (Resident 2) of 4 residents sampled. The facility staff identified the census at 129. The findings are: An interview conducted on 12-28-17 at 9:08 AM with Licensed Practical Nurse A revealed that Resident 2 was struck by Resident 4 in the head a couple months ago. A review of Resident 2's Admission Record dated 12-28-17 revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Admission Record dated 12-28-16 revealed that Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 2's progress note dated 10-18-17 revealed that Resident 2 was hit in the head by Resident 4. The family, doctor, and administrator were notified of the altercation. An interview conducted on 12-28-17 at 12:41 PM with the Director of Nursing (DON) confirmed that Resident 2 was hit by Resident 4 on 10-18-17 and that an investigation was completed regarding the incident, but the incident was not called to the state reporting agency because the facility did not believe it was abuse because Resident 4 was confused and had not hit anyone before. An interview conducted on 12-28-17 at 1:05 PM with the DON confirmed that Resident 4 did not accidentally hit Resident 2. The DON confirmed that Resident 4 did willfully strike Resident 2. The facility staff moved Resident 4 to another room in order to keep Resident 2 safe. A review of the facility's Abuse and Neglect Policy and Procedure dated 12-6-16 revealed the following Definitions of Abuse, Neglect and Abuse Coordinator: Abuse: Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Types of Abuse and Examples: Physical: Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employers, family members, guardian and other visitors. If abuse/neglect is suspected, the facility will: 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety. Reporting/Response: All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received.",2020-09-01
124,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2018-03-20,880,E,0,1,9P1R11,"Licensure Reference Number 12-006.17D Based on observation, interviews, and record review; the facility failed to ensure that staff washed their hands according to facility policy to prevent cross contamination. This had the potential to affect 7 residents (Residents; 9, 19, 5, 18, 20, 1, and 228) on the 200 hall. Findings are: On 03/14/18 at 2:19 PM an observation of NA (Nurse Aide) A, who was assigned to the 200 hall, revealed NA A was completing pericare (a procedure that cleans the resident's perineal area after going to the bathroom) on Resident 5. Following the care, NA A removed gloves and washed and dried hands for 8 seconds. NA A turned the faucet off with bare hands. On 3/19/18 at 1:00 PM observation of NA B, who was assigned to the 200 hall, doing catheter care revealed NA B donned gloves and wet 4 washcloths. NA B placed the washcloths at the bedside and opened up 2 plastic bags for soiled items. NA B transferred Resident 9 into bed and did pericare. NA B opened the bedside drawer and reached in and pulled out an ointment for Resident 9's buttocks, with gloves remaining on. NA B applied the ointment to the resident and placed the ointment back in the drawer. NA B then removed gloves, picked up the soiled linens and trash bag and went out of the room to the bath house. NA B put the code in the door touching the keypad and opened the door and placed the soiled linens and trash into the barrels, lifting the lid of each container. NA B then went across the hall to the clean linen supply, opened the door and got a pad to place under Resident 9. NA B returned to the room, then donned gloves, without washing hands and placed the pad under Resident 9. NA B removed the soiled pad, placed it in a plastic bag, removed gloves and took the soiled linen to the bath house, put the code in the door while touching the keypad and placed the soiled linen in the linen barrel. NA B then washed hands for 10 seconds, dried hands and turned the faucet off with a paper towel. On 3/19/18 at 1:30 PM an interview with NA B confirmed that NA B should have washed hands each time the gloves were removed and that hand washing should be completed for 25 seconds. NA B confirmed hands were not washed after removing gloves and hand washing that was preformed was not 25 seconds in length. On 3/19/18 at 1:45pm an interview with the DON (Director of Nursing) confirmed that hands should be washed after removing gloves and that hand washing should take at least 20 seconds. On 3/19/18 a record review of the policy/procedure-nursing clinical, hand washing dated 5/2007, revealed that staff were to wash their hands before having direct contact with residents, when hands were visibly soiled and after contact with a resident's intact skin, body fluids or excretions, mucous membranes, after contact with inanimate objects in the immediate vicinity of the resident, and after removing gloves. The procedure revealed that staff was to wet hands and apply soap to hands, rub hands in a circular motion for not less than 15 seconds, rub fingers between fingers for fifteen seconds, rinse hands with warm water. Dry hands with paper towel and turn off faucet with paper towel.",2020-09-01
125,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,558,D,0,1,SIVO11,"License Reference Number 175 NAC 12.007.03I (7) Based on observation, record review and interview, the facility failed to ensure residents had call light in reach. This had the potential to affect 1 (Resident 3) from a sample size of 33. The facility census was 37. Findings Are: [NAME] Observation on 07/01/19 at 4:48 PM revealed Resident 3 was lying on right side with pillows behind back. The bed was moved away from the wall/ window. The call light was dangling next to the resident's bed not in reach. An observation on 07/02/19 at 6:22AM revealed Resident 3 lying in bed on back. The call light was dangling from the resident's bedside rail, not in reach of the resident. A observation on 07/02/19 at 9:18 [NAME]M revealed Resident 3 in wheelchair. The call light was not with in resident's reach. The call light was on bed. The resident was in wheelchair in the middle of room. A observation on 07/02/19 at 1:19 P.M revealed resident lying in bed on right side with pillows behind back on left side. The call light was wrapped around bedrail on left side of bed, not in reach of resident. Record Review of Care Plan (A document that explains how to care for a resident) dated 06/25/19 identified that Resident 3 had the potential for pressure ulcer development and falls r/t (related to) Immobility. Interventions included: Call light within reach and encourage to use it to call for assistance as needed. A interview on 07/03/19 at 10:00[NAME]M with the DON (Director of Nursing) confirmed that call lights need to be in residents reach when residents are in their rooms.",2020-09-01
126,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,580,D,0,1,SIVO11,"License Reference Number 175 NAC 12-006.04C3a(6) Based on observation, interview and record review, the facility failed to notify Resident 3's family of change in resident's skin condition. This had the potential to affect 1 (Resident 3) of 4 residents reviewed for skin condition. The facility census was 37. Findings Are: A observation on 07/01/19 at 10:00 AM revealed Resident 3 was in wheelchair and had a healed skin tear to the left hand. A phone Interview on 07/01/19 at 11:26 AM with Resident 3's family revealed they had not been notified of skin tears and were only informed by aides when they came to visit. Record Review of Progress Note dated 5/25/2019 at 09:54 AM revealed Resident 3 was being bathed, right elbow was bumped against tub. Skin tear measured 0. 5 cm. length and jagged. Edges approximated and secured with steri strips (sterile pieces of tape used to close wounds) x 6. There was no documentation of notification of the family. Record Review of Progress Note dated 2/28/2019 at 16:24 revealed a skin tear to right elbow area with steri strips; probably caused from slumping in wheel chair and scraped on arm of chair. There was no documentation of notification of the family. A interview on 07/02/19 at 3:30 P.M with MDS nurse (A MDS nurse is a nurse that is in-charge with the delivery of care for patients that are confined in long-term care medical centers and facilities) confirmed if any incidents occured a resident's family member was to be contacted and documented in Nursing Progress Notes. A interview on 07/03/19 at 7:54 AM with the Director of Nursing (DON) confirmed any change in Residents condition was to be documented in progress notes and family notified.",2020-09-01
127,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,583,F,0,1,SIVO11,"Licensure Reference Number 175 NAC 12,-006.16C2, 12-006.05(21) Based on observation, interview, and record review, the facility failed to A)ensure that EMR (Electronic Medical Records) were not visible to non-staff members on the medication cart in the halls of the facility. This had the potential to affect all current and former residents in the facility. B) The facility also failed to provide privacy for 1 resident (Resident 23) of 1 sampled resident, during the application of ointment. The facility census was 37. FINDINGS ARE: [NAME] An observation on 07/01/19 at 04:40 PM the medication EMR was open and accessible to the public. The name at the top of the computer was the DON (Director of Nurses) This Medication cart was for the Residents on the South hall. An interview on 07/01/19 at 04:45PM with the DON confirmed; the electronic medical records should not have been accessible to the public. An Observation on 07/02/19 at 10:08 AM of the medication EMR was open and accessible to the public. The name at the top of the computer was the DON (Director of Nurses) An observation on 07/02/19 at 10:11with the Administrator and the DON of the open medication EMR for the North Medication Cart. An interview on 07/02/19 at 10:14 AM with the DON confirmed they were aware the screen should be shut down when not in use. The DON reported they had closed the program when they left the computer. Record review of the facility Access Control Policy dated 1/2/19 revealed; access to information and computing resources is granted in a manner that balances restrictions designed to prevent unauthorized access against the need to provide access to information for performance of job responsibilities. Access will be limited to authorized persons whose job responsibilities require it. B. An observation on 07/02/19 at 07:17 AM of the DON (Director of Nurses) with Resident 23 in the hallway by the Nurses station. The DON asked what Resident 23's pain level was and Resident 23 responded 5. The DON pulled Resident 23's right pant leg up above the knee and applied a cream to the Resident's leg. An interview 07/03/19 10:06 AM with the Administrator confirmed; the staff should not apply ointment to residents while they are in a common area. Record review of the Care Plan for Resident 23 revealed; there was no personal preference for ointment application to be done other than in the resident room. Record review of Resident 23's TAR (Treatment Administration Record) revealed; at 7:17 AM Biofreeze Gel 4% to knees topically every 4 hours as needed was applied. Record review of Resident 23's Progress note revealed; on 7/2/2019 at 07:17 Medication Administration Note Text: Biofreeze Gel 4 % Apply to knees topically every 4 hours as needed for pain was applied to both knees and lower back for achiness rated pain 5 out of 10 . Resident was also getting therapy at this time for knee discomfort as well. Record review of Policy for Dignity and Respect revealed the Resident shall be examined and treated in a manner that maintains privacy of their body. Privacy of the body shall be maintained during toileting bathing and other activities of personal hygiene.",2020-09-01
128,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,644,D,0,1,SIVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview; the facility failed to ensure that a required Preadmission Screening and Resident Review (PASRR) (an evaluation used to identify the presence of mental illness) level 2 evaluation was requested for a new medical [DIAGNOSES REDACTED]. This had the potential for the facility to fail to identify specialized services needed by the resident. The facility census was 37. Findings are: Record review of Resident 27's Nebraska Level 1 Form Preadmission Screening and Resident Review (PASRR) dated 5/12/17 revealed no serious mental illness, mental disorders, or [DIAGNOSES REDACTED]. Record review of Resident 27's Consultant Pharmacist MD Communication (a form used to provide communication from the pharmacist to the medical doctor) dated 9/7/18 revealed a new [DIAGNOSES REDACTED]. Record review of Resident 27's MDS (a mandatory comprehensive assessment tool used for care planning) dated 6/4/19 revealed that Resident 27 has not been evaluated by level 2 PASSR and not determined to have a serious mental illness and/or mental [MEDICAL CONDITION] or another related condition. 07/03/19 11:02 AM Interview with the DON confirmed that a request for a PASSR level 2 evaluation should occur for a new [DIAGNOSES REDACTED].",2020-09-01
129,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,657,D,0,1,SIVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09C1c Based on record review and interview the facility failed to review and revise the comprehensive care plan according to the root cause for falls for 1 Resident (Resident 10) of 12 sampled residents. The facility census was 37. Findings are: The facility failed to review and revise and implement interventions to prevent further falls for 1 Resident (Resident 13) Record review of Fall Investigation dated 4/8/19 Predisposing physiological factors were; Incontinence confused, gait imbalance, and impaired memory. The Predisposing Situation Factors were; Exit seeking, wanderer, ambulation without assist, and using a wheeled walker. Record review of Verification of Investigation of Alleged Violations Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident Property document dated 4/8/19 revealed; the cause was gait imbalance and cognitive ability to remember to call for help or push call light button. No corrective action was documented on the form. Record review of Care Plan for falls dated 4/8/19 revealed; an intervention dated 4/10/19 Physician reviewing medication due to increased agitation, and aggression. Record review of Fall Investigation form dated 4/19/19- Predisposing physiological factors were; confused and impaired memory. The Predisposing Situation Factors were; wanderer, ambulation without assist, and recent room change. Record review of Verification of Investigation of Alleged Violations Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident Property document dated 4/19/19 revealed; there was no documentation of the conclusion of the fall and the corrective action to prevent future accidents. Record review of the care planned intervention for the fall dated 4/19/19 revealed; no care planned intervention to prevent further falls. Record review of Fall Investigation dated 5/29/19 revealed; Predisposing physiological factors were; confused. The Predisposing Situation Factors were; ambulation without assist. Record review of Verification of Investigation of Alleged Violations Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident Property document dated 5/30/19 revealed; conclusion regarding cause of injury was that the resident was confused, unclamped the [MEDICAL CONDITION] bag or bumped causing a mess on the floor. Resident was concerned of no one sitting down but not able to relate why was on floor. The corrective action was to unclutter room, and check often. Record review of Fall Care Plan for the date of revealed; no care planned intervention to prevent further falls. Record review of Fall investigation dated 7/1/19 Predisposing physiological factors were; Incontinence confused, gait imbalance, and impaired memory. The Predisposing Situation Factors were; Exit seeking, wanderer, and ambulation without assist. Record review of Verification of Investigation of Alleged Violations Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident Property document not dated but attached to the fall report revealed; the document had not been completed. No documentation noted. Record Review of Care Plan dated 7/1/19 revealed; no care planned intervention to prevent further falls. An interview on 07/03/19 at 11:21 AM with the Administrator who confirmed that the interventions would be updated on the care plan post the falls. The Administrator reported that the investigation paper work on falls needed to be improved.",2020-09-01
130,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,756,D,0,1,SIVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12B Based on Record review and interview, the facility Consultant Pharmacist failed to identify duplicate antidepressant medication use as an irregularity and contact the Physician for a rationale for the continued use of duplicate antidepressant medication for 1 (Resident 31) of 5 residents reviewed. The facility census was 37. Findings are: Record Review of a facility policy and procedure entitled [MEDICAL CONDITION] Drug Use revealed: - The definition of Excessive Dose means the total amount of any medication (including duplicate therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer's label, package insert, and accepted standards of practice for a resident's age and condition. - The definition of Duplicate Therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking. Procedure step 6 states that upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders [REDACTED]. a. [MEDICAL CONDITION] medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record; b. Not in excessive dosage Record review of Resident 31's Admission Face Sheet dated 6/28/19 revealed that Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 31's admission Physician order [REDACTED]. Record review of Resident 31's admission Medication Regimen Review dated 5/14/19 identified the use of Trazadone and [MEDICATION NAME] but did not identify duplicate orders for Therapeutically similar medications. Record review of Resident 31's monthly Medication Regimen review dated 6/8/19 did not identify duplicate antidepressant medications. Interview on 07/03/19 at 08:52 AM with the Consultant Pharmacist (CP) confirmed that Resident 31 used Trazadone for [MEDICAL CONDITION] and [MEDICATION NAME] for depression. The CP stated that they are the same pharmacological class of medications but were used for different indications. The CP confirmed that duplicate antidepressant use was an irregularity and they should have called the physician and gotten a written rationale for the duplicate use for the [MEDICATION NAME] and the Trazadone.",2020-09-01
131,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,758,D,0,1,SIVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview, the facility failed to obtain a 14 day stop date for a PRN (as needed) [MEDICAL CONDITION] ( medications used to treat behavioral conditions) medication for 2 residents (Resident 31 and 29) of 5 residents reviewed for unnecessary medications, failed to ensure duplicate antidepressant medication was not used (Resident 31) and failed to complete a sleep study to ensure that a Hypnotic medication was necessary for Resident 31. The facility census was 37. Findings are: [NAME] Record review of a policy / procedure entitled [MEDICAL CONDITION] Drug Use dated 08/2017 revealed the following: - The definition of Excessive Dose means the total amount of any medication (including duplicate therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer's label, package insert, and accepted standards of practice for a resident's age and condition. - The definition of Duplicate Therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking. Procedure step 6 states that upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders [REDACTED]. a. [MEDICAL CONDITION] medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record; b. Not in excessive dosage d. Monitoring for adverse consequences and effectiveness of medications are in place; e. PRN medications are within guidelines. Policy step 3 states PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. Except for PRN orders for anti-psychotic medications, if the attending physician or prescribing practitioner believes that is appropriate for the PRN [MEDICAL CONDITION] med order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. B. Record review of Resident 31's Admission Face Sheet dated 6/28/19 revealed that Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 31's admission Physician order [REDACTED]. The Physicians order for [MEDICATION NAME] not include a stop date. Record review of Resident 31's (MONTH) 2019 Medication Administration Record [REDACTED]. Resident 31 received a total of 15 doses of the [MEDICATION NAME] the required stop date. Record review of Resident 31's admission Medication Regimen Review dated 5/14/19 identified the use of Trazadone and [MEDICATION NAME] but did not identify duplicate orders for Therapeutically similar medications. It also identifed that the resident had an order for [REDACTED]. Record review of Resident 31's Electronic Medical Record revealed no sleep assessment had been completed to ensure [MEDICATION NAME] a necessary drug. Record review of Resident 31's monthly Medication Regimen review dated 6/8/19 did not identify duplicate antidepressant medications. Interview on 07/03/19 at 08:52 AM with the Consultant Pharmacist (CP) confirmed that Resident 31 used Trazadone for [MEDICAL CONDITION] and [MEDICATION NAME] for depression. The CP stated that they are the same pharmacological class of medications (antidepressants). Interview on 07/02/19 at 03:58 PM with the MDS Coordinator confirmed that no sleep assessment had been completed for Resident 31 to ensure [MEDICATION NAME] necessary to be used. The MDS Coordinator confirmed that Pharmacy had recommended this to be done. Interview on 07/02/19 at 04:03 PM with the MDS Coordinator confirmed that Resident 31'[MEDICATION NAME] ordered on admission and did not have a stop date within 14 days. The MDS Coordinator confirmed that it was used 14 times after the 14th day (5/28/19) as needed until it was changed to a routine medication on 6/19/19. Confirmed that it should have had a stop date within 14 days and that it did not. Interview on 07/03/19 at 07:30 AM with the Director of Nursing confirmed that the pharmacy had recommended a sleep assessment for Resident 31 and that this had not been completed. C. Record review of Resident 29's Medication Review Report dated 6/19/19 revealed that Resident 29 was prescribed [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 0.25 milligrams every 4 hours as needed for anxiety with a start date of 6/12/19. Record review of Resident 29's Order Summary Report dated 7/2/19 revealed that [MEDICATION NAME] 0.25 milligrams every 4 hours as needed was ordered on [DATE] with a start date of 6/12/19. The order contained no stop date. Record review of Resident 29's (MONTH) 2019 Medication Administration Record [REDACTED]. Record review of Resident 29's (MONTH) 2019 Medication Administration Record [REDACTED]. This was 5 days past the required 14 day stop date. Interview with the DON on 7/3/19 confirmed that PRN (as needed) [MEDICAL CONDITION] medications should have a 14 day stop date.",2020-09-01
132,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,759,D,0,1,SIVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number 175 NAC 12.006.10D Based on observation, record review and interviews, the facility failed to maintain a medication administration error rate of 5% or less for 2 (Residents 4, 29) of 8 residents observed. The medication administration error rate was 7.69%. The facility census was 37. Findings are: An Observation on 07/02/19 at 4:22PM revealed LPN-A administering [MEDICATION NAME] (An antibiotic) HCL 100mg tablet to Resident 29 without a meal. Record Review of Physician Orders dated 05/24/19 confirms [MEDICATION NAME] HCI tablet 100mg, Give 1 tablets by mouth two times a day for UTI give with meals. Interview on 07/03/19 at 2:30PM with DON confirmed all Physician Orders are to be followed as written. B. Record review of the facility policy/procedure titled Six Rights of Medication Administration dated 05/2017 revealed step 3 that states medications are checked against the order before they are given. Record review of the facility policy/procedure titled Administration of Drugs dated 05/2007 revealed: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Record review of Resident 4's Order Summary Report of active orders dated 7/3/19 revealed an order for [REDACTED]. Observation of medication administration on 7/3/19 at 6:51 AM revealed that Registered Nurse (RN) C crushed the [MEDICATION NAME] XL tablet prior to administration for Resident 4 even though the order specified that the [MEDICATION NAME] XL was not to be crushed. Interview with the DON on 7/3/19 at 10:56 AM confirmed that medications labeled as Do Not Crush are not to be crushed.",2020-09-01
133,FALLS CITY NURSING AND REHABILITATION CENTER,285055,1720 BURTON DRIVE,FALLS CITY,NE,68355,2019-07-04,880,E,0,1,SIVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number 175 NAC 12-006.17B and 12-006.17D Based on observation, record review and interview the facility failed to disinfect the glucometer after patient use to prevent the potential for cross contamination, this affected 2 residents Resident 28 and 29 of 7 residents that received ACCU checks (the use of a glucometer to test a patient's blood sugar levels), failed ensure hand hygiene was performed prior to catheter cares for 1 resident (Resident 29) of 2 residents with catheters and failed to ensure hand hygiene was performed prior to medication administration for 1 resident (Resident 4) of 8 resident observed to prevent the potential for cross contamination. The facility census was 37. Findings Are: [NAME] An observation on 07/02/19 at 4:30 P.M revealed LPN- B placed a glucometer (a medical device used to determine blood sugar levels) on the medication cart used disposable germicidal surface wiped glucometer for 6 seconds and left on top of medication cart, LPN -B was wearing gloves during this time. An observation 0n 07/02/19 at 5:00 PM revealed LPN- B placed a glucometer on the medication cart, did not apply gloves, and removed a germicidal surface wipe from container. Glucometer was wiped off for 3 seconds and placed on top of wipe lying on medication cart. Record Review of glucometer cleaning and disinfecting policy that was not dated revealed the following steps: Cleaning Step 1: Wear appropriate protective gear such as disposable gloves. Step 2: Open the towelette container and pull out 1 towelette and close the lid. Step 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette to clean blood and other body fluids. Step 4: Dispose of the used towelette in a trash bin. - Note No actual drying of the meter is necessary before starting the disinfecting procedure. Disinfecting (the meter should be cleaned prior to disinfection) Step 5: Open the towelette container and pull out 1 towelette and close the lid. Step 6: Wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood-borne pathogens. Step 7 Dispose of the used towelette in a trash bin. Step 8: Allow exterior to remain wet for the appropriate contact time and then wipe the meter using a dry cloth. Step 9: After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. McKesson Disposable Germicidal Surface Wipes Directions for use: apply this product by wiping to thoroughly wet hard, non-pores surfaces. Contact time: allow hard, non-porous surface to remain wet for 2 minutes to Kill HIV-1 (Human immunodeficiency virus), HBV ([MEDICAL CONDITION] virus) and HCV ([MEDICAL CONDITION] virus). B. Review of the facility policy titled Catheter Care, Foley (a flexible tube inserted into the bladder to drain urine) dated 05/2007 revealed the following steps: 6. Wash hands. 7. Soap and water cloths seperately in one bag, another bag for dirty. 8. Put gloves on. 9. Using the soapy cloth, clean the catheter insertion in a downward motion, repeat with just wet cloth. Use each cloth for one cleansing motion. Clean the length of the Foley catheter (from resident toward bag). 12. Tie trash bag. 13. Remove gloves and wash hands. Review of the Order Summary Report active orders for Resident 29 dated 7/2/219 revealed an order for [REDACTED]. Review of the Order Summary Report active orders for Resident 29 on 7/2/19 revealed an order to perform Foley catheter cares each shift to prevent infection. Observation of catheter care for Resident 29 on 7/3/19 at 8:10 AM revealed that Certified Nurse Assistant (CNA) D entered Resident 29's room and put on gloves without performing hand washing. CNA D removed the socks from Resident 29's feet and dropped the socks into a laundry basket in the closet. CNA D removed clean socks from the dresser and placed them on Resident 29's feet. CNA D placed the Foley bag (a container connected to the Foley catheter to collect urine) through the leg of the resident pants and sat the bag at Resident 29's feet. CNA D opened resident dresser drawers looking for wipes. CNA D obtained a wash cloth and turned on the sink faucet and wet the cloth. CNA D wiped Resident 29's groin area with the cloth. CNA D turned the wash cloth over and wiped Resident 29's urethral meatus (the opening from the body where urine exits) and then wiped 4 inches per visual measurement of the Foley tubing from the meatus downward. CNA D repositioned Resident 29 onto the left side and removed the brief from under the resident left buttock. CNA D used the same wash cloth and wiped Resident 29's anal area. CNA D obtained a trash bag and placed the dirty wash cloth in the trash bag and tied it shut. CNA D placed a new brief under the resident and secured it. CNA D pulled Resident 29's pants up to the resident thighs and then put shoes on Resident 29's feet. CNA D helped Resident 29 to sit at the edge of the bed. CNA D unlocked the wheel chair brakes and moved the wheel chair to the resident and locked the brakes. CNA D assisted Resident 29 to stand. CNA D pulled up the resident pants to the resident waist. Resident 29 sat down in the wheelchair. CNA D unlocked the wheelchair brakes and placed the Foley bag underneath the wheelchair. CNA D placed the foot pedals on the wheelchair. CNA D turned the sink faucet water on and wet a new wash cloth and handed it to the resident. Resident 29 wiped the resident face and hands with the wash cloth. CNA D obtained Resident 29's eyeglasses and washed the eyeglasses with water from the sink faucet and dried them with paper towels. CNA D assisted the resident with putting the eyeglasses on. CNA D turned on the water from the sink faucet and wet the resident's comb and then combed Resident 29's hair. CNA D removed the gloves and pushed the resident out of the room to the dining room in the wheelchair without washing hands after the glove removal. Interview with the DON on 7/3/19 at 10:55 AM confirmed that hand washing is to be performed prior to starting catheter cares. The DON also confirmed that gloves will be removed and hand washing performed when going from a dirty to clean site. C. Review of the facility policy/procedure titled Medication Administration- Oral dated 05/2007 revealed the following steps: 2. Administer drug to resident. 11. Wash hands. 12. Move on to next resident and repeat until all medications are given. Review of the facility procedure titled Eye Drops Administration Procedure dated (YEAR) revealed the following steps: 2. Wash hand per facility policy. 6. Use fore finger and thumb to pull down lower eyelid. 7. Place hand against patient's forehead to steady and instill the required number of drops inside the pouch by pulling down the lower eyelid. 8. Release eyelid. 13. Wash hands per facility policy. Review of the Order Summary Report active orders for Resident 4 dated 7/3/19 revealed an order for [REDACTED]. Observation on 7/3/19 at 6:46 AM revealed that Registered Nurse (RN) C performed alcohol based hand rub hand washing. RN C performed medication set up (arranging medications according to the instructions of the pharmacist and doctor) for Resident 4. RN C completed medication set up and knocked on Resident 4's door and got permission to enter Resident 4's room to perform medication administration. RN C gave Resident 4 the oral medications and Resident 4 swallowed them. RN C provided a Kleenex to Resident 4 and then pulled the bottle of [MEDICATION NAME] Solution 0.3 % (an antibiotic to treat infection) from RN C's pocket. RN C did not perform hand washing and did not put on gloves. RN C pulled Resident 4's right lower eyelid down and administered 1 drop of the [MEDICATION NAME] solution into the right eye. RN C then pulled Resident 4's left lower eyelid down and administered 1 drop [MEDICATION NAME] into the left eye. RN C left Resident 4's room and charted the medication administration for Resident 4. RN C did not perform hand washing. Observation on 7/3/19 at 7:02 AM revealed that RN C pushed the medication cart from outside Resident 4's room to the west end of the 200 hall of the facility and performed medication set up without performing hand washing. Observation on 7/3/19 at 7:29 AM revealed RN C in the hallway outside of room [ROOM NUMBER]. RN C did not perform hand washing and began medication set up for a resident. Interview with the DON on 7/3/19 at 10:56 AM confirmed that hand hygiene is to be performed prior to medication set up.",2020-09-01
134,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-04-11,689,D,1,0,XK2D11,"> Based on observations, record reviews and interview; the facility failed to ensure that residents identified at risk for elopement were unable to exit through the 1st floor kitchen from 1 LifeQuest for one sampled resident (Resident 2). The facility census was 146 with 3 sampled residents. Findings are: Observations were conducted of residents wearing Wanderguard (alarm device) revealed that the alarm would sound alerting the staff if they were close to an exit in the facility including the elevators. Interview with the Administrator on 4/11/19 at 3:25 PM confirmed that Resident 2 had exited the facility through the 1st floor kitchen from 1 LifeQuest. The 1st floor kitchen from 1 LifeQuest did not have a Wanderguard to alert staff if residents were seeking to leave the facility. The Administrator confirmed that the door did not have an alarm and was not secured in the event of a resident seeking to leave the facility. Resident 2 wore a Wanderguard and was at risk for potential elopement due to occasional wandering in the facility.",2020-09-01
135,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2018-06-28,584,E,0,1,QLOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18B3 Based on observation and interview, the facility failed to ensure vents were in working order for 3 resident rooms. (rooms [ROOM NUMBER]) and two of four service galley kitchens. (200 and 300 Life Quest Wings) This had the potential to affect 52 residents. Facility Census was 168. Findings are: Observation on 06/25/18 at 03:10 PM revealed vents in bathrooms in rooms [ROOM NUMBER] were not working. Environmental tour on 06/26/18 at 03:17 PM with the head of maintenance confirmed the vents in rooms [ROOM NUMBER] were not working. Observation on 06/25/18 at 02:10 PM revealed vents in galley kitchens on the 200 and 300 Life Quest Wings were rusty and had a gray matter inside of them. Interview on 06/26/18 03:49 PM with the Administrator confirmed that there was rust and gray matter in the vents in the kitchen galley on the 200 and 300 Life Quest Wings.",2020-09-01
136,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2018-06-28,690,D,0,1,QLOG11,"Licensure Reference Number 175 NAC 12.006.09D3(1) Based on observation, interview and record review; the facility failed to ensure catheter care was provided in a manner to prevent urinary tract infections for 1 resident (Resident 101) out of 1 sampled resident. Findings are: A telephone interview with Resident 101's family on 6/25/18 at 10:54 AM revealed Resident 101 had a catheter and does have occasional urinary tract infections. An observation of catheter care and transfer with the lift on 6/26/18 at 11:10 AM revealed NA (Nurses Aide) A and NA B transferring Resident 101 to the toilet. NA B removed the catheter bag from under the w/c and lifted the bag above Resident 101's bladder as NA B stood to attach the bag to the w/c. An observation of morning cares on 6/27/18 at 8:00 AM revealed NA B and NA C assisted Resident 101 with cares. As NA C dressed the lower half of the resident, NA C raised the catheter above the Resident 101's bladder as NA C placed the catheter bag through the pants leg. On 06/27/18 at 08:18 AM Interview with future DON (Director of Nursing) revealed that the future DON went and educated the staff concerning not to raise the catheters above the bladder level of residents. A record review on 6/27/18 of Policy and Procedure Manual dated 1/20/14 revealed Avoid raising the drainage bag above bladder level. This prevents reflux (backflow) of urine, which may contain bacteria.",2020-09-01
137,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2018-06-28,759,D,0,1,QLOG11,"Licensure Reference Number 175 NAC 12.006.10D Based on observation, record review, and interview; the facility failed to ensure medication error rate was below 5%. The facility had 2 medication errors out of 22 medication administration opportunities, which resulted in a 9% medication error rate. These errors had the potential to effect 2 residents, Residents 131 and 137. The facility census was 169. Findings are: An observation on 06/21/18 at 11:40 AM revealed a short acting insulin given to Resident 137 and lunch was served to Resident 137 at 12:17 PM. An observation on 06/25/18 at 11:25 AM revealed a short acting insulin given to Resident 131, and lunch was served to Resident 131 at 12:10 PM. An interview on 06/27/18 at 3:11 PM with the DON (Director of Nursing) confirmed that according to the pharmacy a short acting insulin should be given as per manufacturer's instructions. A review of the manufacturer's recommendations, dated (MONTH) (YEAR), revealed that a meal should be eaten within 5 to 10 minutes after taking the insulin.",2020-09-01
138,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2018-06-28,760,D,0,1,QLOG11,"Licensure Reference Number NAC 12.006.10D Based on observation, interview and record review, the facility failed to ensure residents who received a short acting insulin received nourishment within the manufacturers time frames in order to prevent a drop in the resident's blood glucose levels which was a potential for a significant medication administration error. This had the potential to affect 2 residents (Resident 137 and Resident 131). 22 medication administration opportunities were observed. The facility census was 169. Findings are: An observation on 06/21/18 at 11:40 AM revealed LPN D (Licensed Practical Nujrse) gave 10 Units of short acting insulin to Resident 137. Resident 137 received lunch at 12:17 PM. An observation on 06/25/18 at 11:25 AM revealed LPN D gave Resident 131 short acting insulin 6 Units, and lunch was served to Resident 131 at 12:10 PM. On 06/27/18 at 03:11 PM an interview with the DON (Director of Nursing) confirmed that according to the pharmacy insulin was to be given according to manufacturer's suggested timing. On 6/27/18 a record review of Tabitha on Spot Education Sheet dated 5/25/16 revealed LPN D was educated concerning insulin administration. A review of the manufacturer's recommendations, dated (MONTH) (YEAR), revealed that a meal should be eaten within 5 to 10 minutes after taking the insulin.",2020-09-01
139,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2018-06-28,812,E,0,1,QLOG11,"Licensure Reference Number 175 NAC 12.006.11D Based observation, interview, and record review, the facility failed to ensure food was served at temperatures in order to prevent potential foodborne illness. This failure had the potential to affect 49 Residents being served meals on 3 Life Quest. The facility census was 169. Findings are An observation on 6/25/18 at 12:10 PM, of food being served to residents residing on 3 Life Quest, revealed a Dietary Staff Member (DSM)-E assessing food temperatures. The hot items to be served included fish, diced potatoes, smothered pork chops, and soup. Pre-service temperatures were revealed the fish at 140 degrees Fahrenheit (F), and all of the other hot items were at 160 degrees F. A sample tray was requested to be dished up and served after the last room tray was delivered to residents. Continued observation revealed plates of food were dished up in a Galley area by Dietary Staff, and the Nursing Staff served the plates immediately to individual residents. An interview on 6/25/18 at 12:40 PM with the DSM indicated all of the residents on 3 Life Quest had been served. The DSM checked and confirmed the post service food temperatures were as follows: fish=108 degrees F, diced potatoes=110 degrees F, smothered pork chop=105 degrees F, and soup=130 degrees F. The food items on the requested sample tray, dished up at 12:40 PM, were noted to be slightly warm when tasted, but not hot. An interview on 6/25/18 at 12:50 PM with Chef-F confirmed the food temperatures were below the recommendations to prevent foodborne illness and revealed the steam table (device used to maintain hot food) had not been turned up all the way, and it needed to be in order to ensure foods were served within recommended temperatures.",2020-09-01
140,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2018-06-28,925,E,0,1,QLOG11,"Licensure Reference Number 175 NAC 12-006.18A(4) Based on observation and interview, the facility failed to ensure the light fixtures in 2 of 4 food service galleys were free from evidence of dead insects. This had the potential to affect 52 residents that were served meals on 200 Life Quest and 300 Life Quest Wings of the main facility. Facility Census was 168. Findings are: Observation on 06/21/18 at 03:11 PM revealed the galley kitchens on the 200 and 300 Life Quest Wings had dead insects in the lights in the ceiling. Observation on 06/25/18 at 02:11 PM revealed the galley kitchens on the 200 and 300 Life Quest Wings had dead insects in the lights in the ceiling. Interview on 06/26/18 at 10:12 AM with the Dietary Manager and the Aministrator confirmed that there were dead insects in the lights in the Gally Kitchens on the 200 and 300 Life Quest Wings.",2020-09-01
141,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2017-07-12,242,D,1,1,LXOF11,"> Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interview and record review, the facility failed to honor one resident's (Resident 253) preferences regarding schedule for awakening in the morning. The facility census was 177 and the sample size was 29. Findings are: Review of Resident 253's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 5/15/17 revealed Resident 253 required staff assistance with transferring, dressing and hygiene. Review of an undated Personal Preferences form revealed Resident 258 preferred to wake up between 8:30 and 10:30 AM. Interview with Resident 253's Family Member on 7/06/2017 at 10:13 AM revealed Resident 253 complained to the Family Member that staff got resident up too early. The Family Member reported Resident 253's usual routine was to get up around 9 am. Observation and Interview with Resident 253 on 07/11/2017 at 8:11 AM revealed Resident 253 was up and in a wheelchair and had already eaten most of breakfast. Resident 253 stated staff sometimes wake (Resident 253) up as early as 4:30 or 5:30 AM and often before 7 AM. Resident 253 reported it must be a rule to get up by breakfast. Interview with Nursing Assistant (NA) A 07/12/2017 at 8:35 AM reported Resident 253 was assisted up between 7 am and 8 am depending on who was working. NA A reported Resident 253 doesn't like to get up and would stay in bed all day if you let (Resident 253). NA A reported that they do not ask Resident 253 if Resident 253 is ready to get up but just tell Resident 253 that it is time to get up for breakfast otherwise Resident 253 would just stay in bed all day.",2020-09-01
142,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2017-07-12,371,E,0,1,LXOF11,"Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure the cleanliness and condition of equipment and walls in accordance with the Nebraska Food Code as evidenced by a buildup of burned liquid in the stove in Greenhouse 2, stains and liquid particles inside the refrigerators, paint scraped walls and paint chipped exterior of the air conditioner (AC) units and liquid stained and spattered on the backsplash above the steam tables on the 2 North unit and the 3 Life quest Unit of the facility. This had the potential to affect 67 residents that resided on those units and ate food served from the satellite kitchens. The facility census was 177. Findings are: Observation on 07/11/2017 between 7:30 AM and 9:00 AM with the Interim Dietary Manager and the Regional Support Manager revealed sanitation concerns in the following satellite kitchens of the facility: - Greenhouse 2: The interior of the stove was soiled with baked on foods and liquids. - 2 North and 3 Life quest areas: The interior of the refrigerator had liquid spills and stains, paint scrapes were present on the exterior of the AC unit in the unit kitchen, the backsplash above the steam tables had dried liquid stains present and the paint was chipped in places on the walls around the satellite kitchens. Interview on 07/11/2017 at 9:00 AM with the Interim Dietary Manager confirmed the equipment, stove, walls, back splash and air conditioner units in those resident areas needed to be cleaned and the issues of concern addressed. Record review of a list of residents that resided on 2 North, 3 Life Quest and Greenhouse 2 revealed a total of total 67 residents ate foods served from those facility satellite kitchens.",2020-09-01
143,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,561,D,0,1,J64C11,"Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interviews and record review, the facility failed to provide bathing for one sample resident (Resident 118) per resident preferences. Sample size was 32 residents. Facility census was 162. Record review of Resident 118's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) records revealed the resident on admission required extensive assistance with bathing. Interview with Resident 118 on 10/17/17 at 11:15 a.m. revealed the resident preferred to bathe two times per week with assistance from staff. The resident stated that the staff were not providing the two baths per week. Record review of Resident 118's care plan for personal preferences with an initiation date of 10/1/19 revealed the resident preferred an a.m. shower and wash hair 2 x/week. Record review of Resident 118's bath charting revealed baths were performed 10/2/19 and 10/14/19. Resident 118 had received two baths between 10/1/19 and 10/17/19. Interview with RN/House Supervisor (Registered Nurse) W on 10/17/19 9:08 a.m. verified that requested bathing two times per week was not being done for Resident 118 based on the documentation in the bathing record. Interview with RN X on on 10/17/19 9:09 a.m. verified that requested bathing two times per week was not being done for Resident 118 based on the documentation in the bathing record. Record review of an undated Tabitha Health Care Services Policy and Procedure Manual Whirlpool bathing Procedure revealed the following. Each client will receive a bed bath, shower, or whirlpool bath at least weekly or according to the client's preferences. The policy was provided 10/17/19.",2020-09-01
144,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,623,D,0,1,J64C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide in writing to resident and resident's representative the reason for transfer to the hospital for 2 residents (Residents 37 and 38) out of 2 residents reviewed. The facility census was 162. Findings are: Review of progress notes dated 8/22/2019 at 07:13 PM stated Resident 37 was transferred to local emergency room for evaluation of nausea and vomiting. Review of progress notes dated 8/23/19 at 01:00 PM stated staff talked to nurse at local hospital and was informed that Resident 37 had been admitted to local hospital with [DIAGNOSES REDACTED]. Review of progress notes dated 08/07/10 stated that after sustaining a laceration to the head from a fall, Resident 38 was transferred at 08:58 AM to local hospital. Review of progress note dated 8/7/19 at 2:14 PM stated that Resident 38 was admitted to the local hospital. Interview with SSD on 10/22/19 at 01:40 PM confirmed that no written documentation of reason for hospital transfer was provided to Residents 37 and 38 or Resident 37 and 38's Representatives.",2020-09-01
145,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,644,D,0,1,J64C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to identify pertinent MI (Mental Illness) [DIAGNOSES REDACTED]. Facility census was 162. Findings are: [NAME] Record review of Resident 86's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) completed 9/17/19 revealed the resident was diagnosed with [REDACTED]. Record review of Resident 86's current care plan revealed the resident could be aggressive and combative during cares and had poor impulse control. The resident chose to remain in bed most of the time and would not allow staff to toilet. Targeted behaviors identified on the current care plan included yelling, screaming and anger. Record review of Resident 86's PASSR assessment completed 7/4/13 recorded the following: - The resident was not diagnosed with [REDACTED]. - The resident was not diagnosed with [REDACTED]. - The resident was identified as not having exhibited any interpersonal symptoms or behaviors in the last six months to include; frequently isolated or avoided others or serious difficulty interacting with others. Interview with LPN (Licensed Practical Nurse) AA on 10/17/19 R 2:28 PM revealed Resident 86 had behaviors of cussing at staff, was rude to staff, often refused to get out of bed, and was care planned to just get out of bed for bathing. The resident had only been out of bed a couple of times this month besides bath day. Resident's Daughter will not allow any psychiatric medications. The resident gets angry and turns the volume up on the TV. Interview with NA BB (Nursing Assistant) on 10/17/19 at 2:33 PM Resident 86 frequently yelled from the room. Numerous other residents had asked what all the yelling was about. Observations of Resident 86 throughout the afternoon of 10/17/19 revealed the resident spent time in the room. The resident was not observed to socialize with other residents. The resident did not leave the room for the noon meal. Interview with Social Services Director on 10/17/19 at 12:10 PM the process for updating PASSR information needed improvement. The PASSR information for Resident 86 and 7 had not been updated. Interview with RN CC (Registered Nurse) on 10/21/19 1:26 PM revealed the mental health issues for Resident 7 had not been addressed on the PASSR. B. Record review of Resident 7's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) completed 7/18/19 revealed the resident was diagnosed with [REDACTED]. Record review of Resident 7's Medication Administration Record [REDACTED]. Record review of Resident 7's PASRR assessment completed 8/25/15 recorded the following: - The resident was not diagnosed with [REDACTED]. - The resident was not diagnosed with [REDACTED]. - The assessment listed Resident 7 as not having been prescribed any psychoactive medications.",2020-09-01
146,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,657,D,0,1,J64C11,"Licensure Reference Number 175NAC 12-006.09C1c Based on observation, record review, and interview the facility failed to ensure that the resident care plan was updated to reflect the current dentition (the condition of the teeth) for 1 resident (Resident 90) of 1 resident observed. The facility census was 162. Findings are: Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 90 revealed that the resident is at nutritional risk and contained the intervention of dentures with all meals and snacks. Record review of the nutrition/dietary note on 9/6/18 at 4:17 PM for Resident 90 noted that the resident's weight was down 13.7 pounds over the last 30 days and confirmed that the resident is edentulous (lacking teeth). Observation on 10/17/19 at 8:28 AM in the unit 2 North dining room revealed that Resident 90 was seated in a wheelchair at a table in middle of dining room. The resident used a spoon to take a bite of yogurt and no teeth were observed in the resident's mouth. Interview with Certified Nursing Assistant (CNA) [NAME] on 10/17/19 at 2:49 PM confirmed that Resident 90 does not have dentures. Interview with Licensed Practical Nurse (LPN) C on 10/17/19 at 2:57 PM confirmed that Resident 90 no longer has dentures. LPN C confirmed that the resident's dentures disappeared and that it was likely that the resident threw them in the trash. LPN C revealed that the family did not want them replaced. Interview on 10/22/19 at 2:00 PM with the Licensed Practical Nurse (LPN) Manager D in the 2 North Unit manager office confirmed that the care plan for Resident 90 contained an intervention for nutrition for dentures with all meals and snacks. LPN Manager D confirmed that the care plan was not updated as the resident no longer has dentures.",2020-09-01
147,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,661,D,0,1,J64C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 661 Based on record review and interview the facility failed to ensure a recapitulation of stay was completed for 1 resident (Resident 125) of 1 resident reviewed for discharge to Long-term Care. The facility census was 162. Findings are: The facility failed to ensure a recapitulation of stay was completed for one resident (Resident 125). Record review of the Recapitulation of stay IDT summary revealed; that the document was not completed. Information on the IDT summary included; 1. Resident 125 had a fall with right hip repair, 2. The admission dx was fracture of unspecified part of neck of right femur. 3. The discharge date was 9 to a SNF (Skilled Nursing Facility). 4. Resident 125 had no complications during stay, 5. The equipment that would be needed was a manual wheelchair and Resident 125 had no teeth. 6. Resident 125'sCognition had not been completed 7. Resident 125's Communication was documented that (gender) was able to make needs known. 8. Resident 125's Dietary needs had not been completed 9. Resident 125's Activity needs had not been completed. 10. Resident 125's vitals had been recorded. 11. Resident 125's ambulation, Transfer, ADL(Activities of Daily Living) status had not been completed. 12. Resident 125's Skin integrity had not been completed. 13. Resident 125 was continent of bowel and bladder. 14. Resident 125's Medications were on the order summary report. 15. Resident 125's Post Discharge Plan of Care revealed; follow up physician appointments. Record review of Lab Corp revealed an order dated 9 for IV [MEDICATION NAME] for 7 days and had been diagnosed with [REDACTED]. Record review of 14 day MDS dated 9 revealed; 1. Section C Cognition revealed Resident 125 had a BIMS (Brief Interview for Mental Status an interview to determine memory loss) score was 12 indicated moderately impaired cognition. 2. Section G revealed; Resident 125 required extensive assist of 2 person with the following ADL's bed mobility, transfers, toileting, and dressing. Resident 125 was total dependent on staff for Locomotion on and off unit. 3. Section Q revealed; Resident 125 had participated in the Assessment. An interview with the ADON (Assistant Director of Nursing) on 10/17/19 at 11:30 AM confirmed; the recapitulation had not been completed for Resident 125",2020-09-01
148,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,759,D,0,1,J64C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].10D Based on observation, interview, and record review; the facility failed to maintain a medication error rate of less than 5%, which affected 1 resident (Resident 69) of 8 residents reviewed. The medication error rate was 6.25%. The facility census was 162. Findings are: Observation of medication administration on [DATE] at 04:31 PM by RN U to Resident 69. When the medication were prepared and the five rights were administered it was noted that the computer field was red in color for medications: [REDACTED] 1. [MEDICATION NAME] 200MG 2 TABS TID (three times a day) 2. [MEDICATION NAME] 0.5mg 1 tablet TID 3. [MEDICATION NAME] 800MG TID PRN (as needed) was requested for Pain and had been documented at 4:23PM on [DATE]. Resident 69 had requested and received antiemetic after (gender) had taken the above medications. RN U had administered a dose antiemetic, 4. [MEDICATION NAME] 8 mg (milligrams) every 8 hours PRN and the documented time for the [MEDICATION NAME] was [DATE] at 4:26PM. Record review of MAR (Medication Administration Record) dated (MONTH) of 2019 revealed; Resident 69 had the following medications ordered for 3:00PM; [MEDICATION NAME] 0.5mg 1 tablet TID, and [MEDICATION NAME] Tablet 200mg 2 tablet TID. An interview with the DON (Director of Nurses) on [DATE] at 08:52 AM confirmed; if medications were given outside the window it is a medication error, unless the resident requested the medication to be later. Record review of the Medication Error Policy not dated revealed; Medication errors were as follows: Wrong medication was administered Wrong dose/amount of medication was administered Wrong form of medication was administered Wrong time Wrong route Wrong resident given the medications/unauthorized medication Omission of medication ordered Use of outdated medications Failure to document a medication An interview on [DATE] at 03:33 PM with the NM (Nurse Manager) V confirmed; that when the computer field was red in color during medication administration it means that the administration window is expired.",2020-09-01
149,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,761,E,0,1,J64C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.12E7 The facility failed to ensure that multi-dose stock medication labels were not faded and were legible to prevent the possibility of medication errors. This had the potential to affect 5 residents (Resident 1, 14, 53, 60, and 326) and the facility failed to ensure a medication card was labeled accurately for 1 resident (Resident 51). The facility census was 162. Findings are: [NAME] An observation on 10/21/19 at 08:30 AM of the Medication cart at the Journey House revealed; A facility stock bottle of Tylenol 325mg label was faded and difficult to read. A facility stock bottle of Tylenol 500mg the label was faded and difficult to read. An interview on 10/21/19 at 08:32 AM with the UM (Unit Manager) V confirmed; that the Tylenol bottles had faded labels and were difficult to read. Record review of Medication Labeling Policy not dated revealed; Medications having soiled, damaged, incomplete or illegible labels are returned to the pharmacy provider for re-labeling or disposed of in accordance with LTC (Long-term Care) facility policy. Record review of Resident 1's MAR (Medication Administration Record) revealed; [MEDICATION NAME] 325mg give 2 tablets as needed by mouth for pain/fever related to pain. Record review of Resident 14's MAR revealed [MEDICATION NAME] 500mg give 1 tablet orally every 6 hours as needed for Elevated Temperature. Record review of Resident 53's MAR revealed; [MEDICATION NAME] 325mg 2 tablets orally as needed for pain/fever related to pain. Record review of Resident 60's MAR revealed; [MEDICATION NAME] 325mg 1 tablet orally every 4 hours as needed for pain. Record review of Resident 326's MAR revealed; [MEDICATION NAME] 325mg 1 tablet every 4 hours as needed for pain. B. Observation on 10/22/19 at 09:31 AM of Resident 51's Carvedilol card revealed the order to give one 3.125 mg tablet twice per day with food. The medication label also included the directive to hold the medication if heart rate less than 50 b.p.m. (beats per minute). Review of Physician orders [REDACTED].p.m. The order was started on 10/18/19. Interview with MA-Y (Medication Aide) on 10/22/19 09:40 AM revealed the parameters of the medication administration had changed and this was not reflected on the card. Interview with Pharmacist Z on 10/22/19 at 12:10 PM revealed the card and the latest Carvedilol order for Resident 51 did not match. Interview with LPN D (Licensed Practical Nurse) on 10/22/19 at 11:49 AM revealed pharmacy should have labeled Resident 51's card with the latest order for the medication Carvedilol. The orders on the card did not match the latest medication orders. Interview with the ADON on 10/22/19 at 2:00 PM revealed the expectation would be for card labeling to match the latest prescriber order for medications. Review of an undated Medication Labeling policy provided 10/22/19 at 1:32 PM revealed the following, If the physician/prescriber changes the directions for use, the pharmacy provider must be notified to ensure that the MAR and container will show the updated label information.",2020-09-01
150,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,812,E,0,1,J64C11,"Licensure Reference Number 175 NAC 12.006.11E Based on observation, record review and interview; the facility failed to ensure all staff entering the Good, Elizabeth and Martha House kitchens wore hairnets or that hairnets worn by staff enclosed all hair to prevent potential food borne illness. This had the potential to affect all residents who eat food prepared in these houses. The facility census was 162. Findings are: Observation on 10/16/19 from 12:08 PM-12:40PM in the Martha House dining room and kitchen revealed Cook H to be plating food from the steam table with hairnet in place that did not fully contain hair in back or on sides, Nursing Assistant (NA) L to be going in and out of the kitchen serving plated food to residents wearing hairnet that did not fully cover all hair strands in back and NA M to enter the kitchen during food service without a hairnet on and then after leaving the kitchen, put on a hairnet with stands of hair exposed in the back and on the sides and proceed to serve plated food to residents. Observation on 10/17/19 at 10:55 AM in the Martha House revealed that Cook H was in kitchen preparing food with hairnet in place that did not fully cover hair in back and on sides, NA L was noted to be standing in the kitchen without a hairnet on and NA N entering and leaving the kitchen with a hairnet on that did not fully contain hair in the back and on the sides. Observation on 10/17/19 from 11:35 AM-12:10 PM in the Good House kitchen and dining room revealed food was being plated and served by Culinary Manager K. NA O was wearing a hairnet with hair exposed in the back and sides, NA P was wearing a hairnet with hair on the sides exposed and RN Q was wearing a hairnet with hair not completely covered in the back and were observed going in and out of the kitchen during this time while food was being served. Observation on 10/21/19 at 08:40 AM in the Martha House revealed that NA R was standing in the kitchen and did not have a hair restraint on. Observation on 10/21/19 at 08:51 AM revealed that NA S was in the kitchen plating and serving food to residents in the Elizabeth House dining room wearing a hairnet that did not completely cover all hair in back and on sides. Observation on 10/21/19 at 10:50 AM revealed Cook I preparing food in the Elizabeth House kitchen with hairnet on that did not completely cover all hair in back and on sides. Observation on 10/21/19 from 12:00 PM-12:30 PM in the Elizabeth House dining room and kitchen revealed Cook I plating and serving food from steam table with hairnet on that did not completely cover all hair in back and on sides. NA S was entering and leaving the kitchen serving plated food to residents eating in the dining room with hairnet on that did not completely cover all hair in back and on sides. Record review of the Nebraska Food Code, Effective date 7/21/16, Hair Restraints 2-402.11 Effective revealed; (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENs; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Interview with Culinary Manager K on 10/21/19 at 12:05 PM confirmed that hairnets on Cook I and NA S did not completely cover all hair and confirmed that hairnets should be worn by all staff whenever entering the kitchen and that hairnets should be worn so that all hair is covered.",2020-09-01
151,TABITHA NURSING HOME,285057,4720 RANDOLPH STREET,LINCOLN,NE,68510,2019-10-22,880,E,0,1,J64C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 12-006.17, 12-006.17D Based on observation, record review, and interview: the facility failed to ensure staff cleaned a sit to stand lift (a mechanical lift used to assist resident from a sitting to standing position)prior to making the lift available for other resident use. This had the potential to affect 8 residents (Residents 98, 16, 84, 85, 106, 40, 105, and 104) who used the sit to stand lift on the unit. The facility failed to ensure staff performed hand hygiene between glove changes while providing [MEDICAL CONDITION] (a surgically created opening in the abdomen in which a piece of the large intestine is diverted outside the abdominal wall) care for 1 resident (Resident 30) of 1 resident observed. The facility failed to ensure staff washed hands after removing gloves during wound care for 1 resident (Resident 71) of 4 residents observed. The facility failed to ensure staff washed hands after removing gloves during catheter (a thin tube placed into the bladder to drain urine) care for 1 resident (Resident 108) of 1 resident observed. The facility failed to ensure the catheter bag (urine collection bag connected to the catheter) was not on the floor for 1 resident (Resident 108) of 1 resident observed. The facility failed to ensure staff performed hand washing for the required 15-20 seconds during wound care for 2 residents (Resident 85 and 90) of 4 residents observed. The facility failed to ensure staff wet hands prior to applying soap during the hand washing procedure for 1 resident (Resident 90) of 2 residents observed. The facility failed to ensure staff scrubbed hands prior to putting hands under running water during hand washing for 1 resident (Resident 90) of 2 residents observed. The facility failed to ensure hand hygiene was performed between contaminated and clean procedure during wound care for 1 resident (Resident 73) of 4 residents observed. Facility census was 162 Findings are: A) Observation on 10/17/19 at 3:27 PM of MA-F (Medication Aide) assisting Resident 105 to the bathroom revealed MA-F used the sit to stand lift to transfer Resident 105 from the wheelchair to the toilet. When Resident 105 was ready MA-F performed peri care (washing the genital area) and transferred the resident back to the wheelchair and unhooked the resident from the sit to stand lift. MA-F did not disinfect the lift before parking the sit to stand lift in the hallway. MA-F then walked down the hall to get a milkshake for Resident 105. Review of Mechanical Lift - Sit-To-Stand/EZ Stand policy dated 5/16/14 revealed step 13 gave direction to apply gloves and wipe machine handles, shin plate, and hand grips with Clorox wipes located in the pouch attached to the lift. Step 14 gave direction to wash hands and put equipment away. Review of Transferring with EZ Stand Competency - RA, MA, AMA, LPN, RN checklist dated 4/20/18 revealed criteria 15 was to observe staff apply gloves and wash the handles, shin cushion, and other contact surfaces of the sit to stand lift with Clorox wipes and return equipment to the storing place. Review of MA-F's Transferring with EZ Stand Competency - RA, MA, AMA, LPN, RN dated 5/23/19 revealed an arrow was drawn down through all criteria, including criteria 15, marking yes. Interview on 10/22/19 at 8:41 AM with the ADON (Assistant Director of Nursing) revealed the expectation for wiping down mechanical lifts after use was for the lifts to be cleaned after each use, and prior to putting the lift in the hallway or storage area so the lift would not be used before being cleaned. Review of undated list of Clients on 3N that utilize a Sit-to-Stand to Transfer revealed Residents 98, 16, 84, 85, 106, 40, 105, and 104 used the sit to stand lift for transfers. B) Interview on 10/16/19 at 2:18 PM with Resident 30 revealed Resident 30 has a [MEDICAL CONDITION]. Review of Resident 30's Order Summary Report dated 10/17/19 revealed direction to ensure Resident 30's [MEDICAL CONDITION] appliance is intact each shift, change [MEDICAL CONDITION] wafer (devices used to hold the [MEDICAL CONDITION] bag in place) as needed, and assess the stoma (the opening in the abdominal wall to allow waste to leave the body) with each wafer change. Observation on 10/17/19 at 2:40 PM of LPN-G changing Resident 30's [MEDICAL CONDITION] wafer revealed LPN-G used ABHR (alcohol based hand rub) then entered the resident's room. LPN-G asked permission to change the [MEDICAL CONDITION] wafer then directed Resident 30 to the bathroom. LPN-G prepared supplies including wet soapy rags, wet rags, and a plastic bag. LPN-G used ABHR and applied gloves, then removed the resident's [MEDICAL CONDITION] bag and wafer. LPN-G cleansed Resident 30's skin with the soapy rags then rinsed with the wet rags. LPN-G removed gloves and did not perform hand hygiene prior to donning a new set of gloves. LPN-G opened the new wafer and applied skin prep to the skin around the resident's stoma, then applied the new wafer. LPN-G put the new [MEDICAL CONDITION] bag on and clipped the opening closed. LPN-G told Resident 30 the procedure was complete, and assisted the resident to stand and adjust clothing. LPN-G removed gloves, collected trash, and left the resident's room. LPN-G took the trash to the dirty utility room then washed hands with soap and water. Interview on 10/22/19 at 3:12 PM with the CE (Clinical Educator) revealed glove change and hand hygiene should be performed between dirty processes, such as cleansing the resident's skin, and clean processes, such as applying the new [MEDICAL CONDITION] wafer. Review of the CDC (Centers for Disease Control and Prevention) Guideline for Hand Hygiene in Health-Care Settings dated 10/25/02 revealed recommendations for indication for hand hygiene include decontaminating hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; and decontaminating hands after removing gloves. C. Observation on 10/17/19 at 09:32 AM revealed RN Q providing wound care for Resident 71. RN Q washed hands and donned gloves. Resident 71 was positioned on R side and [MEDICATION NAME] dressing was present on Resident 71's backside. RN Q removed old dressing, cleaned open area on backside with wound cleanser and patted dry. RN Q then removed gloves and donned new gloves without performing hand hygiene. RN Q then applied [MEDICATION NAME] to open area and new [MEDICATION NAME] dressing. RN Q removed gloves and washed hands. Review of facility policy for glove removal procedure dated 2014 from the NHCA states to remove gloves and discard into the nearest container and then to wash and dry hands thoroughly. Interview on 10/22/19 at 12:15 PM with Nursing Services Manager J confirmed that hand hygiene should be performed after glove removal. D. Observation on 10/17/19 at 09:55 AM revealed NA L performing catheter cares on Resident 108. NA L washed hands and donned gloves. NA L wiped around stoma site on abdomen with wet wipe using different areas of the wipe and wiped from around the catheter to away from catheter and then removed gloves and donned new gloves without performing hand hygiene. NA L then used alcohol pad to wipe the outside of catheter tubing from insertion site and 4 inches downward. NA L then removed gloves and without performing hand hygiene continued with providing cares for Resident 108. Observation on 10/17/19 at 11:20 AM of Resident 108 resting in bed with eyes closed. Foley catheter bag laying on the floor next to bed. Observation on 10/21/19 at 11:20 AM of Resident 108 sitting up in recliner chair in room. Foley catheter bag attached to side of recliner chair and bottom of catheter bag touching the floor. Review of the Basic Nursing Assistant Training Instructor Manual, 5th Edition, (YEAR) Nebraska Health Care Association, Inc. Lincoln, NE, Unit 4-Safety for the Resident and Workers states the floor in all areas is considered dirty. Dirty means something that could contain pathogens, it may or may not contain visible dirt. Review of facility policy for glove removal procedure dated 2014 from the NHCA states to remove gloves and discard into the nearest container and then to wash and dry hands thoroughly. Interview on 10/21/19 at 11:32 AM with LPN T confirmed that Foley catheter bag was touching the floor and confirmed that it shouldn't be. LPN T also stated the catheter bag should be on another part of the chair and then it would not touch the floor. LPN T then repositioned catheter bag so it was not touching the floor. Interview on 10/22/19 at 12:15 PM with Nursing Services Manager J confirmed that hand hygiene should be performed after glove removal. E. Record review of the facility fax to Resident 85's physician dated 9/13/19 revealed that the resident had a wound to the left buttock. Record review of the physician's orders [REDACTED]. Record review of the undated facility Policy titled Tabitha Health Care Services Policy and Procedure Manual Hand Hygiene (washing) revealed that It is the policy of Tabitha Nursing and Rehabilitation Center to utilize appropriate hand hygiene practices to prevent the spread of infection. Record review of the undated facility Hand Washing Competency revealed that during hand washing staff are to apply soap and work into a lather and rub all surfaces of the hands continuously for 15-20 seconds. Observation of wound care for Resident 85 on 10/21/19 at 9:15 AM revealed that Registered Nurse (RN) A squeezed a small amount of the [MEDICATION NAME] cream from the tube into a med cup while at the medication cart and then entered the room of Resident 85. RN A sat the cup containing the [MEDICATION NAME] cream on the sink countertop and performed hand washing with soap for 8 seconds. RN A went into the resident bathroom and obtained a package of skin wipes and put on disposable gloves. RN A assisted Resident 85 to a standing position and exposed the resident's buttocks. An open wound was noted to be lightly pink in color and measured 2 centimeters by 1 centimeter per visual measurement. RN A applied the [MEDICATION NAME] cream from the medication cup to the open wound on the left buttock. RN A removed the disposable gloves and performed hand washing with soap for 5 seconds and then exited the resident room. Interview on 10/22/19 at 2:28 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) was completed in the DON office. The DON and ADON confirmed that during hand washing the staff are to scrub the hands with soap for 15-20 seconds. F. Record review of the Physician note dated 10/1/19 revealed that Resident 90 had an open wound on the first metatarsal head (the bony prominence at the base of the big toe) on the right foot. The note also revealed that step 1 of the plan for the wound care was to continue to treat the wound with [MEDICATION NAME] cream (a topical antibiotic used on skin wounds to prevent infection) and step 3 noted that the secret to success is just keeping this wound from becoming infected. Record review of the physician orders [REDACTED]. Record review of the undated facility Policy titled Tabitha Health Care Services Policy and Procedure Manual Hand Hygiene (washing) revealed that It is the policy of Tabitha Nursing and Rehabilitation Center to utilize appropriate hand hygiene practices to prevent the spread of infection. Record review of the undated facility Hand Washing Competency revealed that during hand washing staff are to wet the hands and then apply soap and work into a lather and rub all surfaces of the hands continuously for 15-20 seconds. Staff then are to rinse hands under running water holding the finger tips downward. Observation on 10/21/19 at 10:14 AM in Resident 90's room revealed that Certified Nursing Assistant (CNA) B assisted Resident 90 with the transfer from the wheelchair to the recliner. CNA B applied soap to dry hands and performed hand washing for 12 seconds and exited the resident room. Observation on 10/21/19 at 10:19 AM revealed that Licensed Practical Nurse (LPN) C entered the room of Resident 90 with an over bed tray with the [MEDICATION NAME] cream and supplies to complete the resident wound care. LPN C performed hand washing with soap for 14 seconds and put on disposable gloves. LPN C removed the resident sock from the right foot and removed the gauze and tape from the wound at the base of the big toe. This surveyor observed a 2 centimeter by 2centimeter per visual measurement circular open area on the side of the bony prominence of the right great toe. The wound had a yellowish surface with a slightly rolled pinkish red edge surrounding the wound. LPN C placed a dry cloth underneath the resident's right foot. LPN C performed hand washing with alcohol based hand rub and put on disposable gloves and wet a wash cloth from the sink faucet. LPN C cleansed the wound with the wet cloth. LPN C used a dry cloth to pat the wound area dry. LPN C removed the disposable gloves and performed hand washing with alcohol based hand rub and put on disposable gloves. LPN C squeezed a small amount of the [MEDICATION NAME] cream from the tube onto a swab tip. LPN C applied the cream to the wound using the swab. LPN C removed the disposable gloves and performed hand washing with alcohol based hand rub and put on disposable gloves. LPN C cut a piece of absorbent foam dressing and placed it over the wound. LPN C removed the disposable gloves and applied soap onto the dry right hand and scrubbed hands underneath the running water for 12 seconds. LPN C exited the resident room to obtain a roll of tape. LPN C returned to the resident room with a roll of tape and performed hand washing with alcohol based hand rub. LPN C applied tape to the absorbent foam dressing and then wrote the date, time, and initials on the dressing. LPN C replaced the gripper sock onto the resident's right foot and repositioned the pillow underneath the resident's legs. LPN C performed hand washing with alcohol based hand rub and exited the resident room. Interview in the Director of Nursing (DON) office on 10/22/19 at 2:28 PM with the DON and Assistant Director of Nursing (ADON) confirmed that the staff is to wet the hands before applying soap during hand washing. The DON and ADON confirmed that the staff are to scrub the hands with soap for 15-20 seconds. The ADON confirmed that the hand washing scrubbing with soap for 15 to 20 seconds is to be performed over the sink and not underneath running water. [NAME] An observation of wound care for Resident 73 on 10/21/19 at 07:15 AM by LPN (Licensed Practical Nurse) G, hand sanitizer was used, the scissors were cleansed with alcohol wipe. NS (Normal Saline) was poured in a cup and 10 cc of NS was drawn up in a syringe. NS bottle was dated the lid placed on the bottle and it was placed in the med cart. LPN G donned gloves, nu-gauze dressing was cut and placed in a cup, PLUROGel was applied to gloves and added to the nu-gauze. Gloves removed. Hand hygiene with hand sanitizer was completed. LPN G entered Resident 73's room by knocking and announced who was there. The door was closed for privacy. LPN G donned gloves, wet 2 cloths with water and applied soap to one cloth and placed them in a plastic bag. Resident 73 was positioned on the left side, wound was uncovered, there was not a wound dressing present. LPN G cleansed and rinsed the wound with the cloths. LPN G performed hand hygiene for 19 seconds and the donned gloves. LPN G irrigated the wound with NS from the syringe. LPN G had not performed hand hygiene and packed the wound with nu-gauze. Two 2x2 gauze was placed on a [MEDICATION NAME] dressing and applied to wound. An interview on 10/22/19 at 03:12 PM with the DON (Director of Nurses) confirmed; that hand hygiene should be performed between contaminated and clean procedure.",2020-09-01
152,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-03-07,580,D,1,0,IWUO11,> LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the physician of blood sugars over 400 for 1 (Resident 20) of 10 residents reviewed. The facility staff identified a census of 93. Findings are: Record review of Resident 20's Medication Administration Record [REDACTED]. Record review of a admission orders [REDACTED]. Further review of the admission orders [REDACTED]. Record review of Resident 20's MAR for (MONTH) (YEAR) revealed on 2-14-2018 Resident 20's BS was 414 at bed time and on 2-15-2018 Resident 20's BS at bed time was 434. Review of Resident 20's medical record revealed there was no evidence the facility staff had notified Resident 20's physician of the BS results. On 3-06-2018 at 3:01 Pm an interview was conducted with Licensed Practical Nurse (LPN) C. During the interview LPN C confirmed Resident 20's physician had not been notified of the BS results and should have been.,2020-09-01
153,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-03-07,609,D,1,0,IWUO11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to report to the state agency and submit their investigation within 5 working days for 1 (Resident 22) of 6 investigations reviewed. The facility staff identified a census of 93. Findings are: [NAME] Record review of a Verification of Incident Investigation/Administrative Summary (VIIAS) sheet with a incident date of 1-19-2018 with the type of incident identified as an allegation of Neglect revealed a family member of Resident 22 had reported to the facility staff that Resident 22 had to wait for staff to assist Resident 22 to the bathroom resulting in Resident 22 becoming incontinent. Further review of the VIIAS dated 1-19-2018 revealed there was no evidence the facility had reported within 2 hours and submitted their investigation to the required state agency within 5 working days. On 3-7-2018 at 8:35 AM an interview was conducted the facility Administrator. During the interview, the facility Administrator confirmed there was no evidence the facility had reported the allegation and that the facility investigation had been submitted to the required state agency within the 5 working days.",2020-09-01
154,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-03-07,688,D,1,0,IWUO11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on record review and interview; the facility staff failed to implement a Restorative Nursing Program (RNP) for 1 (Resident 22) 1 sampled resident for a RNP. The facility staff identified a census of 93. Findings are: Record review of Resident 22's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2-19-2019 revealed the facility staff assessed the following: - Brief Interview for Mental Status (BIMS) was a 15. According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and no RNP. On 3-06-2018 at 6:40 AM and again on [PHONE NUMBER] at 12:07 PM Resident 22 reported (gender) was not receiving any RNP and should have been. Record review of a Physical Therapy Plan of Care note dated 12-20-2017 revealed Resident 22 was on therapy for lower extremities strengthen, pain management and a decrease mobility and range of Motion (ROM). The discharge plan for Resident 22 was to remain in the facility with a RNP. Review of Resident 22's record revealed there was no evidence the facility had developed a RNP for Resident 22. On 3-07-2018 at 8:35 AM an interview was conducted with the facility Administrator. During the interview, the Administrator confirmed Resident 22 did not have a RNP.",2020-09-01
155,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-03-07,689,D,1,0,IWUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observation and interview; the facility staff failed to implement interventions to prevent potential falls for 1 (Resident 23) of 3 sampled Residents. The facility staff identified a census of 93. Findings are: Record review of Resident 23's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 9-18-2018 revealed the facility staff assessed the following about the resident: - Brief Interview for Mental Status score of 15. According to the MDS Manuel a score of 13 to 15 indicates a resident is cognitively intact. -Required extensive assistance with bed mobility, transfers, dressing and toilet use. -had a history of [REDACTED]. Record review of a Fall Report of Incident sheet dated 11-28-2017 revealed Resident 23 had a fall with a resulting laceration to the left side of the head. Record review of Resident 23's Comprehensive Care Plan (CCP) dated 12-14-2017 revealed there was not an identified area for fall prevention with interventions. Observation on 3-05-2018 at 10:40 AM revealed Resident 23 was seated in a wheelchair waiting for a bath. Resident 23's bed was positioned above the waist area. Observation on 3-06-2018 at 9:12 AM of a resident self-transfer revealed Resident 23 locked the wheelchair brakes, removed the foot pedals to the wheel chair and kicked of slipped Resident 23 had been wearing. Further observation revealed Resident 23 had socks on that were not non-skid type. Resident 23 stood up, slowly and with some shakiness held onto the wheelchair arm resident and slowly transferred to the bed that was at Resident 23's waist line. Observation on 3-06-2018 at 12:04 PM revealed Resident 23 was in the room having lunch. Further observation revealed Resident 23's bed was not in the low position. On 3-06-2018 at 4:20 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview, review of Resident 23's CCP was completed. RN A reported during the interview that a low bed and non-skid foot wear should have been on the CCP. RN A provided a copy of a prior CCP that had identified Resident 23 was at risk for falls and had the interventions that included for staff to provide and reinforce the use of non-skid foot wear. Observation on 3-07-2018 at 6:20 AM revealed Resident 23 was in bed with the bed positioned at waist level. On 3-07-2018 at 6:20 AM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview LPN B confirmed Resident 23's bed should have been in the low position.",2020-09-01
156,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-03-07,759,D,1,0,IWUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure it was free of a medication error rate of 5% or greater. Observations of 39 medications administered revealed 3 errors resulting in a medication error rate of 7.69%. The medication errors affect 2 (Resident 27 and 28) of 7 residents. The facility staff identified a census of 93. Findings are: [NAME] Observation on 3-06-2018 at 7:05 AM revealed Licensed Practical Nurse (LPN) D prepared medications For Resident 28 that included [MEDICATION NAME] ( [MEDICATION NAME] medication, also used for treatment of [REDACTED]. Further observation revealed LPN D using a plastic measuring cup prepared 25 milliliters (ml) of the [MEDICATION NAME] medication. Review of the label on the [MEDICATION NAME] bottle revealed 20 ml's would provide the 25 mg's as ordered. On 3-06-2018 at 7:10 AM am interview was conducted with LPN D. During the interview, LPN D confirmed the measured dose of the [MEDICATION NAME] was going to be given to Resident 28. Further review with LPN D of the prepared dose of the [MEDICATION NAME] was completed. LPN D confirmed the dose of [MEDICATION NAME] was not correct. B. Record review of a Self-Administration Assessment (SAA) sheet for medications dated 2-20-2018 revealed the facility had evaluated Resident 28's ability to self-medicate. Further review of the SAA sheet revealed Resident 28 was able to self-administer medications with supervision. Observation on 3-06-2018 at 7:05 AM revealed Licensed Practical Nurse (LPN) D prepared medications for Resident 28 that included [MEDICATION NAME] ([MEDICATION NAME] medication, also used for treatment of [REDACTED]. Staff were to give 7.5 ml per tube every 4 hours as needed. Further observation with LPN C revealed LPN D placed the 3 containers of medication onto Resident 28's tray table. LPN D obtained a container and went into resident 28's bath room to obtain water. Resident 28 using a syringe removed the medication from each container and mixed the medications in the syringe. Resident self-administered the medications and did not flush in between each medication. On 3-06-2018 at 10:03 AM LPN C confirmed Resident 28 had mixed the medications together without flushing in between each medication and confirmed LPN D had been in the bathroom unable to see Resident 28 self-medicate. Record review of the facility Policy for medication Administration Through am enteral Tube dated 10-31-2016 revealed the following information: -#15. Flush after each dose with at least 15 ml of water. C. Record review of an Order Summary Report printed on 3-06-2018 revealed Resident 27 had medications that included 9 units of [MEDICATION NAME]to be given every AM with breakfast, [MEDICATION NAME]2 units in the AM and [MEDICATION NAME]insulin to be administered based upon Resident 27's blood sugar levels Observation on 3-06-2018 at 8:00 AM with the Director of Nursing (DON) revealed LPN [NAME] using an insulin syringe withdrew insulin from the [MEDICATION NAME] bottle. Observation of the dose of [MEDICATION NAME]prepared by LPN [NAME] revealed 7 units were in the insulin syringe. On 3-06-2018 at 8:05 AM during an interview LPN [NAME] confirmed the syringe of [MEDICATION NAME]was going to be given to Resident 27. On 3-07-2018 at 8:25 AM a follow up interview was conducted with LPN E. During the interview when asked how much [MEDICATION NAME]was in the syringe, LPN [NAME] reported 8 units. Upon request LPN [NAME] observed the dose of [MEDICATION NAME]in the syringe and reported 7 units. LPN [NAME] confirmed the incorrect does was going to be given to Resident 27.",2020-09-01
157,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-03-07,760,D,1,0,IWUO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure 1 (Resident 27) of 7 reviewed were free of significant medications errors. The facility staff identified a census of 93. Findings are: Record review of an Order Summary Report printed on 3-06-2018 revealed Resident 27 had medications that included 9 units of [MEDICATION NAME]to be given every AM with breakfast, [MEDICATION NAME]2 units in the AM and [MEDICATION NAME]insulin to be administered based upon Resident 27's blood sugar levels Observation on 3-06-2018 at 8:00 AM with the Director of Nursing (DON) revealed LPN [NAME] using an insulin syringe withdrew insulin from the [MEDICATION NAME] bottle. Observation of the dose of [MEDICATION NAME]prepared by LPN [NAME] revealed 7 units were in the insulin syringe. On 3-06-2018 at 8:05 AM during an interview LPN [NAME] confirmed the syringe of [MEDICATION NAME]was going to be given to Resident 27. On 3-07-2018 at 8:25 AM a follow up interview was conducted with LPN E. During the interview when asked how much [MEDICATION NAME]was in the syringe, LPN [NAME] reported 8 units. Upon request LPN [NAME] observed the dose of [MEDICATION NAME]in the syringe and reported 7 units. LPN [NAME] confirmed the incorrect does was going to be given to Resident 27. On 3-07-2018 at 8:10 AM an interview was conducted with the DON. During the interview, the DON confirmed the incorrect dose of [MEDICATION NAME]was a significant medication error.",2020-09-01
158,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,156,E,0,1,0ROU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide notices of non-coverage of Medicare services for 3 (12,165, 16) and failed to provide a list of services not covered by Medicaid for 2 residents (Resident 122 and 47). Findings are: The facility Policy and Procedure titled When to Deliver the Notice of Medicare Non-Coverage CMS (NOMNC), undated, revealed that: A Medicare provider or health plan must deliver a completed copy of the Notice of Medicare Non-Coverage to beneficiaries/enrollees receiving covered skilled nursing. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. The Provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. A) Record review of Admission Record for Resident 12 revealed that, Resident 12 was admitted to the facility on [DATE] with Medicare services. Record review of Resident 12's Electronic Medical Record revealed that Resident 12 services changed from Medicare to Private pay. Record review revealed the facility did not have documentation of NOMNC or SNF Denial Letter for services. Interview with facility Business Office Manager (BOM) on 7/11/17 at 2:23 PM confirmed that the facility failed to provide Resident 12 with NOMNC and Denial Letter. The BOM confirmed that there was no documentation of Resident 12 being provided notice of when Medicare Services would end. B) Record review of Admission Record for Resident 16 revealed that Resident 16 was admitted to the facility on [DATE] with Medicare services provided Record review of NOMNC, for Resident 16, dated 3/24/17, revealed that, Medicare covered services would end on 3/24/17. The document failed to have resident choice to appeal, and had no Patient or Representative signature or date. Interview with BOM on 7/11/17 at 2:23 PM confirmed that the facility failed to provide NOMNC, and Denial letter for Resident 16. C) Record review of Admission Record for Resident 165 revealed that, Resident 165 was admitted to the facility on [DATE] and received Medicare Services. Record review of NOMNC for Resident 165 dated 1/12/17 revealed Resident was notified of right to appeal denial decision. Resident 165's signature was on the form dated 01/10/17. Record review revealed no documentation that Resident 165 was provided a form with the choice to receive Medicare services, or to appeal Medicare decision, or choose not to receive the services. Interview with the facility BOM on 7/11/17 at 2:23 PM confirmed that Resident 165 was not provided with choice to appeal Medicare decision, pay for services to continue, or to stop services. D. A review of Resident 47's Admission Record dated 7/12/17 revealed that Resident 47 was admitted to the facility on [DATE] and was a Medicaid recipient. An interview conducted on 7/5/17 at 10:59 AM with Resident 47's Responsible Party revealed that the Responsible Party had not received a list of services not covered by Medicaid. A review of Resident 47's medical record revealed no documentation that a list of non-covered services was supplied to the resident's Responsible Party. E. A review of Resident 122's Admission Record dated 7/12/17 revealed that Resident 122 was admitted to the facility on [DATE]. An interview conducted on 7/5/17 at 10:30 AM with Resident 122's spouse revealed that neither the resident nor the spouse received from the facility a list of services not covered by Medicaid. An interview conducted on 7/11/17 at 4:04 PM with the Business Office Assistant revealed that the facility did not have a document to be given to residents on Medicaid to inform them of non-covered services. The Business Office Assistant reported that when a resident transitioned to Medicaid they would review with the resident what the share of cost was and what medications would be covered. The Business Office Assistant reported that they did not know what services were and were not covered by Medicaid.",2020-09-01
159,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,157,D,1,1,0ROU11,"**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 failed to notify the physician of medications not being administer for one of 11 residents sampled, (Resident 48). The facility census was 71. Record review of Admission Record for Resident 48 revealed that Resident 48 was admitted to the facility on [DATE]. The Admission Record revealed Resident 48 [DIAGNOSES REDACTED]. Record review of Resident 48's Brief Interview of Mental Status (BIMS)( According to the RAI Manual Version 3.0 The BIMS of 13-15 indicates Cognitively Intact, 8-12 indicates moderately impaired cognition, 0-7 indicates severe cognitive impairment.) on Resident 48's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed 6/29/17, Resident 48 was 14. Record review of Resident 48's Physicians order dated 5/18/17, revealed Carvedilol tablet 6.25 mg po( heart medication used for Hypertension) , to be administered every morning and at bedtime for Hypertension and Hold the medication if Heart rate is less than 50 or systolic blood pressure (BP) (top number) is less than 95. Record review of Resident 48's Plan of Care revealed that Resident 48 had a altered cardiovascular status related to [DIAGNOSES REDACTED]. The Resident related goal was to be free from complications of cardiac problems. Interventions included Medications as prescribed, monitor for adverse reactions, monitor vital signs as ordered and notify MD of significant abnormalities. Record review of Resident 48's MAR revealed the following -May (YEAR): B/P and pulse were not documented and medication was not given on 5/2, 5/4, 5/12, 5/13, 5/14, 5/16. -On 5/17/17 Resident b/p was below parameters, 84/58, medication was held, no documentation of physician notification was found. -May 19th thru the 29th, there is no b/p or pulse documented on the MAR, medication is documented as administered excluding 5/20 and 5/29 where it was documented as refused. -June (YEAR): Resident 48's B/P was below parameters and medication was not administered, and physician was not notified on the following dates: 6/1 ( 74/57), 6/3 (94/60) , 6/5 (94/57), 6/6 (94/62), 6/7/ (93/57), 6/8 (82/60), 6/12 (78/56), 6/15 (91/63), 6/16 (77/54), 6/17 (84/62), 6/18 (90/64), 6/20 993/71), 6/21 (92/68), 6/23 (92/64). -July (YEAR): medication was below parameters, 1/17 (94/64), and vitals were not obtained on 7/2,7/3,7/5 and 7/9/17 with medication not administered. Interview with the DON (Director of Nursing) on 7/10/15 at 2:23 PM confirmed that Resident 48's medication for his hypertension did have parameters for holding the medication and that the care plan did have the intervention to notify physician of significant abnormalities. The DON confirmed that there was no documentation of physician notification with the low blood pressures, or when the medication had been held several days in a row. Interview with the DON confirmed that the physician should have been notified.",2020-09-01
160,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,223,D,1,1,0ROU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on observations, interviews, and record reviews; the facility failed to ensure 1 resident (Resident 85) of 35 sampled residents was protected from abuse. The facility identified the resident census as 71. A review of Resident 85's Admission Record dated 7/5/17 revealed Resident 85 had been admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 85's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 5/1/17 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which is considered cognitively intact. An interview conducted on 7/5/17 at 12:53 PM with Resident 85 revealed that Resident 85 was having issues with their roommate making messes in the room, pushing their belongings over onto Resident 85's side of the room, and not keeping the curtain pulled between them. An observation conducted on 7/5/17 at 12:53 PM during the interview with Resident 85 revealed Resident 85's roommate entered the room and stopped at the end of Resident 85's bed and told Resident 85 not to talk to the state people. Resident 85's roommate then began talking over Resident 85 when the resident would attempt to answer interview questions. When the roommate was asked to give Resident 85 some privacy in order to finish the interview, the roommate refused to allow the interview to continue with Resident 85. The roommate reported that they go and talk to Resident 85's spouse about the resident and how difficult Resident 85 was and that Resident 85 will listen to their spouse, but will not listen to them. The interview was ended at this time. An interview conducted on 7/5/17 at 1:29 PM with Resident 85 revealed that Resident 85's roommate will sit and just stare at Resident 85. Resident 85 reported that when they turn on their call light to go to the bathroom, their roommate will quickly go into the bathroom and when staff answer the call light the roommate will say the light was on for them. Resident 85 reported they often times had to wait a long period of time to go to the bathroom or receive cares because the roommate was claiming the call light was for them. Resident 85 reported that the roommate was pushing their table onto Resident 85's side of the room and Resident 85 was not able to maneuver in their room due to not enough space between the roommate's table and Resident 85's bed. Resident 85 reported they are scared of their roommate and that it had gotten to the point that the resident could not sleep at night. Resident 85 then then began to sob and said they should not have said anything because the roommate was going to retaliate for having said anything. An interview conducted on 7/5/17 at 2:33 PM with Licensed Practical Nurse (LPN) C revealed that Resident 85 had approached LPN C on 6/30/17 and reported to LPN C that their roommate was always being mean to the resident. LPN C reported that Resident 85 had reported they dropped something in their room and the roommate made a face at them. LPN C reported that they went and talked to Resident 85's roommate and the roommate stated to LPN C that Resident 85 could not hear anything anyway. LPN C reported that they had never seen Resident 85 that upset and felt it was important to report the incident to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). An interview conducted on 7/5/17 at 3:05 PM with the DON and ADON revealed that they were told by LPN C that Resident 85's roommate had made a face at Resident 85. The DON and ADON reported that they would start an abuse investigation and would act accordingly on the concerns that Resident 85 had voiced in the interview. The DON and ADON revealed they had not been informed that Resident 85 was scared of the roommate or was not sleeping at night due to being anxious about the way the roommate treats Resident 85. A review of the facility's investigation into alleged abuse for Resident 85 dated 7/11/17 revealed an interview was conducted with Resident 85's spouse in which the spouse reported that Resident 85's roommate had come to the spouse and their daughter voicing that Resident 85 doesn't like the roommate and ignores the roommate. In the interview it was revealed that Resident 85 had reported to their spouse that they were afraid of their roommate at times. The investigation revealed that Resident 85's roommate was interviewed and admitted to having visited with Resident 85's spouse about concerns the roommate had with Resident 85. The review of the investigation revealed that Resident 85 was moved to the spouse's room and that Resident 85's roommate was informed they were not to visit with Resident 85 and their spouse. A review of Resident 85's Psychosocial Care Plan dated 7/6/17 revealed no intervention to ensure that Resident 85's former roommate was not to have contact with Resident 85 or their spouse. An interview conducted on 7/12/17 at 9:13 AM with the DON and ADON revealed that there is no documentation that staff were educated to ensure that Resident 85's roommate was not to have contact with Resident 85 or their spouse. An interview conducted on 7/12/17 at 9:25 AM with Registered Nurse (RN) J revealed that RN J had not been educated to ensure that Resident 85's previous roommate was not allowed to have contact with Resident 85 or their spouse. An interview conducted on 7/12/17 at 9:25 AM with Medication Aide (MA) [NAME] revealed that MA [NAME] had not been educated to ensure that Resident 85's previous roommate was not allowed to have contact with Resident 85 or their spouse. An interview conducted on 7/12/17 at 9:25 AM with Nursing Assistant (NA) F revealed that NA F had not been educated to ensure that Resident 85's previous roommate was not allowed to have contact with Resident 85 or their spouse until just before the interview was conducted. An interview conducted on 7/12/17 at 9:32 AM with LPN I revealed that LPN I had not been educated to ensure that Resident 85's previous roommate was not allowed to have contact with Resident 85 or their spouse. An interview conducted on 7/12/17 at 9:35 AM with LPN H revealed that LPN H had not been educated to ensure that Resident 85's previous roommate was not allowed to have contact with Resident 85 or their spouse until the morning of 7/12/17. An interview conducted on 7/12/17 at 9:36 AM with Nursing Assistant (NA) G revealed that NA G had not been educated to ensure that Resident 85's previous roommate was not allowed to have contact with Resident 85 or their spouse.",2020-09-01
161,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,225,D,1,1,0ROU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interviews; the facility failed to report and investigate allegations of potential abuse for 5 of 5 residents reviewed Residents 48, 53, 148, 117, and 50. The facility census was 72. [NAME] Review of Resident 117's progress notes revealed on 7/8/2017 friends of Resident 117 voiced concern Resident 117 was being abused. The Assistant Director of Nursing (ADON) was notified. Interview on 7/10/2017 at 11:09 AM with the ADON revealed the staff had reported the allegation of abuse to the ADON on 7/8/2017, however, no report was called to the state agency and an investigation was not started for 2 days. Review of the facility policy titled Abuse Prevention, Intervention, Investigation and crime reporting policy dated (MONTH) (YEAR), revealed all allegations of abuse are to be reported to the state agency immediately but not later than 2 hours after the allegation is made. Interview on 7/11/2017 at 8:53 AM with the Director of Nursing (DON) revealed the facility should have reported the allegation of abuse in the regulatory timeframe. B. A review of Resident 50's Admission Record dated 7/11/17 revealed Resident 50 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 50's medical record revealed a progress note dated 6/9/17 that revealed Resident 50 had yelled at a resident from another unit that they did not belong on Resident 50's unit and to leave. The author of the note documented that Resident 50 became agitated and continued yelling and that the other resident felt threatened and chose to leave. When the other resident got up to leave, Resident 50 walked towards the other resident calling them profane names. An interview conducted on 7/11/17 at 10:35 AM with the Director of Nursing revealed that the incident should have been investigated as suspected abuse and reported to the state agency. C) Interview with Resident 48 on 7/5/17 at 9:30 AM revealed that there was a nurse currently working at the facility that was verbally abusive and called Resident 48 Crazy, he was unsure of the name. Resident revealed that the event took place over a month ago and that the nurse keeps coming into his room. Resident 48 was told that this nurse was not to come into his room except to care for the roommate. Interview with DON on 7/5/17 at 9:45 AM revealed that there was no staff member of the name that Resident 48 had stated, works or had worked there, and that there was not abuse investigation performed during that time for Resident 48. Interview with DON on 7/11/17 at 0800 confirmed that Licensed Practical Nurse (LPN) M was the nurse that Resident 48 had requested not provide care. The facility did provide a Grievance Form dated Resident 48. The DON confirmed that this was not investigated as an abuse allegation and that other residents had not been interviewed. The facility did not follow their abuse policy for this alleged abuse complaint. D) Record review of Grievance Record for Resident 53 revealed that Resident 53 on 5/1/17 reported to Social Service Designee that a NA was going to help with getting dressed, but when Resident 53 had had wanted to put on socks first, the NA then took the pants and shirt, wadded them up, threw them in the chair and told Resident 53 to do it himself. Record review revealed that on 5/1/17 the DON spoke with resident who spoke kindly of the resident and completed the Grievance as resolved on 5/11/17. Interview with DON and ADON on 7/11/17 at 11:34 AM confirmed that the facility did not report or investigate Resident 53's concerns as abuse. The DON and ADON confirmed that this should have been investigated as Abuse under the Facility Abuse Policy and that the proper agencies should have been notified of this investigation. E) Record review of Grievance Record for Resident 148, dated 2/13/17, revealed that Resident 148 and significant other expressed concern regarding late shift aide had yelled and was angry with Resident 148 and told Resident to go to bed. The facility resolution was to educate the NA to use a lower voice when instructing patient to move or not move. Interview with DON and ADON on 7/11/17 at 11:34 AM confirmed that the facility did not report or investigate Resident 148's concerns as abuse. The DON and ADON confirmed that this should have been investigated as Abuse under the Facility Abuse Policy and that the proper agencies should have been notified of this investigation.",2020-09-01
162,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,241,D,1,1,0ROU11,"> Licensure Reference Number: 175 NAC 12-006.05 Based on observation, and interview, the facility failed to ensure residents were treated with dignity related to staff performing tasks on residents without communicating to the resident what was being performed for 1one of 8 sampled residents (Resident 59). The facility census was 71. Findings are: Observation on 7/10/17 at 10:47 AM, Resident 59 being was being provided cares, by NA N and NA O, with the Director of Nursing (DON) present in room. The observation revealed that NA N, and NA O initiated, performed and completed cares without communicating to the resident verbally or nonverbally what they were going to do before they did it. Observation revealed NA O moving Resident 59's hand 3 times without communicating where he should place his hand during a lift to stand mechanical lift being used to assist to the toilet. Interview with DON on 7/10/17 at 14:34 confirmed that NA N and NA O had not provided communication with Resident 59. DON did confirm that speaking to Resident 59, providing instruction and engaging Resident 59 in cares was more dignified for the resident than providing cares without communicating to the resident.",2020-09-01
163,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,253,E,0,1,0ROU11,"Licensure Reference Number: 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure walls, doors, tub covering and tub fixtures were maintained in a clean condition and in good repair for rooms 404, 406,408, 416, 424, 429, and 436. 7/10/2017 10:30 AM Observation during environmental rounds with the Maintenance Director, Maintenance Assistant, and the Interim Administrator was completed and revealed the following: - Painted plywood board located on top of unused tubs in resident bathrooms that are marred and present a non-cleanable surface in rooms 408, 424, 436, 429, 406. - Water dripping and water stain in the unused bathtub in room 404. - Gouges in walls and doors in rooms 416, 404, 429, 406. - Multiple screws in the wall that have not been removed and holes patched in room 404. Interview on 7/11/2017 at 11:00 AM with the administrator revealed the identified environmental issues need to be addressed and a maintenance schedule developed to maintain the condition of the environment.",2020-09-01
164,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,309,D,0,1,0ROU11,"Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview the facility failed to ensure Resident 48 received ongoing evaluation of pain level, blood sugar monitoring,medications and Resident 116 failed to have monitoring of bruising 2 of 42 sampled residents. The facility census was 71. Observation on 7-05-2017 at 1:01 PM revealed Resident 116 was in bed awake. Resident 116 had a night gown on with the arms exposed revealed bruising to the upper and lower left arm. Record review of Resident 116's Nursing Summary sheet dated 7-10-2017 revealed the facility staff had identified bruising to both arms. The areas of bruising was not identified or the size of the bruising. On 7-11-2017 at 2:15 PM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the bruising should have been identified earlier and that the location of the bruising should have been identified and was not.",2020-09-01
165,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,325,D,0,1,0ROU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview, the facility staff failed to implement nutritional interventions for 2 (Resident 96 and 156) of 3 residents reviewed. The facility staff identified a census of 71. Findings are: Record review of a Instructions for after Discharge sheet dated 2-23-2017 from the hospital for Resident 156 revealed the diet section of the discharge orders was Resident 156 was to continue to drink your supplement (Ensure [MEDICATION NAME]) twice a day for 30 days. Record review of a Nutritional Assessment with an effective date of 3-01-2017 revealed the facility Registered Dietician (RD) evaluated Resident 156's nutritional requirements and identified that Ensure Plus would be given to Resident 156 twice a day. Record review of Resident 156 record that included Medication Administration (MARS) and Treatment Administration Record (TARS) for (MONTH) and (MONTH) (YEAR) revealed the ensure was not started until 3-23-2016, 27 days after the original order. On 7-11-2017 at 2:10 PM an interview was conducted with the Director of Nursing (DON). During the interview, review of the Instructions for Discharge orders were reviewed with the DON. The DON confirmed during the interview that Resident 156 should have been started on the Ensure supplement on admission and was not. B. A review of Resident 96's Admission Record dated 7/11/17 revealed was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 96's weights from 1/17/17 to 3/1/17 revealed the following: - 1/17/17 126.8 pounds - 1/19/17 117.8 pounds - 2/16/17 111.0 pounds - 3/1/17 110.4 pounds A review of Resident 96's nutritional assessment dated [DATE] revealed that Resident 96 had experienced a significant weight loss and the plan was to start the resident on a Magic Cup (sherbet style nutritional supplement) twice a day. A review of Resident 96's nutritional assessment dated [DATE] revealed that Resident 96 had experienced a significant weight loss over the last month and the plan was to start the resident on a Magic Cup twice a day. A review of Resident 96's Medication Administration Record [REDACTED]. A review of Resident 96's medical record revealed a dietary progress note dated 3/6/17 that the resident had what the author considered severe weight loss and that the Magic Cup would be ordered for 3 times a day. A review of Resident 96's Severe Malnutrition Care Plan dated 1/30/17 with a closed dated of 6/29/17 revealed an intervention for Magic Cups twice a day that was initiated on 1/30/17 with no discontinuation date. A review of Resident 96's Care Area Assessment (CAA) Worksheet dated 1/24/17 revealed that Resident 96's weight at that time was below an acceptable weight range and that their usual weight was 145 pounds. The CAA worksheet also stated that Resident 96 had a physician order [REDACTED]. An interview conducted on 7/11/17 at 3:26 PM with the Director of Nursing (DON) revealed that Resident 96 should have been receiving Magic Cups 2/16/17 through 3/6/17 based on the nutritional assessment, but was not due to the order having been discontinued when Resident 96 returned from the hospital on [DATE].",2020-09-01
166,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,329,D,0,1,0ROU11,**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 staff failed to monitor specific target behaviors for the use of an antipsychotic medication for 1 (Resident 122) of 5 residents. Findings are: Record review of Resident 122's Medication Administration Record [REDACTED]. Review of Resident 122's record revealed no evidence the facility staff were monitoring specific behaviors related to the use of the [MEDICATION NAME] medication. On 7/11/2017 9:43:25 AM an interview was conducted with the Director of nursing (DON). During the interview the DON confirmed there were not specific behaviors being monitored for Resident 122 related to the reason Resident 122 was on an antipsychotic medication.,2020-09-01
167,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,333,D,1,1,0ROU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to ensure 1 (Resident 127) of 11 residents was free of significant medication errors. The facility staff identified a census of 71. Findings are: Record review of an History and Physical (H&P) dated 6-5-2017 revealed Resident 127 had the [DIAGNOSES REDACTED]. Record review of Resident 127's Medication Administration Record [REDACTED]. Further review of Resident 127's (MONTH) MAR for 29th and 30 revealed the bed time [MEDICATION NAME] was not administered. On 7-11-2017 at 10:17 AM an interview was conducted with Registered Nurse (RN) D. During the interview, RN D confirmed the 35 units of [MEDICATION NAME]was not administered on (MONTH) 29 and (MONTH) 30th. When asked if this would be a significant medication error, RN D stated yes.",2020-09-01
168,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,363,E,0,1,0ROU11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, record review and interview; the facility staff failed to provide the correct portion size for 6 (Resident 43, 113, 4,122, 6 and 45) of 6 residents who received mechanical altered diets. The facility staff identified a census of 71. Findings are: Record review of the menu for the lunch meal on 7-10-2017 revealed the facility resident were to have Lemon Baked Chicken 3 ounces (oz), sauce of choice, orzard pasta, California vegetable blend, bread and fruit cocktail. Observation of the lunch meal service with the Dietary Services Manager (DSM) on 7-10-2017 starting at 11:30 AM revealed Cook L began dishing up the residents food for lunch that included the 6 residents who have a mechanical altered diet. Observations revealed Cook L was using green handled scoop for the resident on a pureed diet and a gray handled scoop for those residents who received a mechanical (ground) diet for the chicken portion of the menu. An interview on 7-10-2017 at 12:32 PM was conducted with the DSM. When asked what the ounces were for the green handled scoop and gray handled scoop was, the DSM reported the scoops were a #12 or 2 ounces in size. The DSM confirmed the resident who received mechanical altered foods did not receive enough of the ground or pureed chicken.",2020-09-01
169,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,371,F,0,1,0ROU11,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff failed to ensure the large mixer, utensil storage rack, ceilings and light fixtures were clean and in good repair. This had the potential to affect all residents who ate food from the kitchen. Findings are: Observation on the initial inspection on 7-05-2017 at 8:20 AM of the kitchen revealed the large mixer had dried on food debris. Observation on 7-10-2017 at 11:30 AM through 12:30 PM of the meal service revealed. The metal shelving unit that stored utensils, pots and pans next to the food prep area had a buildup of dust and grime. Light fixtures above the food prep areas and throughout the kitchen were broken, cracked, stained with the plastic covering sagging. The ceiling over the food preparation area was cracked and peeling with a large amount of brown stains. An interview on 7-10-2017 at 12:32 PM was conducted with the Dietary Services Manager (DSM). During the interview the DSM confirmed the issue that were identified.",2020-09-01
170,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,412,D,0,1,0ROU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on observation, record review and interview; the facility staff failed to ensure 3 (Resident 113, 116 and 131) of 3 residents reviewed received dental services as ordered. The facility staff identified a census of 71. Findings are: [NAME] Record review of a Nursing Summary sheet dated 7-10-2017 revealed Resident 116 was admitted to the facility on [DATE]. Observation on 7-05-2017 at 1:14 PM revealed Resident 116 had missing teeth. Record review of Resident 116's medical record revealed there was no evidence the facility had arranged dental services for Resident 116. B. Record review of Clinic sheet dated 4-25-2017 revealed Resident 113 had been seen by the Dentist. According to the Clinic sheet dated 4-25-2017, Resident 113 was being seen as a follow up to have the remaining teeth removed. The dentist documented for staff to wait 2 to 3 months for bone remodeling prior to dental fabrication. Review of Resident 113's record revealed there was no an indication the facility staff had followed with the dentist related to fabrication of dentures. On 7-11-2017 at 11:16 AM an interview was conducted with Registered Nurse (RN) K. During the interview RN K confirmed dental follow up was not completed for Resident 116 and 113. B. Observation on 7/6/2017 at 8:00 AM revealed Resident 131 had several missing teeth and Residents 131's teeth had brownish staining present. Review of Resident 131's Progress notes for the past 6 months revealed no documentation Resident 131 had been seen by a dentist or that Resident 131 had been offered an appointment to see the dentist. Interview on 07/11/2017 2:42 PM with the Health Information Manager (medical records) revealed the facility was unable to locate any documentation that Resident 131 had been seen by the dentist or offered dental services.",2020-09-01
171,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,441,D,1,1,0ROU11,"> Licensure Reference Number: 175 NAC 12-006.17D Based on observation, interview and record review; the facility staff failed to perform hand hygiene while providing cares for 2 of 8 residents sampled (Residents 59 and 100). The facility census was 71. Findings are: A) The facility Infection Control Policy regarding Glove Use revealed toperform hand hygiene after removing gloves. Observation on 7/10/17 at 10:47 AM Resident 59 was being provided cares, in the bathroom, by Nursing Assistants (NA) N and O, also present in the room was the Director of Nursing (DON). Nursing assistant O was observed to leave the bathroom and enter the bed room area. NA O then removed gloves, without hand hygiene, NA O went to the night stand, removed items from draws, went to Resident 59's closet and removed items. NA O then returned to the bathroom and performed hand washing and applied a new pair of gloves. Interview with NA O on 7/10/17 at 10:54 AM confirmed that NA O had not performed hand hygiene upon removal of gloves, and did touch multiple items in different parts of the Resident 59's room, and belongings. Interview with DON on 7/10/17 at 10:54 AM confirmed that standard precautions and facility policy, hand washing was to be performed upon removal of gloves. DON confirmed that NA) did not perform handwashing after removal of gloves and did touch multiple area's in Resident 59's room. B. An observation conducted on 7/10/17 at 12:54 PM revealed Nursing Assistant (NA) F entered Resident 100's room and offered to take the resident to the bathroom without performing hand hygiene at entrance. NA F took Resident 100 into the bathroom and without performing hand hygiene put on gloves and assisted Resident 100 to the toilet. An observation conducted on 7/10/17 at 1:10 PM revealed NA F put on gloves and removed Resident 100's soiled brief and then put a clean brief in place and proceeded to gather wet washcloths to perform perineal hygiene. With the same gloves still on, NA F performed perineal hygiene following standard technique which resulted in fecal smearing on the washcloths. NA F removed their gloves, and without performing hand hygiene, applied clean gloves. NA F then repeated perineal hygiene technique as before and pulled up Resident 100's brief and pants. NA F removed their gloves, and without performing hand hygiene, assisted Resident 100 back into their wheelchair and wheeled Resident 100 out into their bedroom. NA F then returned to the bathroom, and without performing hand hygiene, applied gloves and gathered the dirty linen and trash. An interview conducted on 7/10/17 at 1:20 PM with the Director of Nursing revealed that the NA F should have performed hand hygiene when they changed or removed gloves. A review of the facility's Glove Use Policy dated 2012 revealed the following Miscellaneous: E. Perform hand hygiene after removing gloves. Procedure Guidelines: B. Removing Gloves: 5. Perform hand hygiene.",2020-09-01
172,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,467,E,0,1,0ROU11,"Licensure Reference Number: 175 NAC 12-007.04D Based on observation and interview, the facility failed to maintain the ventilation system in working condition in rooms 404, 406, 408, 410, 412, 414, 416, 420 and 422. Observations of the ventilation system on 7/11/2017 at 10:30 AM revealed the exhaust ventilation system would not draw a 1 ply piece of toilet tissue. This effected 9 rooms on the fourth floor. Rooms 404, 406, 408, 410, 412, 414, 416, 420, 423. Interview on 7/11/2017 at 10:35 AM with the Maintenance assistant revealed that the system on the roof is checked twice weekly for operation but no documentation of these checks was completed and vents are not checked inside the building to assure a draw is present. Interview on 7/11/2017 at 10:35 AM with the administrator revealed a routine audit should be completed and documented to assure the ventilation system is working. Interview on 7/11/2017 at 4:00 PM with the administrator revealed the exhaust system required 3 motors to be replaced to make the system functional and the facility had no identified the units were not working.",2020-09-01
173,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2017-07-12,520,F,0,1,0ROU11,"Licensure Reference Number: 175 NAC 12-006.07C Based on observation, record review, and interviews; the facility failed to maintain an effective Quality Assurance (QA) program as evidenced by repeat and additional citations. The facility census was 72. After observation, record review and interviews; the facility had 9 repeat deficiencies and 7 additional deficiency citation when compared to the facility performance report (Casper) for the past 3 surveys at the following areas: F156 - Resident Rights F157 - Notify of Changes F225 - Abuse Reporting F241 - Dignity and Respect F253 - Housekeeping and Maintenance F329 - Drug Regimen Review F333 - Significant Medication errors F371 - Food Sanitation F441 - Infection Control 07/11/2017 3:42 PM Interview with the Director of Nursing (DON) the Quality Assurance (QA) Committee discontinued monitoring Federal Tag F225 as of (MONTH) 30 (YEAR) as in the facility Plan of Correction Dated 5/15/2017 and no further monitoring was planned. Record review shows that the facility has repeat tags at F225 for not reporting or investigating episodes or allegations of abuse. 07/11/2017 3:42 PM Interview with the DON and Assistant Director of Nursing (ADON) revealed they are not monitoring any of the areas of the repeat tags. Interviews were completed on 7/11/2017 with 3 staff members, two of the three staff members were aware of the QA committee but Staff A was no aware what the committee was working on or how often they meet. NA B was not aware of how often the committee meets and what the function of the committee is. Interview on 7/11/2017 at 10:00 AM revealed the Interim Administrator was aware that compliance needed to be maintained with the use of the QA process.",2020-09-01
174,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,565,E,0,1,7GF911,"Licensure Reference Number 175 NAC 12-006.06A Based on the group interview, staff interview, review of the facility's policy and review of the Resident Council meeting minutes, the facility failed to resolve grievances brought forth by the resident group for eight of eight residents, (Residents (R)7, R15, R34, R42, R49, R64, R66, and R72) who attended the resident group interview and who regularly attended the facility's Resident Council meetings. Findings include: Review of the facility's policy titled, Grievance Policy dated (MONTH) (YEAR), documented: . Resident Council . All grievances identified during the Resident Council meeting will be submitted immediately to the Grievance Official for investigation and resolution . Resolution . The Grievance Official will complete a written response . which includes . a summary of the grievance . investigation steps . findings . resolution outcome and actions taken . date decision was issued . On 09/10/19, during the resident group interview, the residents in attendance, R7, R15, R34, R42, R49, R64, R66, and R72, all identified themselves as regular attendees of the Resident Council meetings. The eight residents stated they often had grievances that came up in the Resident Council meetings; however, the facility did not respond, and did not resolve the grievances. The eight residents stated their primary concern for several months has been food palatability and variety of food, staffs' cell phone usage, overall staff professionalism, and slow call light response times. The eight residents stated they were not sure who in the facility handled their complaints and were not sure which staff was the designated Grievance Official. Review of the Resident Council Meeting Minutes for 06/21/19 documented complaints of Certified Nursing Assistants (CNAs) dressed inappropriately and playing music on their cell phones as they entered residents' rooms, staff not cleaning up after themselves and not cleaning up after the evening meal, staff smoking outside of designated smoking areas and leaving cigarette butts outside the front entrance of the facility, and overall food palatability and variety. Review of the 07/18/19 Resident Council Meeting Minutes did not document follow-up to the 06/21/19 Resident Council Meeting grievances. Review of the 08/02/19 Resident Council meeting minutes documented concerns with cold food, lack of restorative nursing services, lack of showers, staff rolling their eyes and having an attitude when requests were made, and slow call light response times. On 09/11/19 at 11:04 AM, the Social Services Director (SSD) stated (gender) handled individual grievances, but not necessarily the Resident Council's grievances. The SSD stated (gender) was aware of generalized complaints regarding food and call light response times, but unaware of what the facility was doing to resolve those concerns. The SSD stated (gender) was unsure if (gender) was the facility's designated Grievance Official. The SSD stated that the Administrator typically handled ongoing grievances which had not been resolved. On 09/12/19 at 1:51 PM, the Administrator stated (gender) was aware there were multiple concerns brought up in the Resident Council meetings but did not typically attend the meetings. The Administrator stated food palatability and variety had been a focus for a number of months. The Administrator stated the SSD was the facility's designated Grievance Official, although the SSD may not be familiar with that term. The Administrator stated when there were grievances brought forth in the resident group, the Adnministrator expected the individual department head would handle it, and that the Administrator did not get involved unless the issue was not resolved. The Administrator stated the Administrator had hired a new kitchen manager in the past few months and the kitchen manager was working with the company who supplied the facility's menus in an effort to resolve food complaints. The Administrator stated (gender) was aware of the grievances regarding cell phone use and staff dress, and was working on addressing those issues, but was otherwise unaware of concerns with staff behavior. The Administrator stated (gender) could not be certain the residents were satisfied with the progress the facility was making on the resolution of the group complaints. The Administrator stated (gender) had no documentation as to the resolution of the grievances, and had no evidence of the department heads' response to the residents' grievances. The Administrator stated the facility did not document responses to Resident Council grievances.",2020-09-01
175,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,574,C,0,1,7GF911,"Based on observation and interview, it was determined the facility failed to ensure the contact information for the State Agency was posted in the facility, which impacted all 93 residents residing in the facility. Findings include: On 09/10/19 at 2:02 PM, all eight residents who attended the Resident Group meeting, Resident (R)7, R15, R34, R42, R49, R64, R66, and R72 stated they did not know where in the facility the State Survey Agency contact information was posted. The eight residents who attended the group stated they were not aware they could file grievances directly with the State Survey Agency but thought they could only contact the Ombudsman's office. On 09/12/19 at 3:53 PM, the Administrator stated that the facility did not have the contact information for the State Survey Agency posted and was not aware of the requirement.",2020-09-01
176,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,623,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.05(5) Based on resident and staff interview, clinical record review, and facility policy review the facility failed to provide and send a written copy of Notice of Transfer/Discharge to the resident and the representative of the Office of the State Long-Term Care (LTC) Ombudsman (a public advocate official; one who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights) for one of two sampled residents (Resident (R) 82), who had a non-emergent discharge to the hospital. Findings include: Review of R82's Demographic Sheet in the clinical record dated 09/12/19, revealed he was admitted to the facility on [DATE]. Review of R82's quarterly Minimum Data Set (MDS) resident assessment, dated 08/12/19, revealed he usually understood and usually able to make needs known. R82's Brief Interview for Mental Status score was 12, meaning he was mildly cognitively impaired. On 09/11/19 at 11:00 AM, in an interview with R82, he stated his name and where he was located. He stated during a discussion of his most recent hospital stay, he was not sure he had received any information in writing regarding his non-emergent visit to the hospital. He stated, he really couldn't remember, but he didn't think he or his spouse received anything. On 09/11/19 at 3:12 PM, the Administrator provided a copy of a log titled, Admit/Discharge To/From Report dated 06/01/19 to 08/31/19. The log detailed residents who had been discharged to home or to the hospital in the past three months. The Administrator stated that the log was faxed to the Office of Ombudsman to notify of which residents were transferred or discharged . The Administrator stated it was the Social Services Director (SSD) responsibility to notify the resident/responsible party and provide the Ombudsman's office with a copy of the Notice of Transfer/Discharge that was given to the resident/responsible party. The Administrator stated that the SSD provides the Notice of Transfer/Discharge to the unit nurse to provide to the resident/responsible party during discharge instructions and then the SSD provides a copy to the Ombudsman's office. On 09/12/19 at 9:15 AM, in an interview, the SSD stated that she was only responsible for providing nursing with Notice of Transfer/Discharge forms given to residents/responsible party who were discharged to home or elsewhere in the community. She stated that she kept a binder in her office of the notices when she provided those to nursing to place with the resident's discharge instructions. She stated she also mailed a copy to the Ombudsman's office and kept a log of those notices in a separate binder. The SSD stated it was nursing's responsibility to provide the notices for the rest of the types of discharges such as to the hospital. On 09/12/19 at 10:53 AM, in an interview, the Director of Nursing (DON) stated she was not sure who was responsible for providing the notices to the resident/responsible party and to the Ombudsman. The DON stated that she thought it would be the SSD. She was unable to provide evidence the resident/responsible party or the Ombudsman's office received a copy of the Notice of Transfer/Discharge. On 09/12/19 at 11:15 AM, in an interview, the Administrator stated that the current process for providing the Notice of Transfer/Discharge was not in order and the notices would typically be provided by the SSD and/or Admissions. The Administrator stated\ that the facility had mailed some of the notices to the Ombudsman's office and then provided a back up fax on a monthly basis of all the transfers and discharges from the facility as a notification. She was unable to provide evidence R82 or his responsible party received a Notice of Transfer/Discharge prior to the non-emergent hospital stay. Review of the facility's policy titled, Transfer and Discharge from the Facility dated 10/2018 indicated, .The resident and representative will receive timely notification, adequate preparation, orientation, and information to make the transfer as orderly and safe as possible. The notice contains information about the transfer and information about the resident's appeal rights.If the transfer is due to an emergency, the notice will be issued as soon as practicable.The facility forwards a copy all discharge notices to the Office of the State Long Term Care Ombudsman and required State agencies. (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman.",2020-09-01
177,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,641,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09B Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Assessments (MDS) for two of 41 sampled residents, (Resident (R)45 and R188), reviewed for falls. Findings include: 1. R188's Admission Record located under the Profile tab of her Electronic Health Record (EHR) documented she was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of R188's Nurse's Notes dated 08/23/19 at 7:47 AM, located under the Progress Notes tab of her EHR, documented, fell on the way to the bathroom in the middle of her bedroom floor. R188's Admission MDS, with an Assessment Reference Date (ARD) of 08/29/19, documented under item J1800, that R188 had not fallen since her admission to the facility. During an interview on 09/11/19 at 05:21 PM, the MDS Coordinator reviewed R188's Nurse's Notes and the 08/29/19 MDS. The MDS Coordinator stated the MDS item, J1800, was coded incorrectly. 2. Interview on 09/10/19 at 1:00 PM, R45 stated that he had recently been hospitalized due to a fall. R45 further stated the fall occurred because the resident attempted to transfer from the wheelchair to the bed without assistance from staff. Review of R45's Admission Record with an original admission date of [DATE] and a most recent date of admission as 06/26/19, revealed R45 had a primary [DIAGNOSES REDACTED]. R45's Care Plan dated 05/14/19 indicated, The resident is at risk for falls related to gait/balance problems, unaware of safety needs and included documentation of five falls dated, 04/29/19, 05/01/19, 06/07/19, 06/15/19, and 06/19/19. R45's quarterly MDS, with an ARD of 07/30/19, indicated R45 had two recent falls. On 09/12/19 at 4:25 PM, Registered Nurse (RN) 28 stated R45's MDS dated [DATE] was incorrect and did not reflect accurate information related to R45's recent falls. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/18 indicated, . In addition, an accurate assessment requires collecting information from multiple sources .include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate .",2020-09-01
178,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,656,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09C Based on interview, clinical record reviews, and facility policy review, the facility failed to develop and implement a plan of care for two (of five sampled residents, Resident R8 and R23), who were reviewed for the use of [MEDICAL CONDITION] medications; and failed to develop and implement a care plan for one of two sampled residents, (R22), reviewed for a known history of bedbugs with ongoing exposure in the community. Findings include: 1. A review of R8's Demographic sheet in the clinical record, indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, unspecified dementia without behavioral disturbances, hypertensive [MEDICAL CONDITION], anxiety disorder, cognitive communication deficit, dizziness, and giddiness. A review of R8's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/14/19, specified a Brief Interview for Mental Status (BIMS) (a test to determine resident cognition) was completed with a score of 14 out of 15, which indicated the resident was cognitively intact. R8 was assessed in section E: Behavior to exhibit no behaviors. In section G: Functional Status it was documented the resident required supervision to extensive assist of staff with activities of daily living (ADLs). A review of R8's Physician order [REDACTED]. R8 had an order for [REDACTED]. A review of R8's Care Plan(s) dated for the next review of 12/09/19, was completed. There was no care plan for the use of; nor for the monitoring of the medication, [MEDICATION NAME]. 2. R22's Admission Record located under the Profile tab of her EHR documented the resident was admitted to the facility on [DATE]. The resident diagnoses included left femoral neck fracture and [MEDICAL CONDITION] without behaviors. R22's quarterly MDS assessment with an ARD of 06/27/19, located under the MDS tab of the resident EHR documented a BIMS of 13 out of 15, which indicated the resident was cognitively intact with no acute mental status changes, inattention, disorganized thinking, or altered level of consciousness documented. The MDS did not identify hallucinations or delusions; nor rejection of care by R22. On 06/25/19 at 03:16 PM, a Social Services (SS) note, located in the Progress Notes tab of R22's EHR, documented, .It was reiterated that due to bed bug infestation at home it is important that all clothing and furniture be brought to staff for cleaning before allowing it to go to her room. (Son) voiced understanding and agreed. The next entry in R22's Progress Notes was a second SS note dated 07/18/19 at 04:04 PM. The note documented, Team met with (R22) and the resident friends/family to discuss bed bug problem. It was requested that facility handle all laundry. It was decided any clothing brought into facility will be brought to a staff member to launder before taking to room to curb infestation. (R22) and family agreed to strategy. Review of R22's Baseline Care Plan, dated 06/10/19, and located under the Care Plan tab of the EHR, revealed no care plan regarding the potential for bed bug infestation, or the measures outlined in the SS progress notes for the handling of personal items brought into the facility. On 09/10/19 at 11:11 AM, the Social Services Director (SSD) was interviewed regarding the progress note entries on bed bugs. The SSD stated (gender) recalled the meetings with the resident andthe resident's family, which the former Director of Nursing (DON) also attended. The SSD stated (gender) presumed the former DON updated the R22's care plan to reflect the potential for bed bugs and the interventions discussed, and updated nursing staff accordingly. The SSD reviewed R22's care plan and stated, There's nothing in there. 3. A review of R23's Demographic sheet in the clinical record, indicated R23 was admitted to the facility on [DATE] with diagnoses of, but not limited to, senile degeneration of the brain, anxiety disorder, dementia in other diseases, [MEDICAL CONDITION] disorder, repeated falls, difficulty walking and weakness. A review of R23's significant change in status MDS assessment with an ARD of 07/03/19, specified a BIMS score of 01 out of 15, which meant the resident was severely cognitively impaired. The resident was assessed in section [NAME] Behavior to exhibit only wandering behaviors. In section G Functional Status it was documented she required extensive assist of staff with ADLs. A review of R23's Physician order [REDACTED]. R23 had an order for [REDACTED]. A review of R23's Care Plan(s) dated for the next review of 10/09/19 was completed. There was no care plan for the use of; nor for the monitoring of the medication, [MEDICATION NAME] and/or its potential side effects. An interview with the MDS Coordinator15 on 09/12/19 at 10:35 AM, was completed. (Gender) stated (gender) was responsible for developing and revising the nursing care plans for the residents. The MDS coordinator stated (gender) was not aware R8 and R23 had not had a care plan for the use of and monitoring for antipsychotic medication. On 09/13/19 at 11:18 AM, in an interview with the Director of Nursing (DON) for hospice, (gender) revealed the hospice care plans were completed in collaboration with the facility. (Gender) provided the hospice comprehensive resident assessment and plan of care via fax. A review of R23's Plan of Care/Comprehensive Assessment - Admission- (named agency) forms dated, 07/05/19, received from the DON of hospice was completed. The review indicated there was no plan of care for the use of and monitoring for the prescribed medication [MEDICATION NAME]. In an interview with the DON, the Administrator, and the Director of Clinical Operations on 09/13/19 at 11:45 AM, the DON indicated (gender) was unaware R8's, R22's and R23's care plans had not addressed the use of and monitoring for antipsychotic medications that were prescribed. Review of the facility's policy titled, Care Plan and Resident Conference Schedules dated, 10/18, indicated the purpose: .Ensure that an interdisciplinary care plan is developed for each resident to ensure that there is provision of quality of care. Under the section, General Guidelines: .3. A comprehensive care plan, .must be developed, .and must include and specify: .b. measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs . c. The services that are to be furnished to attain or maintain the resident's highest practicable well-being .",2020-09-01
179,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,657,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09C1c Based on observation, interview, record review, and review of facility policy, the facility failed to review and revise the care plan for one of 41 sampled residents, (Resident (R)43), to include changes in the resident's mood status. Findings include: The facility's Care Plan and Resident Conference Schedule policy, created 10-2018, documented, . The facility must review and revise the care plan at least quarterly or with change in condition or services provided. Review of the care plan must include an interdisciplinary evaluation of the resident's progress relative to the goals established. R43's Admission Record located in the Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE]. R43's [DIAGNOSES REDACTED]. R43's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/19, located in the EHR, documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact; and a PHQ-9 score of 4, indicated minimal depression. R43's care plan did not identify any concerns with the resident's mood state or the need for counseling services. No interventions were in place for R43's psychological/psychosocial well-being. On 08/01/19, a Nurse Practitioner (NP) progress note under the Misc tab of R43's EHR documented the resident had a history of [REDACTED]. On 08/16/19 at 10:40 AM, a Social Services (SS) entry in the Progress Notes tab of R43's EHR documented the resident had been screened for counseling services and deemed as an appropriate candidate for follow-up services. On 09/10/19 at 08:51 AM, R43 was interviewed. When asked about R43's interactions with the other residents, R43 paused and asked for a moment to collect (gender)self. R43's eyes were moist. R43 stated (gender) liked the other residents but had a history of [REDACTED]. R43 described (gender self) as guarded around the other residents and hesitated to formulate relationships or socialize with them. R43 stated (gender) had seen a counselor approximately 3 weeks ago and was hopeful those services would continue, but I haven't seen her since. I'm not sure what the plan is now. I have a care plan meeting on (MONTH) 26, and I've got it marked on my calendar so I can ask. R43 stated (gender) was not sure who to follow up with if (gender) wanted an answer sooner. On 09/11/19 at 10:48 AM, the Social Services Director (SSD) was interviewed. The SSD stated (gender) typically would revise a resident's care plan to include mood state issues only if the resident triggered a Level II PASARR, or if a resident's PHQ-9 score was indicative of the presence of depression. The SSD stated since neither of these issues triggered for R43, (gender) did not think (gender) had to revise R43 care plan, even in light of the newly identified need for counseling services.",2020-09-01
180,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,675,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D2 Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for one of 41 sampled residents (Resident (R)22). R22 reported ongoing distress related to the facility's lack of attention to R22 concerns about bedbugs, even when insect bites were noted on R22 skin. Additionally, the facility failed to provide adequate showers, bed baths, or hygiene for R22. Findings include: The facility's Bed Bugs policy with a Creation Date of 10/2019, documented, . Infestation can cause psychosocial stress or 'psychogenic itching.' R22's Admission Record located under the Profile tab of her EHR documented the resident was admitted to the facility on [DATE]. R22 [DIAGNOSES REDACTED]. R22's Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS- a cognitive evaluation) of 13 out of 15, which indicated the resident was cognitively intact. The assessment did not indicate R22 had acute mental status changes, inattention, disorganized thinking, or altered level of consciousness. The MDS documented no hallucinations or delusions; and no rejections of care for R22. On 06/25/19 at 03:16 PM, a Social Services (SS) note, located in the Progress Notes tab of R22's EHR, documented, .It was reiterated that due to bed bug infestation at home it is important that all clothing and furniture be brought to staff for cleaning before allowing it to go to the resident room. (Son) voiced understanding and agreed. The next entry in R22's Progress Notes was a second SS note dated 07/18/19 at 04:04 PM. The note documented, Team met with (R22) and (gender) friends/family to discuss bed bug problem. It was requested that facility handle all laundry. It was decided any clothing brought into facility will be brought to a staff member to launder before taking to room to curb infestation. (R22) and family agreed to strategy. On 09/02/19 at 12:00 PM R22's Progress Notes revealed a nursing entry: During bath, red small red bumps noticed on upper chest, mid and upper back. Clothing and bed linens changed. On 09/10/19 at 10:00 AM, R22 was observed sitting in a chair outside the fourth-floor shower room. R22 displayed a frustrated facial expression and repeatedly reached up to scratch (gender) neck, then at (gender) forearms, then under the back of (gender) shirt. R22 stated, This place is filthy. It's crawling with bedbugs, and They never shower me. I go for days without showers. R22 showed the surveyor small round red areas on (gender) arms, and several bright red areas on (gender) neck which (gender)described as bedbug bites. R22 agreed to a full skin check while in the shower. On 09/10/19 at 10:30 AM, and observation was made of R22 in the shower. R22 was visibly upset and scratching at R22 neck even as the shower was completed. R22 stated R22 had reported R22 concern with bed bugs to the facility, but they don't listen to me and reiterated (gender) difficulty in getting showers regularly. R22 stated (gender) had bedbugs in (gender) home prior to (gender) admission, but they had been cleared up in the hospital and it wasn't until (gender) was admitted to the facility that the bed bugs returned. The resident described that about 30 minutes after going to bed at night, (gender) started itching all over, and woke up each morning with new bites. Examination of the resident revealed several small, round, reddened, partially dried bumps with serous drainage on (gender) left outer arm and similar areas without drainage on (gender) right arm. The right side of the back of (gender) neck near (gender) upper back had several bright red, raised, rounded bumps with scratch marks on them. Review of R22's bathing record, located under the Tasks tab of the resident EHR, documented the resident had not received a shower between 08/15/19 and 08/20/19, a period of five days. R22 bathing record documented the resident then received a shower on 08/22/19, but no further showers were documented until 09/09/19. Further record review revealed an entry under the Progress Notes tab of R22 EHR that documented a bath was provided on 09/02/19. The facility provided no documentation R22 received a bath or shower during the 11-day period between 08/22/19 and 09/02/19. On 09/10/19 at 10:47 AM, LPN12, who stated LPN12 often cared for R22, was interviewed. LPN12 stated LPN12 knew there were issues with R22's skin, which LPN12 described as pruritis. LPN12 stated the Nurse Practitioner (NP) saw R22 the previous week but was not sure what the results of that examination were. LPN12 looked but was unable to find documentation regarding the NP visit. LPN12 stated LPN12 was not aware of any historical or current concern with R22 having bedbugs or being exposed to bedbugs through family visits. When asked to review the SS documentation in R22's record, LPN12 covered (gender) opened mouth with (gender) hand and stated, Oh no. Oh no. Oh no. LPN12 stated (gender) had looked at R22's skin just after the surveyor left the shower room and did not notice any issues with R22's skin, but stated (gender) would look again. LPN12 and the surveyor went to R22's room where R22 showed LPN12 the areas on R22'a arms and neck. LPN12 stated LPN12 would notify the NP right away. On 09/11/19 at 12:32 PM, the NP was interviewed after examining R22. The NP stated R22 had insect bites of some kind, which may or may not be bedbugs. The NP stated the bites were not infected and would be treated with [MEDICATION NAME] ointment for comfort. The NP stated, I almost think R22 has some kind of trauma related to bedbugs. R22 does have a history of bedbugs and is taken to an environment with bedbugs, so we can't rule it out.",2020-09-01
181,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,677,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D1c Based on observation, interview, and record review, the facility did not ensure a resident received bathing frequency per their preference for one of 41 sampled residents, (Resident (R)22). Findings include: Review of R22's Admission Record located under the Profile tab of R22'a Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R22's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/27/19, located under the MDS tab of R22's EHR, documented a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating the resident was cognitively intact; had no rejection of care; and required physical assistance of one for bathing. Review of R22's care plan dated 07/12/18, located under the Care Plan tab of R22's EHR documented, Bathing/showering. The resident requires (ASSISTANCE) by staff with (SPECIFY CNA bathing/showering) per resident preference and as necessary. The care plan did not document how frequently the resident preferred bathing. On 09/10/19 at 10:00 AM, R22 was seated in a chair in the hallway outside the fourth-floor shower room. R22 stated the resident had an appointment to receive a shower at 10:00 AM. R22 stated the resident did not receive showers on a regular basis, and often felt dirty. Review of R22's bathing record, located under the Tasks tab of R22's EHRd documented the resident had not received a shower between 08/15/19 and 08/20/19, a period of five days. R22's bathing record documented the resident then received a shower on 08/22/19, but no further showers were documented until 09/09/19. Further record review revealed an entry under the Progress Notes tab of the resident EHR that documented a bath was provided on 09/02/19. The facility provided no documentation R22 received a bath during the 11-day period between 08/22/19 and 09/02/19. On 09/10/19 at 10:47 AM, Licensed Practical Nurse (LPN)12, who identified herself as one of R22's regular nurses, stated R22 had received a shower on 09/09/19. LPN12 stated she was not aware of any previous gaps in R22's shower routine, but stated the resident moved from a room on the second floor to the resident current room on the fourth floor sometime in August, so that might explain it. On 09/11/19 at 12:32 PM, R22's Nurse Practitioner (NP) was informed of the gaps of five and 11 days in (MONTH) where no baths or showers were documented for this resident. The NP stated, That's terrible. That's gross. On 09/12/19 at 11:08 AM, LPN8, who was also the facility's Wound Nurse, stated the facility did not have a policy and procedure for bathing frequency, but based such frequency on resident preference. LPN8 stated the resident's preference should be documented on the care plan.",2020-09-01
182,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,686,D,0,1,7GF912,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent a potential decline in pressure ulcer healing for 1 (Resident 505) of 3 sampled residents. The facility staff identified a census of 86. Findings are: Record review of a Skin Only Evaluation sheet dated 11-05-2019 revealed Resident 505 was identified as having a left heel blister like area. Record review of a Wound-Weekly Observation Tool (WWOT) dated 11-08-2019 revealed Resident 505 was evaluated as having a Pressure Ulcer to the left heel area. According to the information on the WWOT dated 11-08-2019 revealed the facility had obtained a treatment to the pressure ulcers and in addition staff were to float heels with Prevalon boots ( pressure reducing type of soft boots) at all times. Record review of a sheet titled Pressure Ulcer dated 11-08-2019 revealed the Prevalon boots were to be worn at all times. Record review of Resident 505's Comprehensive Care Plan (CCP) dated 7-17-2019 revealed Resident 505 was to wear Prevalon boots at all times. Record review of Resident 505's current practitioners orders printed on 11-22-2019 revealed Resident 505 was to wear heel lift boots to both feet at all times in a chair and bed. Observation on 11-20-2019 at 2:50 PM Resident 505 was in the dining room for an ice cream activity. Residents 505 did not have Prevalon boots on. Observation on 11-21-2019 at 12:05 PM revealed Resident 505 was seated in a wheelchair and did not have the Prevalon boots on. On 11-21-2019 at 12:07 PM an interview was conducted with Licensed Practical Nurse (LPN) C. During the interview LPN C confirmed Resident 505 was not wearing the Prevalon boots. Observation on 11-21-2019 at 1:05 PM revealed Resident 505 was in Resident 505's room, seated in a wheelchair without the Prevalon boots on.",2020-09-01
183,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,688,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D4 Based on observation, interview, record review and review of the facility's policy, the facility failed to implement restorative nursing programs recommended by Physical Therapy to ensure residents received Restorative Nursing Services (RNA) to maintain mobility and Range of Motion (ROM) for three of 41 sampled residents, (Resident R3, R9, and R67). Findings include: The facility's Restorative Nursing Program and Philosophy dated (MONTH) (YEAR) and identified by the facility's Wound Nurse, Licensed Practical Nurse (LPN)105, as the facility's policy for Restorative Nursing Services, documented: . Generally, restorative nursing programs are initiated when a resident is discharged from formalized occupational, physical or speech therapy . .Restorative nursing is an attitude, further defined by a dynamic interdisciplinary (IDT) approach and commitment by all associates to maintain the (facility name) residents at their optimal level of functioning . The Restorative Nursing Program employs trained staff to manage a specific caseload of residents to provide a continuum of rehabilitative care while active on therapy caseload and/or after the resident has been discharged and/or after the resident has been discharged from therapy services . .Restorative nursing is a service provided by (facility name) through the nursing department .Restorative nursing staff is supervised by the Director of Nursing (DON) . Restorative Nursing Program includes . therapy referrals are written on the Restorative Nursing Request form . the request would include training of restorative aides with the resident and the referring therapist . . Completion of required documentation . the Neighborhood Nurse will contact the resident's physician . Restorative Aide will indicate resident participation on a daily basis using the Restorative Nursing Flow Sheet . Restorative Nurse completes a monthly summary on all residents in the Restorative Nursing Caseload form . Monthly summaries are written in the IDT section of the resident's chart . 1. R9's Admission Record located under the Profile tab of his Electronic Health Record (EHR), documented the resident was admitted to the facility on [DATE]. The Medical [DIAGNOSES REDACTED]. R9's most recent Physical Therapy Discharge Summary provided by the Director of Rehab, documented R9 was discharged from physical therapy on 01/11/19. The summary documented the resident had contractures in the resident's knees, hips, and ankles at the time of discharge from therapy services and was referred to a Restorative Nursing Program (RNP) for a Passive Range of Motion (PROM) program to prevent further decline. Review of R9's EHR revealed no documentation of a physician's orders [REDACTED]. R9's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/15/19, located under the MDS tab of the resident's EHR, documented the resident did not reject cares; was dependent on two people for bed mobility and transfers; had no range of motion impairment in the resident's upper extremities; had range of motion impairment in both lower extremities; was currently receiving Occupational Therapy (OT) services; and was not receiving either Physical Therapy (PT) or Restorative Nursing services. R9's quarterly MDS assessment with an ARD of 06/11/19, located under the MDS tab of the resident's EHR, documented the resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact; had no rejection of cares; required extensive assistance of two for bed mobility and transfers; had no range of motion impairment in the resident's upper extremities; had range of motion impairment in both lower extremities; was not receiving PT, OT, or Restorative Nursing services. Review of R9's annual MDS with an ARD of 08/27/19, documented a BIMS score of 13 out of 15, indicating the resident was cognitively intact; did not reject cares; was dependent on two persons for bed mobility; required extensive assistance of two for transfers; had impaired range of motion in all extremities; and was not receiving PT, OT, or Restorative Nursing services. On 09/11/19 at 1:44 PM, the Director of Rehab stated typically when a resident was discharged from therapy services, a Restorative Nursing Request Form was developed and given to the Assistant Director of Nursing (ADON) for implementation. The Director of Rehab stated that the facility has not been providing Restorative Nursing Services for quite a while now and (gender) was not sure what happened to the Restorative referrals once they were given to nursing. The Director of Rehab stated a form had been generated when R9 was discharged from PT, however, nursing had not implemented the restorative nursing as recommended by PT. The Director of Rehab stated (gender) did not think any residents in the facility were currently receiving Restorative Nursing services. On 09/12/19 at 9:29 AM, the Director of Rehab stated R9 came to the therapy room daily to complain that the resident was not receiving Restorative Nursing services as discussed when the resident was discharged from PT and asking when those services would be initiated. Review of R9's Care Plan dated 09/12/19, located under the Care Plan tab of the resident's EHR, documented no interventions to provide PROM related to the resident's contractures or Restorative Nursing. On 09/12/19 at 9:56 AM, R9 was observed in the therapy room in a motorized wheelchair. Three fingers on the resident's right hand were drawn tightly into the resident's palm, with the resident's pointer finger extended straight out. The resident had a soiled strap around the residents palm under the residents fingers, which R9 stated was a palm aid so R9 could hold silverware more effectively at meals. R9's left arm was held snug against the residents torso with a soiled blue sling. R9's feet were resting in padded foot rests, with each foot rotated inward. R9 stated, The therapist told me some time ago I should be getting exercises with nursing, but it's never happened. They (nursing) have never mentioned why. I come down here (to the therapy room) every day to ask about it, because I don't know what else to do. R9 lifted the resident's right arm slightly and stated, I used to be able to lift this arm. I need them to do some range of motion because I can still move it just a little. And I don't think my (pointer) finger used to be like this. I just don't want to get any worse. R9 stated (gender) had spoken with (gender) physician about (gender) frustrations last month, and (gender) physician had written a note to the facility to do better, but nothing had improved. On 09/12/19 at 11:12 AM, the ADON stated the facility had no dedicated restorative staff and ADON had been under the impression Restorative Nursing services were being provided by the floor staff. The ADON stated ADON was not completing monthly summaries for residents receiving Restorative Nursing services, as ADON could not be sure whether the floor staff had performed restorative nursing. The ADON stated in the past few weeks, it has become apparent the floor staff did not have the training they needed to carry out restorative duties. The ADON stated in the past she had not been sure what to do with restorative referral due to lack of dedicated staff. The ADON stated that the facility has not been providing restorative nursing services. On 09/13/19 at 10:46 AM, the MDS Coordinator stated the facility had no formalized process for what to do when they received a restorative referral from therapy, in terms of physician's orders [REDACTED]. The MDS Coordinator stated there was simply a basic understanding that nursing will act on those referrals once we get them. The MDS Coordinator stated there were only a couple of residents in the building I know of that we're supposed to be receiving restorative nursing. The MDS Coordinator stated any documentation regarding Restorative Nursing services would be in the Progress Notes and Tasks tabs of the EHR. The MDS Coordinator reviewed R9's record and confirmed there was no care plan or documentation for a restorative or range of motion program for the resident. The Nurse Practitioner (NP) affiliated with the facility's Medical Director (MD) was also present and stated that until informed by the surveyors that there was no restorative nursing program, she and the MD had not been aware that the facility lacked such a program. 2. R3's Admission Record located under the Profile tab of the resident's EHR, documented the resident was admitted to the facility on [DATE] with the Medical [DIAGNOSES REDACTED]. R3's annual MDS assessment with an ARD of 03/01/19 documented the resident was independent with ambulation with a walker in the resident's room, corridor, and off and on the unit; was not steady but able to stabilize when moving from a seated to a standing position, while walking, and when turning around while walking. The BIMS section of the MDS was blank. The MDS documented the resident did not reject care and was receiving PT and OT services. R3's quarterly MDS assessment with an ARD of 05/28/19 documented the resident required set-up and supervision for ambulation with a walker in the resident's room, the corridor, and on and off the unit; was not steady but able to stabilize when moving from a seated to a standing position; while walking; and when turning around while walking. The MDS documented a BIMS of 15 out of 15, indicating the resident was cognitively intact, and that the resident did not reject care. The MDS documented the resident was not receiving PT, OT, or Restorative Nursing services. R3's physician's orders [REDACTED]. using the resident's walker 3 (times) per day. The order was initiated on 04/03/18 and revised on 06/23/19. R3's quarterly MDS assessment with an ARD of 08/27/19 documented a BIMS of 15 out of 15, indicating the resident was cognitively intact; did not reject care; and had upper and lower extremity range of motion impairment on one side. The MDS documented the resident was independent with ambulation with a walker in his room and in the corridor, but locomotion off and on the unit had occurred only once or twice in the past seven days. The MDS documented the resident was not steady but able to stabilize when moving from a seated to a standing position; while ambulating with his walker; and when turning around while walking. On 09/13/19 at 8:41 AM, Certified Nursing Assistant (CNA)20 stated CNA20 regularly cared for R3. CNA20 stated, There is no restorative program for (R3) and no expectation that CNAs are to perform strengthening or maintenance exercises with this resident. CNA20 stated (gender) had not been trained to complete any type of Restorative Nursing program. CNA20 stated, We used to have a restorative program two or three years ago, with dedicated restorative aides. Now there's only a few people we chart on for restorative, (R3) is one of them. We don't do anything so we just chart 'not applicable.' Review of R3's Restorative Nursing documentation for the past 30 days, located under the Tasks tab of the EHR documented that the Nursing Rehab program from 08/14/19 through 09/13/19 indicated, Not Applicable on 13 occasions, Resident not Available on two occasions, and Resident Refused on one occasion. No other entries were documented for this resident. On 09/13/19 at 8:59 AM, R3 was interviewed. R3 stated that (gender) knew (gender) was supposed to have a walking program with nursing, which was supposed to start several months ago. Nothing has happened yet, and I don't know when it will. I just sit here and wait. 3. R67's Admission Record located under the Profile tab of the resident's EHR, documented the resident was admitted to the facility on [DATE] with Medical [DIAGNOSES REDACTED]. Review of R67's Physical Therapy Discharge Summary provided by the Director of Rehab, documented the resident was discharged from Physical Therapy on 12/14/18. The summary documented R67 had been non-compliant with skilled therapy due to complaints of the stomach flu and was referred instead to a Restorative Nursing Program for bed mobility, transfers, and range of motion. Review of R67's EHR revealed no new physician's orders [REDACTED]. R67's annual MDS assessment, with an ARD of 05/24/19, documented a BIMS of 12 out of 15, indicating moderate cognitive impairment; no rejection of care; extensive assistance of two required for bed mobility and transfers; impaired range of motion in one of the resident's lower extremities; and no restorative nursing services were provided. R67's quarterly MDS assessment, with an ARD of 08/20/19, documented a BIMS of 12 out of 15; no rejection of care; extensive assistance of two required for bed mobility; dependent on two persons for transfers; impaired range of motion in one of his lower extremities; and no restorative nursing services provided. On 09/09/19 at 9:53 AM, R67 stated F67 had been experiencing limited range of motion in the resident's right leg, which R67 perceived was worsening. R67 stated (gender) had received physical therapy in the facility in the past and was supposed to be receiving restorative nursing services to maintain (gendrer) abilities, but that had been several months ago and no such services had been provided. Review of R67's record contained no documentation confirming the residents range of motion had deteriorated since the residents discharge from PT. On 09/11/19 at 1:44 PM, the Director of Rehab was interviewed regarding R67. The Director of Rehab stated that R67 had been on PT and OT services in (MONTH) (YEAR), and that PT made a referral for restorative nursing services after discharge from PT. The Director of Rehab stated the process would have been for PT to fill out a restorative nursing referral form and hand it off to either the Restorative Nurse or the MDS nurse. The Director of Rehab stated both of those positions had experienced turnover several times in the past few months, so she could not be certain who should receive the referral. The Director of Rehab stated it had been at least a couple of years since the facility had a restorative nursing program. On 09/11/19 at 3:31 PM, the DON stated she had identified the lack of a Restorative Nursing program. On 09/11/19 at 4:47 PM, the Administrator stated the facility had included the provision of Restorative Nursing services in their most recent all-staff in-service, with the expectation that the floor staff would provide those services. The Administrator provided a copy of a sign-in sheet from an All-Staff meeting, dated 06/04/19. The attachments to the sign-in sheet included several power point slides listing the definitions of various types of restorative nursing services. There was no documentation that hands-on training for the provision of those services, or competency checks for staff who received the training. Only 11 total nursing staff (LPNs and CNAs) were present for the training.",2020-09-01
184,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,690,D,0,1,7GF912,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and interview; the facility staff failed to implement a toileting program for 1 (Resident 504) of 3 sampled residents. The facility staff identified a census of 86. Findings are: [NAME] On 11-20-2019 at 3:10 PM an interview was conducted with Resident 504. During the interview Resident 504 reported being incontinet of bladder at times and needs staff assistance. When asked if Resident 504 was on a toileting program, Resident 504 reported no. Record review of Resident 504's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) sighed and dated 10-31-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was a 9. According to the MDS Manuel, a score of 8 to 12 indicated moderately impaired cognition. -Required limited assistance, with one person physically assisting for bed mobility, transfers, dressing, toilet use and personal hygiene. -No trial of a toileting program, prompted voiding or bladder training had been completed and Resident 504 was occasionally incontinent of bladder. -Resident 504 was evaluated as occasionally incontinent of bowel and no toileting program had been implemented. Record review of a Bowel and Bladder Program Screener dated 10-21-2019 revealed Resident 504 was a candidate for a scheduled toileting. Record review of Resident 504's Comprehensive Care Plan (CCP) revised on 10-30-2019 revealed Resident 504 is occasionally incontinent of bowel and bladder. Further review of Resident 504's CCP revised on 10-30-2019 revealed Resident 504 required assistance's with transfers and on and off the toilet. On 11-26-2019 at 9:00 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 504 was not on a toileting program and should have been.",2020-09-01
185,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,695,D,0,1,7GF911,"LICENSURE REFERENCE 175 NAC 12-006.09D6 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that the oxygen tubing was changed and dated per the facility policy for one of 41 sampled residents (Resident (R) 84). Findings include: During a tour of the facility's fourth-floor unit on 09/09/19 at 4:48 PM, R84 was in bed receiving 02 (oxygen) therapy via a nasal cannula with the tubing attached to a concentrator. A label (made of white tape) on the tubing read,9/2/19. Review of R84's Physician Orders, dated 04/26/17, indicated, Change oxygen tubing every (two) weeks and PRN (as needed) every night shift every 14 day(s) and as needed when visibly soiled. This order was documented as being discontinued on 04/26/19. Review of R84's Physician Orders, dated 08/21/19, revealed that there was no order to change the oxygen tubing. Review of R84's Medication Administration Record (MAR) for (MONTH) and (MONTH) 2019 revealed no documentation to indicate the oxygen tubing had been, or was being, changed as per the facility's policy. During an interview with the Director of Nursing (DON) on 09/13/19 at 8:51 AM, the DON indicated that the facility's policy was that oxygen tubing is changed weekly and the staff should have a physician order. The DON stated that staff changing the tubing should be dating the tubing and documenting that procedure on either the MAR or the Treatment Administration Record (TAR). During an interview with the Assistant Director of Nursing (ADON) on 09/12/19 at 2:25 PM, the ADON stated she randomly checks the 02 tubings to be sure they are dated and changed. The ADON stated that some nurses document the change on the MAR and some document on the TAR. Observation on 09/12/19 at 2:30 PM. revealed R84's oxygen tubing still bore the date of 09/02/19. Review of R84's MAR and TAR indicated there was no documentation that the O2 tubing was changed, or which staff changed it. During an interview with Certified Medication Technician (CMT)22 on 09/12/19 at 2:40 PM, CMT22 stated that changing oxygen tubing is usually done on the night shift, but he was not sure where it would be documented. During an interview with Licensed Practical Nurse (LPN)21 on 09/12/19 at 2:35 PM, LPN21 was not able to find documentation on R84's MAR or TAR to indicated when the tubing was last changed or the name of the staff that changed the tubing. Review of the facility's policy titled, RT103 Oxygen Administration (via nasal cannula) indicated that the oxygen tubing should be changed weekly and or sooner if it appears dirty",2020-09-01
186,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,740,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the timely provision of counseling services for one of 41 sampled residents, (Resident R43) in that the facility did not follow up on a recommendation from the counselor for services for R43 for over one month after the resident was screened for services. Findings include: Review of R43's Admission Record located under the Profile tab of the resident's Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy titled, Mental Health and Rehabilitative Services effective (MONTH) (YEAR), documented, .Residents with mental illness . will receive all services necessary to maintain or achieve independence and self-determination . In conjunction with other disciplines, social services staff will ensure that interventions and approaches are developed to meet identified needs and are incorporated into the resident's interdisciplinary care plan . Services will be provided according to assessed needs. These services include . individual, group, and family psychological services . R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/19, located under the MDS tab of the resident's EHR, documented the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact; and a Patient Health Questionnaire (PHQ)-9 score of four, indicating minimal depression. R43's care plan, located under the Care Plan tab of the resident's EHR, did not document any difficulty with the resident mood state or the need for counseling services. Review of the Nurse Practitioner (NP) progress note dated 08/01/19 under the Misc tab of R43's EHR documented the resident had a history of [REDACTED]. Review of a Social Services (SS) entry dated 08/16/19 at 10:40 AM, in the Progress Notes tab of R43's EHR documented, . (Counseling Service) here on 8/9/18. Notes are as follows . (R43) is a great therapy candidate. (Gender) had a lot to share. We spent about 40 minutes with (gender) simply getting this off (gender) chest. I mentioned to (gender) that (gender) is Medicaid pending and if therapy is an option it would be paid for as private pay. Can you revisit this with (gender) and let me know what (gender) says? On 09/10/19 at 8:51 AM, R43 was interviewed. When asked about (gender) interactions with the other residents, R43 paused and asked for a moment to collect (gender)self. R43's eyes were moist. R43 stated (gender) liked the other residents but had a history of [REDACTED]. R43 described (gender)self as guarded around the other residents and hesitated to formulate relationships or socialize with them. R43 stated (gender) had seen a counselor approximately three weeks ago and was hopeful those services would continue, but I haven't seen her since. I'm not sure what the plan is now. I have a care plan meeting on (MONTH) 26, and I've got it marked on my calendar so I can ask. R43 stated (gender) was not sure who to follow up with if (gender) wanted an answer sooner. Review of SS note on 09/10/19 at 11:21AM under the Progress Notes tab of R43's EHR documented, . call out to POA (Power of Attorney) . on 9/6/19 asking if they are willing to pay for . mental health provider . received voicemail back today . Review of a SS note dated 09/11/19 at 8:24 AM under the Progress Notes tab of the EHR documented, . POA gave permission to treat for mental health . Interview on 09/11/19 at 10:48 AM, the Social Services Director (SSD) stated she was aware of the counseling referral and recommendations, but R43 did not have insurance to cover the expenses so she needed to reach out to the resident's POA to see if they were agreeable to paying privately for the services. The SSD stated she thought she had made contact with the POA before the progress note in (MONTH) but could not recall exactly when and apparently I did not document. Interview on 09/12/19 at 02:09 PM, the Administrator stated since (MONTH) there was no in-house counseling services. The Administrator stated the facility had been able to add such services over the past few months, but the provision of those services was still dependent on a resident having a payor source. The Administrator stated it would be her expectation that contact would have been made with a resident's POA sooner than three to four after the initial counseling referral to ascertain payment for services and establish care.",2020-09-01
187,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,755,E,0,1,7GF911,"LICENSURE REFERENCE 175 NAC 12-006.12E1b Based on observation, interview, document review, and review of the facility's policy, the facility failed to follow their pharmacy policy that required the signatures of the on-coming and off-going staff who verified the narcotic count on each medication cart at the change of shift. Controlled Drug Receipt/Proof of Use/Disposition Forms for four of four medication carts (Second floor A and B, and Fourth floor A and B) lacked signatures of the on-coming and off-going nursing staff. Findings include: Review of the facility policy titled, Policy CO17, Controlled Substances and Prescription Drugs Diversion Prevention Policy, dated 05/18 indicated, Nurses must count controlled drugs every time the keys change hands, included in the exchange of keys narcotic count is the narcotic box number of cards/bottles/boxes count for each cart, the count is listed and includes how many individual items are in the drawer. Each box, bottle, syringe, and card should be included in this total count. The nurse going off duty verifies documentation in the narcotic count book on the proof of use sheets, the nurse coming on duty verifies the actual medication amount remaining, the count is done together, and if the count is correct, both nurses or medication aide and a nurse, sign the narcotic dose count and number of cards/bottles/boxes/syringes count log. Observation of the of the second floor A hall medication cart on 09/10/19 at 11:10 AM, revealed the staff used a record book to record controlled drug administration and change of shift counts. Review of the record book revealed it was missing the two signatures required to indicate that the controlled drug count had been done by two people and the count of the drugs was correct at each change of shift 6:00 AM and 6:00 PM, daily on multiple days for the nine residents receiving controlled medications on the A hall. Observation of the second floor B hall medication cart on 09/10/19 at 11:00 AM, revealed the record book used by staff to record controlled drug administration and change of shift counts was missing the two signatures required to indicate that the controlled drug count had been done by two people and the count of the drugs was correct at each change of shift, 6:00 AM and 6:00 PM, daily on multiple days for the ten residents receiving controlled medications on the B hall. During an interview with Medication Aide (MA)40 and Licensed Practical Nurse (LPN)23 on 09/10/19 at 11:00 AM, regarding the Controlled Drug Receipt/Proof of Use/Disposition Forms, both staff stated they don't always sign the book at the time that they verify the narcotic count with either the staff coming on or going off duty. They both stated they thought this practice was acceptable. MA40 and LPN23 viewed the record book for the A and B halls and confirmed that there were missing signatures on multiple days for each of the residents receiving controlled medications on the second floor. Observation of the fourth floor A hall medication cart on 09/10/19 at 11:30 AM, revealed the record book used by staff to record controlled drug administration and change of shift counts was missing the two signatures required to indicate that the controlled drug count had been done by two people and the count of the drugs was correct at each change of shift, 6:00 AM and 6:00 PM, daily on multiple days for the ten residents receiving controlled medications on the A hall. Observation of the fourth floor B hall medication cart 0on 09/10/19 at 11:35 AM, revealed the record book used by staff to record controlled drug administration and change of shift counts was missing the two signatures required to indicate that the controlled drug count had been done by two people and the count of the drugs was correct at each change of shift, 6:00 AM and 6:00 PM, daily on multiple days for the nine residents receiving controlled medications on the B hall. During an interview with LPN12 and Certified Medical Technician (CMT)10 on 09/10/19 at 11:40 AM, both stated that they were unaware both staff members were to sign the forms at the same time of the controlled drug count. LPN12 and CMT10 viewed the record book for the A and B halls and confirmed there were missing signatures on multiple days for each of the residents receiving controlled medications on the second floor. During an interview with the Director of Nursing (DON) on 09/13/19 at 8:35 AM, the DON stated that at the change of shift, the controlled substance count should be performed by two staff and each resident's Controlled Drug Receipt/Proof of Use/Disposition Form, signed off by both staff at the time of the count of each residents' medication. During an interview with the Assistant Director of Nursing (ADON) on 09/12/19 at 9:50 AM, the ADON stated that when on-coming and off-going staff perform the controlled drug count there should be two signatures on each resident's Controlled Drug Receipt/Proof of Use/Disposition Form, to verify the count of each medication was correct. The ADON stated that she had spoken with the staff responsible for the medication carts on the day they were inspected, and all staff had admitted that they were aware of the proper procedure and had not been doing it.",2020-09-01
188,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,758,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.12B5 Based on interviews, record reviews, and facility policy review, the facility failed to ensure three of five residents reviewed for unnecessary [MEDICAL CONDITION] medication use (medications that alter a person's mind and/or mood) had proper indications/diagnoses for the use of [MEDICAL CONDITION] medications; failed to monitor for adverse effects of the medications; failed to identify and monitor for target behaviors; and failed to perform gradual dose reductions (GDRs) or clearly document a contraindication for a GDR attempt for the three residents, (Resident (R)8, R23, and R188). Findings include: 1. A review of R8's Demographic sheet in the clinical record, indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, unspecified dementia without behavioral disturbances, hypertensive [MEDICAL CONDITION], anxiety disorder, cognitive communication deficit, dizziness and giddiness. The medical record review indicated there was no diagnoses to support the use of the antipsychotic medication, [MEDICATION NAME]. A review of R8's admission Minimum Data Set ((MDS) dated [DATE], specified a Brief Interview for Mental Status (BIMS) (a cognitive evaluation) was completed with a score of 14 out of 15, which indicated R8 was cognitively intact. In section G: Functional Status, it was documented R8 required supervision to extensive assist of staff with activities of daily living (ADL). In section E: Behavior, it was documented R8 had no hallucinations or delusions, and no behaviors during the assessment period. In section N Medications, it was documented R8 received no antipsychotic medications. A review of R8's quarterly MDS assessment dated [DATE], specified a BIMS was completed with a score of 14 out of 15. R8 was assessed in section [NAME] Behavior, to exhibit no behaviors. In section G Functional Status, it was documented R8 required supervision to extensive assist of staff with activities of daily living (ADL). In section N Medications, it was indicated R8 had received antipsychotic medications on seven of seven days of the assessment period. A review of R8's Physician order [REDACTED]. R8 had an order for [REDACTED]. Review of the diagnoses section of the Demographic sheet indicated there were no diagnoses for psych nor a diagnosis/indication for the use of an antipsychotic medication. In a Progress Note dated 08/30/19, from the pharmacist, it was documented, Recommend AIMS (Abnormal Involuntary Movements Scale - used to determine adverse effects of a psychoactive medication) test due to [MEDICATION NAME] order and requesting GDR (Gradual Dose Reduction) on psychoactive medications. A review of R8's Care Plan(s) dated for the next review of 12/09/19, was completed. There was no care plan for monitoring target behaviors, non-pharmacological interventions or the use of the antipsychotic medication; [MEDICATION NAME]. Review of R8's Progress Notes dated 03/01/19 to 09/11/19, was completed. There were no documented target behaviors or monitoring for the use of [MEDICATION NAME] medication. Observation of R8 on 09/12/19 at 10:55 AM, revealed the resident was in the common area, smiling and socially interacting with other residents and staff. In an interview with Certified Nursing Assistant (CNA)29 on 09/12/19 at 11:10 AM, the CNA stated she routinely took care of R8, and stated the resident was always pleasant, somewhat independent, up daily unless R8 didn't feel well or was too sleepy. CNA29 stated, R8 was easily directed, exhibited no aggression towards staff and had no behaviors at any time. CNA29 stated, she had no concerns with taking care of R8. She stated, she would not consider R8 having any abnormal behaviors. She stated, R8 had dementia and it was progressing. CNA29 stated, she was trained on how to care for residents with [DIAGNOSES REDACTED]. In an interview with CNA13 on 09/12/19 at 11:15 AM, she stated she was familiar with R8 and had taken care of her on many occasions. She stated, R8 was pleasant, cooperative with care and easily re-directed if she became anxious. She stated, for most of the time, R8 was calm with no behaviors and easy to care for. She stated, she was provided training on dementia residents and their behaviors. She stated, R8's dementia was getting a little worse, however, R8 continued to not have any behaviors. 2. A review of R23's Demographic sheet in the clinical record, indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, senile degeneration of the brain, anxiety disorder, dementia in other diseases, [MEDICAL CONDITION] disorder, repeated falls, difficulty walking and weakness. There were no diagnoses supporting the indication for the use of the antipsychotic medication, [MEDICATION NAME]. [MEDICATION NAME] is an antipsychotic medication used in the treatment of [REDACTED]. Antipsychotic use in the elderly should be avoided except for treating [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). There is an increased risk of cognitive decline (problems with memory, language, thinking and judgement), morbidity (disease), and mortality (death) in elderly patients treated with antipsychotics for dementia-related [MEDICAL CONDITION] (hallucinations and/or delusions) (PDR.net). A review of R23's admission MDS assessment dated [DATE], specified a BIMS was completed with a score of 05 out of 15, which meant R23 was severely cognitively impaired. R23 was assessed in section E: Behavior to exhibit occasional wandering. In section N: Medications, it was indicated R23 received antipsychotic medications on seven of seven days during the assessment period. A review of R23's quarterly MDS assessment dated [DATE], specified a BIMS was completed with a score of 00 out of 15, which indicated R23 had a decline in cognition since the previous assessment, and was severely cognitively impaired. R23 was assessed in section E: Behavior to have exhibited verbal behavior directed towards others one to three times during the assessment period, but had no symptoms of hallucinations or delusions. In section N: Medications, it was indicated she received antipsychotic medications on seven (of seven) days of during the assessment period. A review of R23's significant change in status MDS assessment dated [DATE], specified a BIMS was completed with a score of 01 out of 15, which meant she was severely cognitively impaired. She was assessed in section E: Behavior to exhibit occasional wandering, but no hallucinations or delusions. In section G: Functional Status it was documented R23 required extensive assist of staff with ADLs. In section N Medications, it was indicated R23 received seven days of antipsychotic medication during the assessment period. A review of R23's Physician order [REDACTED]. R23 had an order for [REDACTED]. A review of R23's Care Plan(s) dated for the next review of 10/09/19, was completed. There was no care plan for monitoring target behaviors, non-pharmacological interventions or the use of the antipsychotic medication; [MEDICATION NAME]. An observation of R23 on 09/12/19 at 10:18 AM, revealed R23 was in bed, eyes closed with no distress. An interview with the MDS Coordinator15 on 09/12/19 at 10:35 AM, was completed. She stated she was responsible for developing and revising the nursing care plans for the residents. She stated, she was not aware R8 and R23 had not had a care plan for target behaviors, nor for the use of, and monitoring for an antipsychotic medication. She also stated, she was responsible for verifying each medication had a proper diagnosis, however, she was not responsible for linking the correct [DIAGNOSES REDACTED]. A review of R23's CNA behavior documentation titled, Follow Up Question Report for 03/13/19 to 09/13/19, was completed. The behaviors listed were frequent crying, kicking/hitting, rejection of care, wandering, abusive language, and yelling/screaming. Behaviors were not documented daily. When a behavior was documented, the effective intervention was redirection. There were no documented behaviors, or symptoms of hallucinations or delusions noted with ineffective non pharmacological interventions warranting the use of medication. A review of R23's Progress Notes dated 03/25/19 to 09/13/19, was completed and indicated no documented targeted behaviors indicating the use of [MEDICATION NAME]. On 08/30/19 a Pharmacist entry timed at 11:15 AM indicated a recommendation for an, AIMS test and attempting non-drug orders prior to the PRN (as necessary) [MEDICATION NAME] order. There was no follow-up documentation to reply to the Pharmacist's recommendations. A review of R23's hospice Care Notes dated 07/01/19 to 09/09/19 was completed. From 07/01/19 to 08/06/19 there were no behaviors documented. On 08/07/19 and 08/09/19 it was documented the resident became agitated when awoken. From 08/14/19 to 08/20/19 there were no behaviors documented. On 08/28/19 it was documented the resident became agitated. From 08/30/19 to 09/04/19 there were no behaviors documented. On 09/06/19 it was documented the resident became agitated and was striking out. On 09/09/19 it was documented the resident became agitated and [MEDICATION NAME] was given. No non-pharmacological interventions were documented. In an interview with the Pharmacist43, on 09/13/19 at 9:00 AM, she indicated she made recommendations for GDRs on [MEDICAL CONDITION] medications routinely. She stated her pharmacy had recently taken over the facility as a new contract and she was still catching up her reviews. She stated some of the recommendations she had made so far, had not been scanned in the facility computer system and were lost. She stated she would be revisiting those in the current month and re-recommending those [MEDICAL CONDITION] be addressed for indication for use, monitoring and GDRs. She stated when she reviews for unnecessary medications, she reviews the [DIAGNOSES REDACTED]. She stated she would be providing monthly reports on unnecessary medications and in QAPI meetings. In an interview with the Administrator on 09/13/19 at 9:20 AM, regarding the pharmacy recommendations for R8 and R23 dated 08/30/19 requesting an AIMS test, non-pharmacological interventions and GDRs; the Administrator stated, Sorry, we missed this one. On 09/13/19 at 11:18 AM, in an interview with the Director of Nursing (DON) for hospice, she stated she was unaware the medication [MEDICATION NAME] could not be prescribed for a resident's behaviors such as refusing care. She stated R23 had been prescribed [MEDICATION NAME] related to her behaviors of refusing vital signs taken and verbally requesting the staff to leave her alone. She stated R23 had one occasion where she hit her head on the wall due to being upset with the staff. She stated she was learning a lot from our conversation and had not realized R23's [MEDICATION NAME] order was prescribed for indication of use for agitation and restlessness and not an actual diagnosis. She stated hospice had admitted the resident to their care on 06/10/19 and the resident had been prescribed the [MEDICATION NAME] prior to that. She stated, We just kept the medication due to her behaviors. A review of R23's hospice Plan of Care/Comprehensive Assessment - Admission- (named agency) forms dated 07/05/19, received from the DON of hospice was completed. The review indicated there was no plan of care for the use of, and monitoring for, the medication [MEDICATION NAME]. In an interview with the DON, the Administrator, and the Director of Clinical Operations on 09/13/19 at 11:45 AM, the DON stated she was unaware R8's, R22's and 188's prescribed [MEDICAL CONDITION] medications did not have an indication and [DIAGNOSES REDACTED]. 3. R188's Admission Record located under the Profile tab of R188 electronic health record (EHR) documented R188 was admitted to the facility on [DATE]. R188's History and Physical located under the Misc tab in R188's EHR documented diagnoses included acute on chronic [MEDICAL CONDITION], severe protein calorie malnutrition, and [MEDICAL CONDITION]. There was no [DIAGNOSES REDACTED]. R188's physician's orders [REDACTED]. On 09/11/19 at 10:04 AM, R188's EHR was reviewed and revealed no documentation of a pharmacy review to address her antipsychotic medications. On 09/11/19 at 11:00 AM, the Social Services Director (SSD) was interviewed and stated she was not sure why R188 received [MEDICATION NAME]. The SSD reviewed R188's record and stated, I don't see a [DIAGNOSES REDACTED]. When asked if depression or anxiety would be an appropriate [DIAGNOSES REDACTED]. I'm not a nurse. On 09/11/19 at 3:14 PM, the MDS Coordinator was interviewed, and stated that prior to the completion of the Admission MDS assessment, the pharmacist should have reviewed the resident's medications and made recommendations regarding [MEDICATION NAME] usage. The MDS Coordinator reviewed R188's record on her computer and stated, It looks like that (pharmacy review) didn't happen here. We are planning to implement a new system to track medications when residents are first admitted , so hopefully things like this won't happen again. (R188) is on the list to be seen by the psychiatrist as soon as we receive (insurance) authorization. On 09/11/19, R188's Diagnosis List located under the [DIAGNOSES REDACTED]. On 09/13/19 at 9:15 AM, the Pharmacist was interviewed via telephone. The Pharmacist stated her computer system showed a pharmacy review was completed at the end of August, and a recommendation made to ensure there was an appropriate [DIAGNOSES REDACTED]. On 09/13/19 at 10:41 AM, the medical Nurse Practitioner (NP) was interviewed. The NP stated most often when residents were admitted to the facility with orders for [MEDICAL CONDITION] medications, they had been on them in the community prior to admission. The NP stated if the resident's History and Physical did not document an appropriate [DIAGNOSES REDACTED]. The NP stated she would expect the facility to arrange for a resident receiving [MEDICAL CONDITION] medications to be reviewed by a psychiatrist if the history was still not clear. The NP stated the facility should forward pharmacy recommendations to her right away so that she could act on the recommendations. Review of the facility's policy titled, Use of Antipsychotic Drugs dated 10/2018, indicated the policy was to ensure .Each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs.1. Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat specific condition as diagnosed and documented in the clinical record. Generally, these conditions include: .a. [MEDICAL CONDITION], b. Delusional disorder, c. Mood disorders (e.g. [MEDICAL CONDITION] disorder, severe depression refractory to other therapies and/or with psychotic features), d. [MEDICAL CONDITION] in the absence of dementia, e. Medical illness with psychotic symptoms (e.g. neoplastic disease or [MEDICAL CONDITION]), f. [MEDICAL CONDITION]'s disorder, g. [MEDICAL CONDITION], h. Hiccups (no induced by other medications), and i. Nausea and vomiting associated [MEDICAL CONDITION] or [MEDICAL CONDITION]. d. Antipsychotic medication in persons with dementia should not be used if the only indication is one or more of the following: .wandering, poor self-care, restlessness, impaired memory, mild anxiety, [MEDICAL CONDITION], inattention or indifference to surroundings, sadness or crying alone that is not related to depression or other psychiatric disorders, fidgeting, nervousness and uncooperativeness (refusal of or difficulty receiving care).",2020-09-01
189,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,759,D,0,1,7GF912,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less then 5%. Observations of 39 medications administered revealed 5 errors resulting in an error rate of 12.82%. The medication errors were related to 2 (Resident 507 and 62) of 4 residents. The facility staff identified census of 86. Findings are: [NAME] Record review of Resident 507's Medication Administration Record [REDACTED]. Observation on 11-25-2019 at 7:55 AM revealed Certified Medication Assistant (CMA) D prepared Resident 507's medications that included the [MEDICATION NAME]. CMA D gave Resident 507 the medications that were to be swallowed, then gave Resident 507 the [MEDICATION NAME]. Resident 507 inhaled the medication as instructed, CMA D did not have Resient 507 rinse the mouth after inhaling the [MEDICATION NAME]. On 11-25-2019 at 8:07 AM an interview was conducted with CMA D. During the interview CMA D confirmed Resident 507 was not instructed to rinse the mouth after taking the [MEDICATION NAME] medication. B. Record review of a Order Summary Sheet active as of 11-25-2019 revealed Resident 62's practitioner ordered medications that included the following: -Refresh ( similar to artificial tears). -[MEDICATION NAME] Aerosol inhaler for asthma, 2 puffs every 12 hours. -[MEDICATION NAME] once a day in the morning to prevent [MEDICATION NAME]. -[MEDICATION NAME] (antianxiety medication) 0.5 milligrams (mg), one time a day every Monday Wednesday and Fridays 30 minutes prior to [MEDICAL TREATMENT]. -[MEDICATION NAME] Aerosol inhalant as needed for [MEDICAL CONDITIONS]. Observation on 11-25-2019 at 8:15 AM revealed CMA [NAME] prepared Resident 62's medications that included the [MEDICATION NAME] and [MEDICATION NAME] and 2 vials of the [MEDICATION NAME] inhalant medication. CMA separated the [MEDICATION NAME] medication into a small clear plastic envelope and took the medications into Resient 62's room. CMA [NAME] gave Resident 62 the [MEDICATION NAME] medication to administer. Resident 62 inhaled the [MEDICATION NAME] medication, then with out rinsing the mouth, took 2 puffs of the [MEDICATION NAME] and did not rinse the mouth. CMA [NAME] handed Resident 62 the [MEDICATION NAME] medication and Resident 62 placed the [MEDICATION NAME] into a pocket. CMA [NAME] opened one of the [MEDICATION NAME] vials placed the medication into a nebulizer machine. CMA [NAME] then started to open the second vial of [MEDICATION NAME] and explained to Resident 62 his medication was the refresh. Prior to administering the medication, CMA [NAME] was reminded to check the vial of medication. CMA [NAME] discarded the second vial of [MEDICATION NAME] medication, obtained the refresh and administered the medication. On 11-25-2019 at 8:20 AM a interview was conducted with CMA E. During the interview CMA [NAME] confirmed Resident 62 was not instructed to rinse the mouth after using the [MEDICATION NAME] and [MEDICATION NAME] medication, confirmed the [MEDICATION NAME] medication was given to Resident 62 to take later and further confirmed the [MEDICATION NAME] into the eyes would have been a medication error. On 11-25-2019 at 2:30 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed after using the [MEDICATION NAME], the mouth should be rinsed and if not, that would be an error. Record review of Patient Information for use of [MEDICATION NAME] at www.[MEDICATION NAME].com revealed patients are to rinse the mouth after each dose (2 puffs) and not to swallow the water. This lessens the chance of getting a fungal infection (thrush).",2020-09-01
190,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,761,D,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.12E4 Based on observation and interview, the facility failed to ensure that stock medications stored in medication storage rooms on the second and fourth floors of the facility were not expired. Findings include: An inspection of the second-floor medication storage room on 09/12/19 at 3:30 PM revealed the following expired medications were included with the stock medications: [REDACTED] -One bottle of [MEDICATION NAME] 220 milligram tablets with an expiration date of 04/(20)19; -One bottle of Multivitamin tablets with an expiration date of 06/(20)19; -One bottle of Mineral Oil laxative with an expiration date of 03/(20)19; -One bottle of Tylenol 500 milligram tablets with an expiration date of 12/(20)18; -One bottle of [MEDICATION NAME] 50 milligram tablets with an expiration date of 04/(20)19; -One bottle of liquid Multivitamins with an expiration date of 07/(20)19. The expiration dates of the above medications were verified by Registered Nurse (RN)14 on 09/12/19 at 3:50 PM. An inspection of the fourth-floor medication storage room on 09/12/19 at 3:00 PM revealed the following expired medications were included with the stock medications: [REDACTED] -One bottle of Sodium chloride tablets, one gram each, with an expiration date of 03/(20)19; -One bottle of Multivitamin tablets with an expiration date of 03/(20)19; -One Nicotine patch 21 micrograms with an expiration date of 07/(20)19; -One bottle of Vitamin B1 100 milligram tablets with an expiration date of 02/(20)19; -One box of Glucose control strips with an expiration date of 07/31/18; -One box of Hemoccult test slides with an expiration date of 11/(20)18. The expiration dates of the above medications were verified by Certified Medication Technician (CMT)22 and Licensed Practical Nurse (LPN)21 on 09/12/19 at 3:15 PM. During an interview with the Director of Nursing (DON) on 09/13/19 at 8:35 AM, the DON stated that stock medications were ordered through the pharmacy and that stock medications' expiration dates should be monitored by both the medication aides and the consulting pharmacist during her two weekly visits. Interview with the Consulting Pharmacist on 09/13/19 at 09:05 AM, revealed that the facility's stock medications were ordered from the pharmacy. The Consulting Pharmacist stated that the medication aides should check the medications' expiration dates. The facility policy relative to stock medications and expiration dates was requested from LPN8 on 09/12/19. LPN8 stated there was no facility policy relative to the monitoring of stock medications' expiration dates.",2020-09-01
191,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,804,E,0,1,7GF911,"LICENSURE REFERENCE 175 NAC 12-006.11D Based on resident interviews, record review and review of the facility's policy, the facility's staff failed to provide each resident with a palatable diet. This deficient practice had the potential to affect the 90 residents of the facility capable of oral intake out a total census of 93 residents on the first day of the survey. Findings include: On 09/09/19 at 9:53 AM, R67 was observed eating his breakfast in his room. R67 had mechanical soft ham and scrambled eggs on his plate. R67 took a bite of his ham, coughed, and spit it into a cup. R67 stated, It's terrible. Nothing but gristle. R67 then took a bite of his eggs and stated, They're dry, with no flavor at all. R67 added salt to his eggs, took another bite and stated, Still no flavor. R67 stated, I've complained so many times, I stopped complaining about every bad meal. They're all bad. An interview with R62 on 09/10/19 at 2:23 PM, R62 stated the food served in the facility was always nasty and cold. During an interview with R34 on 09/10/19 at 12:08 PM, R34 stated the food served at the facility does not taste good. Review of the facility's Resident Council Meeting Minutes, dated 06/21/19, documented multiple complaints about the food. The minutes documented eggs were served piled in a bowl; condiments were not being provided with meals; and the residents did not like the taste of the regular bread used by the facility. Review of the facility's Resident Council Meeting Minutes, dated 08/02/19, documented meals were served cold, particularly breakfast. On 09/09/19 at 2:00 PM, during the Group Meeting, the eight residents that attended the meeting, Resident (R)7, R15, R34, R42, R49, R64, R66, and R72, all stated the food in the facility, has gone from bad to worse. Specifically, the residents stated, Sometimes a hotdog is on a soggy bun; food was not served hot; the food was cold enough when served in the dining rooms but became even colder when the carts were taken down the halls to deliver the trays to residents who ate in their rooms; the ground turkey lacked flavor and the taste was noticeably bland; the pressed turkey was dry and tasted like cardboard. The eight residents that attended the Group Meeting stated that they had complained over and over but nothing ever changes. On 09/11/19 at 5:45 PM, in the fourth-floor dining room area, a sampled food test tray which consisted of roast beef (regular consistency), mashed potatoes, rice, and pureed carrots. The bowl of rice was measured 110 degrees Fahrenheit (F) and tasted lukewarm and bland. The pureed carrots measured 112 degrees F and tasted bland. On 09/12/19 at 1:21 PM, the Dietary Supervisor (DS) was interviewed and stated she was aware of feedback from the residents regarding food palatability. The DS stated cold food was a common complaint. On 09/12/19 at 1:21 PM, the Administrator stated that she was also aware of ongoing food complaints. On 09/12/19 at 2:13 PM, the Dietary Manager (DM) stated that he was aware of the resident complaints On 09/12/19 at 4:20 PM, R42 showed his meal tray, which revealed tater tots and two slices of white bread with a small hamburger patty and grilled onions in between. No condiments were visible on the tray. There were two small bowls containing fresh watermelon mixed with canned pineapple. R42 stated, This is what we were talking about. Completely plain, no flavor, doesn't even look good on the plate. R42 stated the meal was inedible and threw it in the trash. An interview was conducted with the DM on 09/13/19 at 8:30 AM. The DM stated he did not taste any of the food served during the evening meal on 09/11/19, and could not ensure the food was palatable prior to service. Review of the facility's document titled, Resident Rights, dated 2012, stated the facility was responsible to, provide each resident with a .palatable . diet .",2020-09-01
192,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,812,L,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC ,[DATE].11E Based on observations, interviews, review of facility documents, and review of facility policies and procedures, the facility failed to ensure the staff used non-expired test strips to test the sanitizer level of the dishwashing machine, and failed to ensure the water temperature of the dishwashing machine was maintained within an acceptable range for the effective sanitization of kitchen and food-service dishware and utensils. This deficient practice created a likelihood for the occurrence of serious injury, harm, impairment, or death from foodborne illness and placed the 90 residents capable of oral intake in immediate jeopardy. The facility had a census of 93 residents on the first day of the survey. Findings include: During the initial tour of the kitchen, accompanied by the facility's Dietary Manager (DM), on [DATE] beginning at 8:38 AM, observation revealed, and the DM confirmed, that the facility used a low-temp dishwashing machine to clean and sanitize the facility's kitchen ware and food-service ware. At 8:40 AM, observation revealed Dietary Aide (DA)17 checked the water temperature of the dishwashing machine by visualizing the water temperature gauge on the front of the machine below a built-in water reservoir. DA17 reported the water temperature registered 115 degrees Fahrenheit (F). During the observation, the DM confirmed that the water temperature was below the acceptable range of 120 degrees F at the time the temperature was tested . DA17 then tested the level of sanitizer in the water by dipping a test strip into the sanitizing solution collected in the built-in water reservoir on the front of the machine. DA17 reported the sanitizer level as 100 parts per million. At that time, observation of the container of test strips just used by DA17 to test the sanitizer level, revealed the test strips had an expiration date of [DATE]. During an interview at that same time, both DA17 and the DM stated the test strips in the container had been supplied by the vendor that installed the new dishwasher on [DATE], and had been used exclusively since that date to test the sanitizer level of the dishwasher solution. A review of the Dish Machine Log - Low Temp forms posted next to the dishwasher revealed the forms were in a monthly format, and each day of the month was divided into three spaces labeled breakfast, lunch, and dinner. Each of the three daily timeslots had a place to log both the temperature of the water and the sanitizer level. Further review of the (MONTH) 2019 log entries from [DATE] through [DATE] revealed the following information: On [DATE] and [DATE]: No entries were logged for either the water temperatures or the sanitizer levels for any of the three meals on those two dates. On [DATE] and [DATE]: No entries were logged for either the water temperatures or the sanitizer levels for the breakfast and lunch meals on those dates. Supper water temperatures were logged as 100 degrees F, with sanitizer levels within normal limits. On [DATE]: Breakfast and lunch water temperatures were both logged as 100 degrees F, with no water temperature or sanitizer level entries logged for the supper meal. On ,[DATE] /19: Breakfast, lunch, and supper water temperatures were all logged as 100 degrees F, with sanitizer levels within normal limits. On [DATE]: No entries were logged for the breakfast and lunch water temperatures or sanitizer levels. The supper water temperature was logged as 100 degrees F, and the sanitizer level was within normal limits. On [DATE]: No entries were logged for the breakfast and lunch water temperatures or sanitizer levels. The supper water temperature was logged as 115 degrees F, with the sanitizer level within normal limits. On [DATE]: The breakfast water temperature of 115 degrees F, and the sanitizer level of 100 parts per million were logged post-breakfast at 8:50 AM that day. During an interview at the time of the observation, the DM stated he was responsible for ensuring the water temperature was tested prior to cleaning dishes and he failed to monitor the temperature logs for the dishwashing machine during the current month. During an interview with the Grounds Director (GD), the DM, and the Director of Procurement (DOP) on [DATE] at 9:30 AM, the GD stated the water in the building would only be heated to a maximum temperature of 119 degrees F and the dishwashing machine did not have a booster' to increase the temperature to acceptable minimum required temperature for cleaning or rinsing dishes. In addition, the GD stated there had been no work orders submitted for repairs to the dishwashing machine. During an interview on [DATE] at 9:40 AM, the Administrator stated she had not been notified of any problems with the new dishwashing machine and there had been no work order submitted regarding problem with the safe operation of the machine. Review of a facility electronic mail (email) message titled, Dishwasher Replacement, dated [DATE], from the DM to the Administrator, the DOP, and the owners of the facility revealed the DM recommended a High Heat Washer be purchased to replace the facility's dishwasher. The reasons noted by the DM for this recommendation were noted as follows: 1) You wouldn't need a booster due to the machine heating the water which would solve our problem right now, 2) The facility would save money because, you wouldn't need to buy chemicals, and 3) it improves dry times on items washed. A follow-up interview was conducted with the DM on [DATE] at 11:00 AM. The DM confirmed he sent a message to the Administrator, the DOP, and the owners of the facility because there had been problems with inconsistent water temperatures with the facility dishwashing machine and plans were made to replace the machine. A review of a facility's Kitchen Audit, dated [DATE], and conducted by the Registered Dietician (RD) revealed the water temperature noted on the facility's dishwashing machine at the time of the audit was measured as 110 degrees. The audit guidelines noted a low temperature machine's water temperature should be equal to or greater than 120 degrees and should follow the manufacturer's guidelines. The RD's note on the audit reads, temp 110 - replacing dishwasher, An interview with the DOP was conducted on [DATE] at 12:30 PM. The DOP stated he was responsible for the purchase of the new dishwashing machine for the facility. The DOP confirmed he was aware of the recommendations made by the DM to purchase a high temperature dishwashing machine were made on [DATE]. In addition, the DOP confirmed he was aware the facility needed to purchase a new dishwashing machine due to problems with inconsistent water temperatures on the machine. The DOP stated he received a recommendation from a vendor to purchase a low temperature washer and the new dishwashing machine was installed on [DATE]. The DOP did not provide an explanation for why the recommendation to purchase a high temperature dishwashing machine from the DM was not considered and the DOP did not provide an explanation for why a booster was not purchased to increase the temperature of the new machine. An interview was conducted with the Administrator and Regional Administrator on [DATE] at 2:25 PM. The Administrator stated the DOP was responsible for the purchase of a new dishwashing machine for the facility kitchen. The Administrator confirmed she understood the facility needed to purchase a new dishwasher due to inconsistent water temperatures. In addition, the Administrator confirmed she was aware a low temperature dishwashing machine would need a booster to increase water temperatures because the hot water temperatures set in the building would only reach 119 degrees. The Administrator stated she had not been made aware of any problems with the new dishwashing machine and there had been no work orders submitted at the facility related to problems with the operation of the new dishwashing machine since the installation date of [DATE]. The Administrator stated the DOP was responsible for communicating with vendors related to the purchase and would have expected a booster to be purchased at the time the new machine was purchased but could not provide an explanation for the facility's failure to purchase a booster to increase the water temperature for safe operation of the new machine. Observation on [DATE] at 2:35 PM, revealed the manufacturer's guideline and the National Sanitary Foundation requirements were posted on the Data Plate on the front of the dishwasher and read, Wash Temp. - Minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit, Rinse Temp.- Minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit. A review of facility policy titled, Dish Machine Usage, dated ,[DATE], stated the purpose of the policy was, to ensure proper techniques when washing tableware (i.e., dishes, silverware, glasses and cups). The procedure outlined in the policy stated, Wash and rinse tanks should be filled with clear water. Check the temperature of the wash and rinse cycles, verifying that both meet the temperature posted on the dish machine.",2020-09-01
193,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,880,F,0,1,7GF911,"LICENSURE REFERENCE 175 NAC 12-006.17A Based on interview and facility policies reviewed, the facility failed to maintain and implement an effective infection prevention and control program (IPCP) regarding waterborne pathogens, specifically (legionella) known as Legionnaire's disease. This had the potential to affect all residents residing in the facility. The survey census was 93. Findings include: Interview on 09/10/19 at 10:00 AM, the Maintenance Director revealed he had not had any training or education on Legionnaire's disease or waterborne pathogens as related to IPCP and the facility's water management. Review of the facility's Infection Prevention and Control Program (IPCP) and policies and procedures dated 08/2019, revealed they had not implemented an effective program to prevent, detect and control waterborne contaminants including legionella, known as Legionnaire's disease. The Director of Nursing (DON), who was responsible for the IPCP stated in an interview on 09/10/19 at 10:48 AM, to her knowledge, the facility had not completed education and training on Legionnaire's disease or waterborne pathogens, nor could she provide for any of the facility staff, evidence of education and training in the past. An interview on 09/10/19 at 11:00 AM the Administrator stated, that she was familiar with the infection control requirement for facility education and training on Legionnaire's disease and waterborne pathogens, however, could not recall if or when the last time the facility had been educated or trained. An interview on 09/12/19 05:55 PM, the Assistant Director of Nursing (ADON), who was partially responsible for staff education and development, stated that waterborne pathogens was not one of the components of the facility's mandatory infection control education and training provided. Review of the facility's policy titled, Infection Prevention and Control Program dated 08/2019 revealed the policy statement, .A policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Under the section, Policy Explanation and Compliance Guidance: indicated, .3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. There was no mention of the education and training of waterborne pathogens, Legionnaire's Disease or facility water management in relation to infection control practices. Review of the facility's policy titled, Legionnaire's Disease dated 06/2019 indicated policy statement, .Legionnaire's disease may occur and could be either facility or community acquired. Specific actions should be taken for prevention of Legionella and for investigation should a case occur. The policy described clinical symptoms of Legionnaire's Disease and indicated, .The Medical Director and the Nursing Department shall track facility acquired pneumonia as part of the quality monitoring system.",2020-09-01
194,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2019-09-12,925,E,0,1,7GF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.18A4 Based on observations, resident and staff interviews, facility policy review, and review of exterminator invoices the facility failed to prevent and/or reduce the recurrence of bed bug infestation. This failure affected two of four floors in the facility, and for one of 41 sampled residents, (Resident (R)22). Findings include: The facility's Bed Bugs policy with a Creation Date of 10/2019, documented, Staff will employ infection control strategies to prevent and manage infestation of bed bugs . The General Guidelines section of the policy documented, .4. They feed primarily at night. Each feeding 'session' lasts for approximately 5 minutes, after which the bugs return to their hiding places - under mattresses, in linens or rugs, or on clothing .7. Lifespan of bed bugs can be up to two years with a food source and up to a year without . The Steps in the Procedure area of the policy documented, .Identifying and eradicating bed bug infestation is a multi-disciplinary task, involving nursing, infection control, administration, and housekeeping .Monitoring .2. Thoroughly screen newly admitted residents, as well as those returning from a stay away from the facility .4. Ask the resident if they have been exposed to bed bugs or have experienced pruritis .6. Pay particular attention to unusual developments in skin appearance in any resident. 7. Remain alert to complaints of pruritis .Identification .2. Inspect adjacent areas in the facility for signs of infestation. a. Check resident rooms at night when bed bugs are active. Use a flashlight to check linens, mattresses, etc., for signs of bed bug activity .Eradication of Infestation. 1. Remove and/or treat all infected materials using non-chemical methods, including: a. Washing and drying bedding, linens, and clothing at high temperatures; b. Vacuuming or steam cleaning floors, mattresses, and any porous surfaces that cannot be machine-washed; c. Steaming or heat-treating infested rooms and areas (commercial heating services can be contracted for this procedure); d. Using mattress encasements that are specifically designed to stop bed bugs .Follow up .4. Monitor for bed bugs on a daily basis .Documentation. The following should be documented at the facility level. 1. Identified instances of infestation (including who reported, how it was confirmed, and the date and time). 2. Response to the report of infestation. 3. Actions taken, including all interventions and strategies to eliminate the infestation. 4. Staff training on eradication measures .6. The facility wide plan to monitor and respond to future infestation. The following should be documented at the resident level for those directly affected by the infestation: 1. Resident response to the infestation. 2. Interventions and treatments .4. If complications ensue (bites psychological stress, infections, etc.,) accident/incident reports must be completed for each resident affected .Reporting. Check with local health departments regarding mandatory reporting of bed bug infestation. R22's Admission Record located under the Profile tab of R22 EHR documented the resident was admitted to the facility on [DATE]. R22's [DIAGNOSES REDACTED]. Review of R22's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS - a cognitive evaluation) of 13, which indicated the resident was cognitively intact. The MDS did not indicate the resident had acute mental status changes, inattention, disorganized thinking, or altered level of consciousness. There were no hallucinations, delusions, or behaviors (including rejection of care) identified for R22. On 06/25/19 at 3:16 PM, a Social Services (SS) note, located in the Progress Notes tab of R22's EHR, documented, .It was reiterated that due to bed bug infestation at home it is important that all clothing and furniture be brought to staff for cleaning before allowing it to go to the resident room. (Son) voiced understanding and agreed. The next entry in R22's Progress Notes was a second SS note dated 07/18/19 at 04:04 PM. The note documented, Team met with (R22) and (gender) friends/family to discuss bed bug problem. It was requested that facility handle all laundry. It was decided any clothing brought into facility will be brought to a staff member to launder before taking to room to curb infestation. (R22) and family agreed to strategy. On 09/02/19 at 12:00 PM R22's Progress Notes documented a nursing entry, During bath, red small red bumps noticed on upper chest, mid and upper back. Clothing and bed linens changed. On 09/10/19 at 7:04 AM, Housekeeping Aide (HA)16 was observed cleaning R22's room and was interviewed immediately after. HA16 stated there were no specialized treatments or precautions when cleaning R22's room then whispered, Are you talking about the bedbugs? HA16 stated one of the CNAs, she could not recall which one, asked her about a week ago to look for bedbugs in R22's room. HA16 stated, I looked, but didn't see anything. HA16 stated she looked at the mattress and sheets when changing the bed, during daylight hours. HA16 stated she had never been informed (aside from that request from the CNA) that R22 might be at risk for bedbugs and had not reported the CNA's request to a supervisor. HA16 stated if she had found bedbugs in the room, she would have completed a deep clean but not necessarily reported this to her supervisor. On 09/10/19 at 7:24 AM CNA27, who was caring for R22 that day, was interviewed. She stated she was an agency CNA who worked approximately once a week with R22. CNA27 stated she had not worked with R22 since the previous week, and since R22 dressed (gender) in the morning, had not looked at the resident's skin. CNA27 stated she had not been informed of any potential concern with bedbugs for R22 and was unaware of any precautions should R22 go out with her family, or should the resident's family bring in clothing or other personal items. On 09/10/19 at 10:00 AM, R22 was observed sitting in a chair outside the fourth-floor shower room. R22 stated, This place is filthy. It's crawling with bedbugs. R22 showed the surveyor small round red areas on the resident arms, and several bright red areas on the resident neck which the resident described as bedbug bites. R22 agreed to a full skin check while in the shower. On 09/10/19 at 10:30 AM, and observation was made of R22 in the shower. R22 stated (gender) had reported (gender) concern with bed bugs to the facility, but they don't listen to me. R22 stated (gender) had bedbugs in (gender) home prior to (gender) admission, but they had been cleared up in the hospital and it wasn't until the resident was admitted to the facility that the bed bugs returned. The resident described that about 30 minutes after going to bed at night, the resident started itching all over, and woke up each morning with new bites. Examination of the resident revealed several small, round, reddened, partially dried bumps with serous drainage on the resident's left outer arm and similar areas without drainage on the resident's right arm. The right side of the back of the resident's neck, near the resident's upper back, had several bright red, raised rounded bumps with scratch marks on them. On 09/10/19 at 10:47 AM, LPN12, who stated she often cared for R22, was interviewed. LPN12 stated she knew there were issues with R22's skin, which she described as pruritis. LPN12 stated the Nurse Practitioner (NP) saw R22 the previous week but was not sure what the results of that examination were. LPN12 looked but was unable to find documentation regarding the NP visit. LPN12 stated she was not aware of any historical or current concern with R22 having bedbugs or being exposed to bedbugs through family visits. When asked to review the SS documentation in R22's record, LPN12 covered her opened mouth with her hand and stated, Oh no. Oh no. Oh no. LPN12 stated she had looked at R22's skin just after the surveyor left the shower room and did not notice any issues with R22's skin, but stated she would look again. LPN12 and the surveyor went to R22's room where R22 showed LPN12 the areas on the resident's arms and neck. LPN12 stated she would notify the NP right away. In an interview on 09/10/19 at 12:04 PM, the Director of Nursing (DON) stated she had worked in the facility less than two weeks and had only been informed of the bedbug concern with R22 that morning after they surveyor started asking questions. The DON stated she had instituted a new process to have any belongings brought to the facility for R22 inspected and laundered prior to being taken to her room. The DON stated that the facility would ask R22 to refrain from family outings until the new system was implemented, because of the concern that R22 was being exposed to bedbugs during those outings. The DON stated she would ask the Administrator to call someone to check for bedbugs. On 09/11/19 at 8:26 AM, the DON was interviewed again. The DON stated R22 would be examined by the NP that day, and she anticipated a [DIAGNOSES REDACTED]. The DON stated R22 liked to go out with (gender) son, which presented a challenge as it was thought the son's home had a bedbug infestation. The DON stated the facility had implemented a new plan that when R22 returned from an outing with (gender) son, the resident would be intercepted at the door, taken immediately to the shower, and provided with a change of facility-laundered clothing before returning to the resident room. The DON stated they had also asked R22's son to have any personal items brought into the facility given to nursing staff for inspection and cleaning before being taken to R22's room. The DON stated housekeeping had completed a terminal clean of R22's room that morning, which meant the room had been completely cleaned as if for a new resident; and the exterminator would be out that morning to inspect the room as well. The DON stated R22's roommate and roommate's belongings would be inspected and cleaned, and the roommate would be moved to another room. On 09/11/19 at 12:32 PM, the NP was interviewed after examining R22. The NP stated R22 had insect bites of some kind, which may or may not be bedbugs. The NP stated the bites were not infected and would be treated with [MEDICATION NAME] ointment for comfort. The NP stated, (Gender) does have a history of bedbugs and is taken to an environment with bedbugs, so we can't rule it out. On 09/11/19 at 01:01 PM, the Exterminator was interviewed via telephone. The Exterminator stated he was summoned to the facility that morning to evaluate for bedbugs and asked to inspect R22's room for signs of infestation. The Exterminator stated he inspected areas of the room where bedbugs tend to congregate, including the bed, dresser drawers, and baseboards; and looked for signs of bedbugs including shed casings, live bugs, and black specs. The Exterminator was aware the room had been cleaned prior to his arrival and was not sure if that would impact evidence of bedbugs, but stated he found no evidence of bedbugs during his inspection. The Exterminator stated he was only asked to inspect R22's room that morning and did not inspect adjacent rooms or other areas of the facility. The Exterminator stated his company regularly provided preventive services to the facility and had treated three times in the past year for bedbugs. He described the bedbug issue at the facility as minimal. On 09/11/19 from 5:40 PM to 5:50 PM, the following was observed: R22 entered the facility from the outside entrance door with two male companions. R22 was wearing a light [NAME]et, black and white striped shirt, and green skirt. R22 and (gender) companions approached the elevator, where the MDS Coordinator and surveyor were also waiting. R22 and (gender) companions entered the elevator along with the surveyor and MDS Coordinator and began chatting about the outing from which they had just returned. The MDS Coordinator did not address the resident or (gender) companions. The younger of R22's companions had a rectangular cloth decorative basket under his right arm. The surveyor and MDS Coordinator both exited the elevator on the second floor, with the resident and (gender) companions continuing to the fourth floor. The surveyor accompanied the MDS Coordinator to her office for a brief question, then took the stairwell to the fourth floor, which exited just outside R22's room. After exiting the stairwell, the surveyor observed R22 and (gender) companions exiting the elevator and walking down the hall towards the resident room. R22 and the resident's companions entered the resident's room, where R22 removed the resident's [NAME]et and hung it on a coatrack, and the companion set the cloth basket down on the resident's overbed table. R22 and the residents companions left the room and returned towards the elevator and nurse's station, with R22 still wearing the same clothing the resident was wearing when the resident returned to the facility. As R22 and the residents companions approached the nurse's station, the resident encountered the Assistant Director of Nursing (ADON). R22 introduced the resident's younger companion as the resident's son, stated they had just returned from an outing, and made an inquiry about R22's roommate who had been removed from the room that day. The ADON did not ascertain whether R22 had been showered and offered a change of clothing upon the resident's return. At that time, the DON exited the elevator. R22 and the resident's companions approached the DON, introductions were made, with both the DON and ADON leaving the area after a few minutes of conversation. At 6:00 PM R22, wearing the same clothing R22 had on when the resident returned to the facility, and R22'a two companions went into the dining room and sat at a table while other residents were finishing their meals. Neither the MDS Coordinator, ADON, or DON had intervened when the R22 returned to the facility with R22's son. The MDS Coordinator, the ADON, and the DON failed to address or implement any of the precautions the DON said the facility had in place to prevent the spread of the infestation. No one offered to shower the resident and/or launder R22's clothes and possessions immediately upon R22's return to the facility. On 09/11/19 at 6:05 PM, the DON was located in her office on the first floor of the facility and informed of the above observation. The DON stated, I thought they had been visiting here. (Gender)'s supposed to be on isolation, and left her office to find the resident. The DON had said nothing to the resident or her visitors to indicate the resident had been placed on isolation precautions during the encounter she had with R22 and her family only a few minutes before. There was no evidence in the medical record and no physician's order for isolation. R22 was not aware she had been placed on isolation. There was no signage to indicate to staff and visitors the resident was being isolated, or to alert staff and visitors of any necessary precautions when entering R22's room. On 09/12/19 at 9:00 AM the Administrator was interviewed. The Administrator stated the facility had an ongoing pest control contract with regular visits from an exterminator and had called for additional visits each time bedbugs were discovered in the facility. The Administrator provided an email from the Exterminator to the facility's Director of Procurement. The email identified a history of bedbug treatments in the facility as follows: room [ROOM NUMBER] 11/21/18 - treatment for [REDACTED].>12/05/18 - second treatment 12/19/18 - follow up inspection, no activity noted. 01/17/19 - follow up inspection, no activity noted, room cleared. 05/28/19 - Reoccurrence from current occupant's family bringing clothes into the room. treatment for [REDACTED]. 06/11/19 -second treatment 06/27/19- third treatment. Family advised to no longer bring clothing or materials from home to the occupant. 07/25/19- recheck, no activity found, room cleared. room [ROOM NUMBER] 07/18/19 - treatment 08/08/19 - second treatment 08/22/19 - recheck, no activity found 09/05/19 - no activity present On 09/13/19 at 10:46 AM the NP was interviewed again. The NP stated the facility tended to admit marginal residents who had been living in challenging situations prior to admission, up to and including homelessness, and often are infested with bedbugs at the time of admission or receive visits from people infested with bedbugs. The NP stated this made it very hard for the facility to keep infestations from coming back. The facility was not able to provide evidence of implementation of the following per the facility policy: R22 not checked for bedbugs when returning from outings; R22 was not questioned or examined about bedbugs after skin changes were noted; The facility did not have evidence adjacent rooms were inspected when bedbugs were noted in room [ROOM NUMBER] or room [ROOM NUMBER]; The facility did not have evidence nighttime inspections were carried out; The facility did not have evidence of steam cleaning; The facility did not provide specialized mattress encasements; The facility did not complete facility-level or resident-level documentation; The facility did not document actions taken aside from Exterminator visits; The facility did not have evidence of staff training regarding bedbugs; The facility did not have evidence of a facility-wide plan to monitor for bedbugs; The facility did not have evidence they had met reporting requirements to the local health department.",2020-09-01
195,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,561,D,0,1,A8U811,"LISENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on interviews and record reviews, the facility failed to ensure resident's bathing choices related to the number of baths the resident requested weekly were assessed for 1 sampled resident (Resident 43). The sample size was 53. The facility census was 87. Findings are: Interview on 9/18/18 at 12:12 PM with Resident 43 and Staff Member C who was acting as the resident's interpreter, revealed that bathing had been 2 days a week. Resident 43 confirmed that the resident wanted to bath 3 times a week related to an increase in sweating and itching. Resident 43 confirmed that the resident preferred to be bathed on Monday, Wednesday and Friday. Interview on 9/24/18 at 09:56 AM with the Activity Director revealed that the bathing preferences were documented by the Activity Aide, after the nurse aides had gotten the information. The Activity Director confirmed that during the assessments an interpreter was not used. Interview on 9/24/18 at 10:00 AM with the DON (Director of Nurses) confirmed that after the initial bathing preference questions were asked, there was no follow up on bathing preferences. Record review of Resident 43's Care Plan dated 8/17/18 revealed a focus of Activities of Daily Living. Resident 43 had a Bathing preference for a shower during the day 2 times per week on Monday and Friday.",2020-09-01
196,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,584,E,1,1,A8U811,"> Licensure Reference Number: 175 NAC 12-006.18A(1) Based on observation and interview the facility failed to ensure dining room was free from a scrapped up wall, discolored ceiling tile and foul odors in the hallway of the 400 wing. Sample size was 53. Facility census was 87 Findings are: Observation on 09/17/18 at 3:11 PM revealed the Dining Room on the 400 wing had a wall that was scraped up and the ceiling tiles had light brown stains in places. Observation on 09/19/18 at 2:36 PM revealed the Dining room on the 400 wing had a wall that was scraped up and the ceiling tiles had light brown stains in places. Interview with the Administrator on 09/20/18 at 10:55 AM confirmed that the wall on the 400 wing dining room was scraped up and the ceiling tiles had light brown stains in places. B. Observation on 9/17/18 at 9:30AM revealed a strong foul odor on 4th floor. Observation on 9/18/18 at 9:30 AM revealed a strong foul odor on 4th floor. Observation on 9/19/18 at 08:25PM soiled wheelchair with dark color stain noted in hall. Interview on 9/17/18 at 10:52 Am with Resident 85 confirmed that there were times when the area is odorous. Interview on 9/19/18 at 2:05PM with Resident 60 confirmed that there was a foul odor on 4th floor, Resident 60 reported that it is not as clean as it should be. Interview on 9/19/18 at 825PM interview with Administrator confirmed the odor was strong related to incontinence.",2020-09-01
197,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,641,D,1,1,A8U811,"> Licensure Reference Number 175 NAC 12.006.09B Based on interviews, observations, and record reviews; the facility failed to document the preferred Language and need for interpretive services on the comprehensive MDS for 1 resident (Resident 43) of 53 sampled residents. The facility census was 87. Findings are: Record review of Resident 43's MDS Annual Assessment, dated 12/19/17 revealed the resident was Hispanic or Latino and the resident did not need interpretive services and had no response for the preferred language of the resident. Observation on 9/18/18 at 2:40PM of Resident 43 in an Activity, in which the residents were talking about hunting and fishing, directed by Activity Aide B revealed Resident 43 was at a table and was observed for 15 minutes with no verbal communication with Activity Aide B and the other residents. Activity Aide B asked Resident 43 How long did it take you to catch your first fish? Resident 43 did not respond. Resident 36 who attended the activity, interpreted the question in Spanish and Resident 43 answered the question with 3 hours. Interview on 09/23/18 at 07:56 PM with Resident 43 revealed when the resident was asked, are you able to make choices in how many baths you would like per week the resident was slow to respond. When asked if the resident would like an interpreter Resident 43 responded with yes. Staff Member C, in Spanish, asked the question of are you able to make choices in how many baths you would like per week and Resident 43 answered the question in Spanish. Staff Member C revealed that Resident 43 would like to have 3 baths per week and was only getting 2 baths per week. Interview on 09/24/18 at 09:45 AM with Social Services confirmed that an interpreter was used at times when needed for communicating with Resident 43.",2020-09-01
198,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,656,D,0,1,A8U811,"Licensure Reference Number 175 NAC 12-006.043a (5) Based on record review, observation and interviews; the facility failed to develop a care plan to address language barriers and bathing preferences for 1 resident (Resident 43) of 53 sampled residents. The facility census was 87. Findings are: Record review for the Care Plan of Resident 43 with a revision date of 8/27/18 revealed the language barrier/preference and the need for interpretive services was not located in the care plan. Resident 43's preferences related to bathing were documented as 2 days per week. Observation on 9/18/18 at 2:40PM of Resident 43 in an Activity, in which the residents were talking about hunting and fishing, directed by Activity Aide B revealed Resident 43 was at a table and was observed for 15 minutes with no verbal communication with Activity Aide B and the other residents. Activity Aide B asked Resident 43 How long did it take you to catch your first fish? Resident 43 did not respond. Resident 36 who attended the activity, interpreted the question in Spanish and Resident 43 answered the question with 3 hours. Interview on 09/23/18 at 07:56 PM with Resident 43 revealed when the resident was asked, are you able to make choices in how many baths you would like per week the resident was slow to respond. When asked if the resident would like an interpreter Resident 43 responded with yes. Staff Member C, in Spanish, asked the question of are you able to make choices in how many baths you would like per week and Resident 43 answered the question in Spanish. Staff Member C revealed that Resident 43 would like to have 3 baths per week and was only getting 2 baths per week . Interview on 09/24/18 at 09:45 AM with the MDS (Minimal Data Set: a comprehensive assessment used to complete a person centered plan of care) Coordinator confirmed the Language barrier/language preference had not been addressed in the care plan. Record review for the care plan of Resident 43 with a revision date of 8/27/18 revealed the language barrier and the need for interpretive services was not located in the care plan. The bathing preferences related to bathing were 2 days per week.",2020-09-01
199,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,756,D,0,1,A8U811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12B (5) Based on record review the facility failed to provide pharmacy reviews that recognized a potential irregularity related to the indication for use for a medication. This had the potential to affect two residents. (Residents 61 and 69) out of 53 sampled residents. Findings are: [NAME] Resident 61's record review revealed the MDS (Minimum Data Set which is a comprehensive assessment for long term care residents ) dated 9/6/18 revealed a BIMs (Brief Interview for Mental Status) score of 15, (a score of 13-15 the person is intact cognitively) [DIAGNOSES REDACTED]. Record review of the physician orders [REDACTED]. Record review of electronic and paper documentation revealed no documentation of indications for use, why the resident received the [MEDICATION NAME], [MEDICATION NAME], Tylenol Extra Strength, [MEDICATION NAME] and [MEDICATION NAME]. Record review of (MONTH) MAR (Medication Administration Record) revealed resident received the following medications on a daily basis from (MONTH) 1st through (MONTH) 23rd, [MEDICATION NAME] two times daily, [MEDICATION NAME] two times daily, [MEDICATION NAME] three times daily. The following medications were given for pain from (MONTH) 1st through (MONTH) 23rd, Tylenol Extra Strength two tablets two times daily, [MEDICATION NAME] 22 doses, [MEDICATION NAME] 52 doses, [MEDICATION NAME] 9 doses, and [MEDICATION NAME] 18 doses. On 9/25/18 at 3:15 PM, an interview with the DON (Director of Nursing) confirmed there was no documentation as to why Resident 61 had been prescribed and no pharmacy review related to these medications. B. Resident 69's record review revealed the MDS dated [DATE] revealed a BIMS score of 9 (a score of 8-12 points the person is moderately impaired), [DIAGNOSES REDACTED]. Record review of the physician orders [REDACTED]. Record review of electronic and paper documentation revealed no documentation of indications for use, why the resident received [MEDICATION NAME] and Trazadone. Record review of the (MONTH) MAR indicated [REDACTED]. On 9/25/18 at 3:15 PM, an interview with the DON (Director of Nursing) confirmed there was no documentation as to why Resident 61 had been prescribed and no pharmacy review related to these medications.",2020-09-01
200,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,758,E,0,1,A8U811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12B Based on record review and interview, the facility failed to provide a clinical rationale for the use of an antipsychotic medication for three residents (Residents 22, 23, and 61). The sample size was 53 and the facility census was 87. Findings are: [NAME] Review of Resident 61's Physician orders [REDACTED]. Review of the resident's medical report did not identify that the resident had a [DIAGNOSES REDACTED]. A review of the resident's MDS (Minimal Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 8/31/18 identified that the resident was on an antidepressant medication on a routine basis. B. Review of Resident 22's Physician orders [REDACTED]. Review of the resident's medical report did not identify that the resident had a [DIAGNOSES REDACTED]. A review of the resident's MDS (Minimal Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/18/18 identified that the resident was on an antidepressant medication on a routine basis. Interview on 09/25/18 at 3:08 PM with the Director of Nursing confirmed that Resident 22 was taking a medication for depression and did not have a [DIAGNOSES REDACTED]. C. Review of Resident 23's Physician orders [REDACTED]. Review of the resident's medical report did not identify that the resident had a [DIAGNOSES REDACTED]. A review of the resident's MDS (Minimal Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/19/18 identified that the resident was on an antidepressant medication on a routine basis. Interview on 09/25/18 at 3:08 PM with the Director of Nursing confirmed that Resident 23 was taking a medication for depression and did not have a [DIAGNOSES REDACTED].",2020-09-01
201,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,812,F,1,1,A8U811,"> Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure proper hand washing during meal service having the potential to affect all residents being served from the kitchen. Findings are: On 9/20/2018 at 11:34 AM the Dietary Cook was observed hand washing, after completing hand washing, Dietary Cook I was observed taking the same paper towels used to dry his hands to turn the knob of the faucet. Dietary Cook I went from hand drying directly to the service line to serve food for all the residents that received meal trays on the 2nd and 4th floors of the facility. On 9/20/2018 at 12:03 PM Dietary Cook I was observed by the Dietary Manager and Surveyor washing his hands. The Dietary Manager confirmed hand drying is to be done with clean paper towel and not used again to touch contact surfaces. The Dietary Manager confirmed the paper towels that were used to turn the faucet knob were the same paper towels that were used to dry the cook's hands. Review of the 7/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for food service sanitation practices, revealed the following: 3-301.11 (A) Food employees shall wash their hands as specified under 2-301.12. (1) Food employees shall wash their hands as specified in the Nebraska Pure Food Act.",2020-09-01
202,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,880,E,0,1,A8U811,"License Reference Number. 175 NAC 12-006.17B Based on observation, and interview the facility failed to ensure that residents sharing a room have personal items separated from each other in the bathroom to prevent cross contamination. This had the potential to affect (Residents 19, 63, 24, 77, 81, and 36). Sample size was 53. Facility Census was 87. FACILITY Infection Control Observation on 09/18/18 at 2:00 PM revealed that Residents 19, 63, 24, 77, 81, and 36 that live in the same room and share the bathroom had personal items that were not marked with identification, separated, or divided from each other to prevent cross contamination. Observation on 09/19/18 at 12:53 PM revealed that Residents 19, 63, 24, 77, 81, and 36 that live in the same room and share the bathroom had personal items that were not marked with identification, separated, or divided from each other to prevent cross contamination. Interview with the Administrator on 09/20/18 at 1:03 PM confirmed that Residents 19, 63, 24, 77, 81, and 36 that live in the same room and share the bathroom had personal items that were not marked with identification, separated, or divided from each other to prevent cross contamination.",2020-09-01
203,RIVER CITY NURSING AND REHABILITATION,285058,7410 MERCY ROAD,OMAHA,NE,68124,2018-09-25,925,E,0,1,A8U811,Licensure Reference Number 175 NAC 12-006.18A(4) Based on observation and interview the facility failed to ensure that dead insects were not in light fixtures in the dining room area on the 200 and 400 units. Sample size was 53. Facility Census was 87. Findings are: Observation on 09/17/18 at 2:36 PM revealed the Dining Rooms in the 200 and 400 wings had dead insects in the overhead light fixtures. Observation on 09/18/18 at 3:37 PM revealed the Dining Rooms in the 200 and 400 wings had dead insects in the overhead light fixtures. Interview with the Administrator on 09/19/18 at 07:00 PM confirmed there were dead insects in the light fixtures in the 200 and 400 dining rooms.,2020-09-01
204,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2018-01-31,880,E,0,1,JGP011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview and record review; the facility failed to perform hand hygiene during cares and treatments for Residents 49, 65, 88, and 27. Sample size was 6. The facility census was 91. Findings are: [NAME] Record review of the facility policy and procedure, dated as revised in (MONTH) (YEAR) and reviewed (MONTH) (YEAR), revealed the following: Hand hygiene is the primary means of preventing the transmission of infection. All personnel working in the facility are required to perform hand hygiene to aide in preventing the spread of infection. 1) Hand hygiene will be performed during certain situation. These situations include but are not limited to: a) When coming on duty b) Before and after direct resident contact, eating or handling food, performing invasive procedures. c) after removing gloves, handling soiled linens, equipment, care items, personal hygiene, and using the bathroom. Record review of the facility policy and procedure Infection Prevention and Control Program, modified (MONTH) (YEAR), revealed: Standard Precautions: is a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed [DIAGNOSES REDACTED]. Standard Precautions is a combination and expansion of Universal Precautions and Body Substance Isolation.1) All blood, body fluids, secretions, excretions except sweat, non-intact skin and mucous membranes may contain transmissible infectious agents. 3) Hand hygiene will be performed a minimum of before and after Resident contact, after removing glove, handling soiled lines, and equipment. B. Observation on 1/30/18 at 10:32 AM, revealed Nurse A performing wound care on Resident 49. Nurse A performed handwashing and applied gloves to perform the wound care to Resident 49's wounds. Nurse A after removing a soiled bandage, removed gloves and replaced with new gloves. Nurse A did not perform hand hygiene upon removal of gloves. Interview with Nurse A on 1/30/18 at 11:12AM confirmed that hand hygiene had not been performed upon changing gloves. Interview on 1/30/18 at 11:25AM, with facility Nurse Manager B, confirmed that it was the facility policy to perform hand hygiene upon removing gloves before application of a new pair of gloves, and that upon removing a soiled dressing, the nurse was to remove the gloves, perform hand hygiene and then put on fresh gloves. C. Observation on 1/30/18 at 8:13 AM, Nurse C was observed to prepare medication for administration to Resident 27. Resident 27 was observed to have a nose bleed. Resident 7 had tissue placed inside his nose and removed it to reveal tissue had blood on it. Resident 27 was removing the blood saturated part of the tissue by twisting it off and placing it on the table. Resident 27 was observed to repeat this process. Nurse C sat the medications cup, and a medication cup with applesauce and spoon, onto the table and obtained gloves from the medication cart. Nurse C then picked the blood soiled tissues up and placed them in the gloved hand. Nurse C was then observed to remove the gloves and without performing hand hygiene picked up the medications cup and the applesauce cup from the table. Nurse C then placed the medication cup onto the medication cart top. Nurse C then performed hand hygiene with gel. Nurse C returned to the medication cup and picked it up without gloves and placed it inside the medication drawer for later use. Interview on 1/30/18 at 8:20 AM, with Nurse C, confirmed that the medication cup had been sitting on the table where Resident 27 was having bleeding. Nurse C confirmed that the bloody tissues had been picked up with the gloved hand. Nurse C confirmed that the glove was then contaminated and that hand hygiene was not performed upon removing gloves. Nurse C confirmed that the medication cup would be considered contaminated after being placed on the table where Resident 27 was placing tissues with visible blood. Interview on 1/30/18 at 9:15 AM, with Nurse Manager B, confirmed that upon picking up tissues with visible blood gloves were to be removed and hand hygiene performed. Nurse Manager B confirmed that medication cup placed on the table where Resident 27 had visible blood, that the medication cup would be considered contaminated and infection control practice would not allow the medication cup to be placed in drawer of the medication cart. D. An observation conducted on 1-29-18 at 4:29 PM revealed Nursing Assistant (NA) D entered Resident 65's room and without performing hand hygiene applied gloves and put Resident 65's shoes on. NA D then removed their gloves and without performing hand hygiene applied a new pair of gloves. NA D then pulled down Resident 65's pants and began performing perineal cleansing on the residents front perineal area. NA D then removed their gloves and without performing hand hygiene applied a new pair of gloves. NA D and NA [NAME] roll the resident to their side and NA D completed back side perineal cares. NA D then removed their gloves, went into the bathroom and grabbed more gloves. Without performing hand hygiene, NA D applied new gloves and applied a barrier cream to Resident 65's buttocks. NA D then removed their gloves, went into the bathroom and rinsed off their hands without using soap and for only 10 seconds. NA D then applied gloves and returned to the resident and completed front perineal cares again. Both NA D and NA [NAME] removed their gloves and without performing had hygiene applied new gloved and assisted resident to pull up their pants. NA D and NA [NAME] then rolled the resident side to side to remove the old pad from under the resident. NA D then removed their gloves and without performing hand hygiene applied new gloves and started working with the resident to transfer out of the bed. An interview conducted on 1-19-18 at 4:40 PM with NA G revealed that NA D should have washed or sanitized their hands every time they changed gloves. E. An observation conducted on 1-31-18 at 7:18 AM revealed NA H and NA I entered Resident 88's room to perform catheter cares. NA H and NA I both washed their hands upon entering the resident's room. Both NA H and NA I applied gloves. NA H completed the catheter cares on the resident and removed their gloves. Without performing hand hygiene, NA H applied a new pair of gloves and then rolled resident to complete perineal cares on the resident's back side.",2020-09-01
205,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2019-05-09,550,D,0,1,MOHQ11,"LICENSE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observation and interview, the facility failed to ensure residents were treated with dignity related to staff standing while assisting resident with meal for one of 6 residents sampled (Resident 50 ). Facility census was 91. FINDINGS ARE: Observations on 5/6/19 in the dining room revealed: - At 11:50 AM Registered Nurse (RN) B stood to feed Resident 50 a bite of applesauce. - At 11:53 AM RN B took another resident out of the dining room and returned to feed Resident 50, standing beside the resident. - At 11:59 AM RN B walked away from Resident 50 and returns to give the resident a drink, asked dietary staff for Resident 50's plate. - At 12:00 PM Resident 50's food was served to table, RN B was wondering around room and returned to feed Resident 50, RN B continued to stand. - At 12:03 PM anther resident's food was served and RN B went over and cut up that resident's food. - At 12:05 PM RN B returns to Resident 50 and assisted the resident to eat, continued to stand. - At 12:18 PM brownies were served and Resident 50 was fed by RN B while standing. Observations on 05/08/19 in the dining room revealed: - At 11:40 AM Nursing Assistant (NA) C, stood while feeding Resident 50 soup. - At 11:45 am NA C went over to another table assisting a different resident, - At 11:46 AM returns to Resident 50's table, and gave resident a bite of soup, and then went over and helped a resident at another table fill out a menu. - At 11:48 AM NA C returned to Resident 50's table, touched resident to wake resident up and gave resident another bite, and then walked around the dining room. - At 12:00 PM NA C returned to Resident 50's table and then walked around the dining room. - At 12:04 PM Resident 50 was taken out of dining room. - At 12:25 PM an interview with NA C revealed that NA C had fed Resident 50, but the resident didn't eat as well as the resident usually does, NA C did not know why. On 5/8/19 at 2:35 PM an interview with the Director of Nurses (DON) confirmed that staff are expected to sit down to assist residents to eat meals.",2020-09-01
206,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2019-05-09,812,E,1,1,MOHQ11,"> Licensure Reference Number: 175 NAC 12-006.11E Based on observation record review and interviews, the facility failed to ensure staff do not have bare hand contact with ready to eat food during food service on the Northwest hall. This had the potential to affect 22 residents that eat food served in the Northwest hall dining area. The facility census was 91 Findings are: Observation on 05/08/19 at 11:50 AM of Server A revealed Server A took a croissant off the serving tray with bare hands and placed it on a plate. Server A then reached into a container with raw lettuce with bare hands and without hand hygiene and retrieved a leaf of lettuce and placed the lettuce on the croissant. Using a spoon added imitation crab salad to the croissant. Continued observation on 05/09/19 until 12:23 AM revealed Server A served 5 more croissant sandwiches in the same manner with bare hand contact and no hand hygiene. Interview on 05/09/19 at 3:00 PM with the Dietary Manager revealed Server A should have used tongs to handle the croissant and no bare hand contact. Review of the facility census list revealed 22 residents reside on the Northwest unit and eat food served from the serving line.",2020-09-01
207,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2019-05-09,880,D,0,1,MOHQ11,"LICENSE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview and record review, the facility failed to ensure staff performed hand hygiene while assisting 3 of 6 sampled residents to eat in the dining room. (Residents 9, 54, 50) The facility census was 91. FINDINGS ARE: Dining Observation on 5/8/19 revealed the following concerns: - At 11:40 AM an observation of Nursing Assistant (NA) C, who was feeding Resident 50 soup. - At 11:45 AM NA C went over to another table assisted a different resident to set up food, no hand hygiene was preformed. - At 11:46 AM NA C returned to Resident 50's table, no hand hygiene preformed and gave the resident a bite of soup, adjusted her own hair, and then helped a resident at another table to fill out a menu. - At 11:48 AM NA C returned to Resident 50's table and touched the resident to wake the resident up and gave the resident another bite of food, no hand washing hygiene was preformed. - At 12:20 PM Resident 54 was served, NA D came over to prepare resident's meal, cutting sandwich with fork and knife, adjusted Resident 54's glasses, after NA D walked away from another table where NA D had been assisting another resident to eat. No hand hygiene was preformed. Then NA D fed Resident 9 the meal without hand hygiene being performed. On 5/8/19 at 2:35 PM, an interview with the Director of Nursing (DON) confirmed that hand hygiene should be performed between residents who are assisted to eat in dining room. On 05/08/19 at 03:06 PM a record review of Hand Hygiene and Glove Policy And Procedure, dated (MONTH) 2019, revealed hand hygiene will be performed during certain situations. These situations include but are not limited to: Before and after direct resident contact, eating or handling food, performing invasive procedures.",2020-09-01
208,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,272,D,0,1,W3MZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on observation, record review and interview; the facility staff failed to complete a significant change in condition Minimum Data Set (MDS) for Resident 87 and failed to identify dental issues on the MDS for Resident 1. The facility also failed to identify the resident had a life expectancy of less than 6 months on Resident 34 ' s MDS. The sample size was 23 residents. The facility staff identified a census of 86. Findings are: [NAME] Record review of Resident 87's MDS signed as completed on 3-22-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 14. According to the MDS Manuel a score of 13 to 15 indicated intact cognition. -Required supervision for personal hygiene. -Independent with eating and bed mobility. -Limited assistance with transfers. -Extensive assistance with dressing and toilet use. -Occasionally incontinent of bladder and always continent of bowel. Review of Resident 87's MDS signed as completed on 9-19-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 15. -Required supervision for eating and personal hygiene. -Extensive assistance with bed mobility, transfers, dressing and toilet use. -Frequently incontinent of bowel and bladder and no trial of a toileting program. Observation on 12-1-2016 at 8:00 AM revealed Nursing Assistant (NA) [NAME] and NA F transferred Resident 87 from bed to a wheelchair. An interview on 12-01-2016 at 8:00 AM was conducted with NA E. During the interview NA [NAME] reported Resident 87 had been a 1 person assist with transfers and now is a 2 person assist. On 12-01-2016 at 8:35 AM an interview was conducted with RN C. During the interview, Resident 87's MDS's for 3-22-2016 and 9-19-2016 were reviewed. RN C confirmed that Resident 87 had a change in condition. B. Observation on 11-28-2016 at 2:15 PM revealed Resident 1 had broken and missing teeth. Record review of Resident 1's Minimum Data Set ( MDS,a federally mandated assessment tool used for care planning) dated as completed on 10-13-2016 revealed resident 1 had the [DIAGNOSES REDACTED]. Further review of Resident 1's MDS dated [DATE] revealed no dental issues were identified for the resident. Record review of a Dental Appointment sheet dated 11-2-2016 revealed Resident 1's Dentist had completed an examine and documented Resident 1's clinical condition remains unchanged with multiple root tips, non-storable teeth and fillings that need to be placed. An interview with Registered Nurse (RN) C was conducted on 11-30-2016 at 11:23 AM. During the interview, RN C reported not being able to visualize Resident 1's teeth. RN C confirmed Resident 1's had not changed and did have a prior Dental appointment sheet that indicated the same condition as the report dated 11-30-2016. RN C confirmed the MDS dated [DATE] was incorrect related to Resident 1's dental condition. C. A record review of Resident 34's MDS dated [DATE] revealed under Section J Health Conditions that the resident didn ' t have a life expectancy of less than 6 months A record review of Resident 34's Hospice Plan of Care, signed 11/11/2016, revealed that Resident 34 was admitted to hospice on 07/23/2015. Under section 20, the prognosis was a life expectancy of 6 months or less. Interview with RN C on 12/01/2016 at 10:19 AM revealed the confirmed that Resident 34 was on hospice. RN C confirmed that the Resident 34 ' s Hospice Plan of Care showed that the resident had a prognosis of a life expectancy of 6 months or less to live. RN C confirmed that the MDS answer for J1400 was incorrect for Resident 34.",2020-09-01
209,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,309,G,0,1,W3MZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to re-evaluate pain indicators and implement interventions to manage pain for 1 (Resident 112) of 1 residents reviewed. The facility staff identified a census of 86. Findings are: Record review of Resident 112's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-26-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 3. According to the MDS Manual, a score of 0 to 7 indicated severe cognition impairment. -Independent with bed mobility. -Supervision with personal hygiene. -Limited assistance with on and off the unit. -Extensive assistance with dressing and toilet use. -Received as needed (PRN) pain medication or was offered and the resident declined the medication. Record review of Resident 112's Comprehensive Care Plan (CCP) dated 6-13-2016 revealed Resident 112 had back pain. The goal for Resident 112 was that Resident 112 would rate pain below a 4 on the pain scale. Typed in interventions on the CCP were to balance rest and activity, use numeric scale to rate pain, Tylenol and [MEDICATION NAME] (pain medication) PRN.[MEDICATION NAME] (pain medication) PRN. Further review of Resident 112's CCP dated 6-13-2016 revealed a hand written entry update that Resident 112 received an x-ray due to increased pain and the update dated 10-26-2016 that Resident 112 was to receive Tylenol routine for back pain. Observation on 11-30-2016 at 8:02 AM of personal care for Resident 112 revealed Nursing Assistant (NA) [NAME] and NA F washed hands and donned gloves. Resident 112 was observed to be in bed. Resident 112 yelled out Oh that hurts and was heard to moan and groan as NA F started to cleans the front peri area. Resident 112 continued to yell out stop at NA F and then started to hit at NA F. NA [NAME] assisted Resident 112 into a right laying position for further cleaning. Resident 112 yelled out Your killing me, Oh God Help me, it hurts, Daddy Daddy, oh boy that hurts. NA [NAME] and NA F positioned Resident 112 onto a back laying position and pulled up Resident 112's clothing. When asked by NA F if (gender) wanted to go to breakfast, Resident 112 reported, no. NA [NAME] and NA F did not stop the procedure when Resident 112 complained of pain to report it to the charge nurse. On 11-30-2016 during the observation of care at 8:02 AM, NA [NAME] said Resident 112 was always in pain. Observation on 11-30-2016 at 1:10 PM of Resident 112 being transferred from a wheelchair to the bed revealed NA [NAME] and NA F placed a transfer belt around Resident 112. Both NA [NAME] and NA F explained the transfer task to be completed to the resident. NA [NAME] and NA F began to transfer Resident 112 from the wheelchair and Resident 112 yelled out in pain stating ouch, that hurts and was transferred into bed. NA [NAME] and NA F pulled down Resident 112 pants and positioned the resident onto the resident ' s right side. During the repositioning, Resident 112 yelled out Oh it hurts, help me god, don't move me. NA [NAME] and NA F completed the personal care. An interview was conducted on 11-30-2016 at 1:10 PM after the personal care was completed. When attempting to ask Resident 112 to rate the pain, Resident 112 stated little bit, little bit with furrowed brows. Resident 112 was not able to state a number on a scale of 0 to 10. An interview on 11-30-2016 at 2:01 PM was conducted with Licensed Practical Nurse (LPN) B. During the interview, LPN B reported that NA [NAME] and NA F had informed (gender) about Resident 112's pain. LPN B reported Resident 112 had identified the pain as a little bit. When asked if LPN B had evaluated Resident 112's pain after being notified, LPN B stated no. Record review of The Facility Pain assessment and Treatment Program Policy and Procedure dated 7-2013 revealed the following information: -Policy: All residents will have their pain recognized, assessed and treated. Pain may manifest itself as verbal expression of pain, moaning, sleep disturbances, agitation, rocking, grimacing, withdrawal, crying, and guarding of affected area(s). -Procedure: -1. The resident will be assessed for pain by the licensed nurse at admission, re-admission, quarterly and as needed. -5. Staff will continue to monitor for verbal and nonverbal signs of pain. It may be necessary to ask the resident are you having pain?, are you comfortable?, do you have discomfort or do you ache anywhere?. The pain assessment scale will be utilized to rate the severity of pain. -6. Information regarding the resident's pain, interventions and management will be included in the resident's plan of care. This will be reviewed and modified needed. -treatment plan: [REDACTED] -1. treatment of [REDACTED]. -2. Non-Pharmacological interventions can include repositioning, music, relaxation, distraction, exercise, physical or occupational therapy and application of ice or heat. -4. It may also be necessary to administer pain medication prior to certain activities such as physical or occupational therapy or medical procedures. -5. The licensed nurse will notify the physician if the residents is not experiencing relief with the current treatment plan or are experiencing a new acute onset of pain and pain is interfering with their comfort and/or functional status. The resident will be placed on triggered charting until the resident is free of pain or the pain controlled within the resident's stated acceptance level The facility staff did not provide additional information prior to survey exit.",2020-09-01
210,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,311,D,0,1,W3MZ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility staff failed to implement interventions to prevent a decline in the ability to complete Activities of Daily Living (ADL's) for 1 (Resident 87) of 3 residents. The facility staff identified a census of 86. Findings are: Record review of Resident 87's Minimum Data Set ( a federally mandated assessment tool used for care planning) signed as completed on 3-22-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 14. According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Required supervision for personal hygiene. -Independent with eating and bed mobility. Limited assistance with transfers. -Extensive assistance with dressing and toilet use. - Occasionally incontinent of bladder and always continent of bowel. Review of Resident 87's MDS signed as completed on 9-19-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 15. According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Required supervision for eating and personal hygiene. -Extensive assistance with bed mobility, transfers, dressing and toilet use. -Frequently incontinent of bowel and bladder and no trial of a toileting program. Observation on 12-1-2016 at 8:00 AM revealed Nursing Assistant (NA) [NAME] and NA F transferred resident 87 from bed to a wheelchair. An interview on 12-01-2016 at 8:00 AM was conducted with NA E. During the interview NA [NAME] reported Resident 87 had been a 1 person assist with transfers and now is a 2 person assist. Record review of Resident of Resident 87's medical record revealed there was not evidence the facility staff had implemented interventions to prevent additional declines in ADL status. On 12-01-2016 at 8:35 AM an interview was conducted with RN C. During the interview, Resident 87's MDS's for 3-22-2016 and 9-19-2016 were reviewed. RN C confirmed that Resident 87 had a change in condition. On 12-01-2016 at 10:29 AM an interview was conducted with the Director of nursing (DON). During the interview, the DON confirmed no interventions had been implement, such as therapy, to prevent further decline in ADL status.",2020-09-01
211,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,315,E,0,1,W3MZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(2) Based on record review and interview; the facility staff failed to evaluate a toileting program for 4 (Resident 71, 87, 112 and 82) of 4 sampled residents. The facility staff identified a census of 86. Findings are: [NAME] Record review of the Facility Policy and procedure for Urinary Incontinence (Assessment and Treatment) revised on 11-2013 revealed the following information: -Policy: -All residents will be assessed for urinary incontinence (UI). Residents who have UI will receive treatment and services to prevent complications and restore as much function as possible. -Purpose: -To identify the type/cause, precipitating factors and patterns of urinary incontinence and initiate effective interventions. -Achieve the highest practicable level of urinary continence. -To eliminate or reduce urinary incontinence, the complications caused by incontinence such as urinary tract infection and pressure ulcers and keep the resident odor free. -Restore bladder function if possible. -To maintain the dignity of the resident. -New or change in continence: -1. Attempt to determine a reason for the new or change in continence. -3. Place the resident on triggered charting. All nurses will document the change in condition in the medical record. The documentation will include but not limited to: the number of times they were incontinent during their shift, if the resident was toileted did the resident void on the toilet. -5. The Interdisciplinary Care plan team will develop an individualized care plan to reflect the resident's incontinence, goals and interventions to meet the residents needs. B. Record review of Resident 71's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 11-22-2016 revealed the facility staff assessed the following about the resident: -Brief interview for Mental Status (BIMS) was a 4. According to the MDS Manuel, a score of 0 to 7 indicates severe impairment. -Limited assistance with bed mobility, transfers, and personal hygiene. -Extensive assistance with dressing and toilet use. -Frequently incontinent of bladder without a trail of a toileting program and occasionally incontinent of bowel and no toileting program currently being used. On 11-30-2016 at 12:08 PM an interview was conducted with Registered Nurse (RN) C. During the interview, RN C confirmed Resident 71 was incontinent and Resident 71 was not on a toileting program. C. Review of Resident 87's MDS signed as completed on 9-19-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 15. According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Required supervision for eating and personal hygiene. -Extensive assistance with bed mobility, transfers, dressing and toilet use. -Frequently incontinent of bowel and bladder and no trial of a toileting program. On 11-29-2016 at 4:46 PM an interview was conducted with RN [NAME] During an interview, RN A confirmed Resident 87 had not been evaluated for a toileting program. D. Record review of Resident 112's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-26-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 3. According to the MDS Manuel, a score of 0 to 7 indicates severe cognition impairment. -Independent with bed mobility. -Supervision with personal hygiene. -Limited assistance with on and off the unit. -Extensive assistance with dressing and toilet use. -Occasionally incontinent of bowel and bladder and no toileting program. An interview on 11-30-2016 at 11:57 AM was conducted with RN C. During the interview RN C confirmed Resident 112 had not been evaluated for a tilting program. E. A comparison record review of Resident 82'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 06/22/2016 and 09/12/2016, revealed under Section H-Bladder and Bowel, question H0300 Urinary Continence- Admission MDS assessment dated [DATE] was answered-1 (Occasionally incontinent (less than 7 episodes of incontinence)) and when this was compared to the 90-Day MDS assessment dated [DATE] answered-2 (Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)). A record review of Resident 82's Face Sheet dated 12/01/2016 revealed that Resident 82 was admitted to the facility on [DATE] for some of the following Diagnoses: [REDACTED]. A record review of Resident's 82's Admission Assessment and Initial Care Plan dated 06/15/2016 revealed under section Bladder: check marks under questions-Continent and Incontinent and the question Toileting Plan: Staff Assist. A record review of Resident 82's Plan of Care, dated 06/15/2016 under ADL deficit approaches section-Toileting: Wears pull-ups in case of occasional incontinence. Interview with Registered Nurse D (RN D) on 12/01/2016 at 11:15 AM revealed the following-RN D stated that (gender) reviews charting and interviews with nursing assistants, nurses and family and that would be the assessment and that RN D does not conduct a formal bladder and bowel assessment. RN D would then create a non-specific individual plan in the care plan under toileting. With Resident 82, RN D stated, this was not done for Resident 82. RN D concurred that the comparison showed Resident 82 declined and that no assessment was completed.",2020-09-01
212,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,323,D,0,1,W3MZ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1 (Resident 87) of 1 residents reviewed for falls. The facility staff identified a census of 86. Findings are: Review of Resident 87's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-19-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 15. According to the MDS Manuel, a score of 13 to 15 indicates intact cognition. -Required supervision for eating and personal hygiene. -Extensive assistance with bed mobility, transfers, dressing and toilet use. -Frequently incontinent of bowel and bladder and no trial of a toileting program. -Has had 1 fall since admission. Record review of Resident 87's Comprehensive Care Plan (CCP) dated 6-27-2014 revealed Resident 87 was at risk for falls. The goal identified for Resident 87 was not to have injurious falls. Interventions identified on the CCP included bed and chair alarms, low bed and to instruct Resident 87 to call for assistance. Record review of a Resident Incident Report dated 11-01-2016 revealed Resident 87 was found on (gender) knees. According to the information on the Resident Incident Report sheet dated 11-01-2016, Resident 87 reported to the nurse that (gender) was attempting to pick something up and fell on to the floor. Record review of a departmental Notes sheet dated 11-02-2016 revealed the new intervention to be implemented in an attempt to prevent further falls was to provide a reacher device for Resident 87 to use. Observation on 11-30-2016 at 1:07 PM revealed the reacher device was not seen in Resident 87's room. An interview was conducted on 11-30-2016 with Licensed Practical Nurse (LPN) B. During the interview LPN B searched Resident 87's room and located 2 reachers next to the wall that were covered with papers. When as if Resident 87 could reach the reachers, LPN B report no. LPN B confirmed during the interview that the reachers should be within reach for Resident 87 to use. Observation on 12-01-2016 at 8:03 AM revealed 2 reacher devices were on the floor next to the wall and out of reach for Resident 87.",2020-09-01
213,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,329,D,0,1,W3MZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure psychoactive medications were evaluated for indication for use for 2 sampled residents (Residents 16 and 87) and failed to ensure recommendations for gradual dose reductions were addressed for 2 sampled residents (Resident 16 and 34) of 5 total sampled residents. The facility had a total census of 86 residents. Findings are: [NAME] Resident 16 was admitted to facility on 8/22/13 with a [DIAGNOSES REDACTED]. A review of 11/2016 MAR (Medication Administration Record) revealed Resident 16 had a physician's order for Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) an anti-psychotic medication) 12.5 mg daily at 8 PM for a [DIAGNOSES REDACTED]. A review of Resident 16's Care Plan revealed a problem dated 6/24/15 of psychosocial mood with a [DIAGNOSES REDACTED]. An approach dated 7/14/15 for identified Resident 16 was receiving [MEDICATION NAME] at bed time related to [MEDICAL CONDITION] and [MEDICATION NAME] use (a medication used for [MEDICAL CONDITION]). A review of Resident 16's Informed Consent Form for Psychoactive Medications dated 10/17/16 stated Resident 16 received [MEDICATION NAME] 12.5 mg every bed time for [MEDICAL CONDITION]. The section for target behaviors, expected benefits, and alternative therapies was not completed. A review of 10/6/16, 7/7/16, 4/7/16, and 1/7/16 quarterly Social Services Notes revealed Resident 16 had no behavioral indicators noted. A review of Pharmacy Note to Physician dated 1/7/16 requested an evaluation of Resident 16's use of [MEDICATION NAME] 12.5 mg at bed time. The note did not include a response from Resident 16 ' s physician. In interviews on 12/1/16 at 9 AM and 10:32 AM, Registered Nurse A confirmed no target behaviors had been documented for Resident 16 ' s [DIAGNOSES REDACTED]. A review of facility policy titled Unnecessary Medications dated 7/2015 revealed if a resident is receiving psychoactive medications, the nurse will initiate the Informed Consent for Psychoactive Medications form and will obtain a pertinent diagnosis, target behaviors, expected benefits and alternative therapies. B. Record review of Resident 87's Medication Administration Record [REDACTED]. Review of Resident 87's medical record revealed there was not evidence the facility staff had completed a sleep study. Record review of the facility Policy and Procedure for Sleep assessment dated ,[DATE] revealed the following: -Policy: A sleep assessment will be completed on any resident who experiencing a sleep problem, prior to requesting a routine or PRN (as needed) sleep medication. -Procedure: -The sleep assessment will be initiated when a resident is admitted on medication for sleep either routinely or prn. -The sleep assessment will began the first day at 8:00 PM and continue until 7:00 PM on the 3rd day. The will encompass a full 72 hours of wake and sleep times. An interview on 11-30-2016 at 3:50 PM was conducted with RN [NAME] During the interview RN A reported a sleep study had not been completed and should have been. C. Record review of the face sheet dated 11/30/16 reveals that Resident 34 was admitted on [DATE] for some of the following Diagnoses: [REDACTED]. A record review of the Medication Administration Record [REDACTED]. A record review of the MAR indicated [REDACTED]. A record review of the Medication Regimen Review revealed under 08/09/2016 there is the consultant pharmacist noted note 1) [MEDICATION NAME] letter-no response. A record review of the Resident 34's chart revealed the following: there were no letters for the physician from the consultant pharmacist found in the chart. A record review of two letters Note to Attending Physician/Prescriber dated 06/06/2016 and 07/07/2016 revealed the consultant pharmacist was requesting a review of the medication [MEDICATION NAME] and to consider a gradual dose reduction (GDR) of the medication. An interview with the Director of Nursing (DON) on 12/01/2016 at 10:15 AM confirmed the following: The DON was not able to find any evidence that the Note to Attending Physician/Prescriber had been sent to the physician's office for their review.",2020-09-01
214,ROSE BLUMKIN JEWISH HOME,285059,323 SOUTH 132ND STREET,OMAHA,NE,68154,2016-12-01,467,E,0,1,W3MZ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based upon observations and interviews, the facility failed to ensure functional ventilation fans for resident rooms 412, 414, 415, 418 and 421. This had the potential to affect 5 residents in the facility of 35 residents reviewed. The facility census was identified as 86. Findings Are: [NAME] Environment tour conducted on 11/30/2016 from 10:04 AM to 10:22 AM with the Facility Executive Director (ED) and the EVS (Environmental Services)/Laundry Supervisor revealed the following resident rooms' ventilation fans were not functioning: Room 412 Room 414 Room 415 Room 418 Room 421 An interview with the Campus Manager (CM) and ED, on 11/30/2016 at 10:22 AM, confirmed the above bathrooms ventilation systems were not functioning. A follow-up interview with the CM on 11/30/2016 at 10:55 AM, confirmed that there is no check list in place to ensure that the ventilation fans are checked on a regular basis nor is there any policy/procedure for conducting the checks of the ventilation fans.",2020-09-01
215,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,609,D,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.2(8) Based on observation, record review, and interview, the facility failed to report an allegtion of abuse for residents (Resident 24) 1 of 1 sampled residents. The facility census at the time of the survey was 30. Findings are: Review of documentation in Resident 24's EHR (Electronic Health Record) revealed Resident 24 had a bruise on the right arm that was 13 cm X 7 cm purplish/pink which documented on a Skin Observation Tool. An observation on 2/24/2020 at 4:39 PM of the area on Resident 24's right forearm arm the bruise was approximately the size of the human hand. Review of the admission status revealed an admission date of [DATE]. Review of Skin Sheets under the assessment tab revealed the following skins issues: a.) Review of Skin Observation Tool dated 1/3/2020 revealed Right arm bruise 2 cm X 2 cm. Left arm scattered bruises 3.2 x 1 cm. Right foot-3rd toe reddened on top. Left 3rd toe 0.4 cm X 0.4 cm. Right shin bruise 1 cm 1 cm X 1 cm. and fading. Left shin 1.2 cm X 1 cm. no new skin issues noted. b.) Review of Skin Observation Tool dated 1/10/2020 Right arm bruise 2 cm X 2 cm. Left arm scattered bruises-3.2 x 1 cm. Right foot-3rd toe reddened on top. Left 3rd toe 0.4 cm X 0.4 cm. Right shin bruise 1 cm X 1 cm X 1 cm. and fading. Left shin 1.2 cm X 1 cm. No new skin issues noted. c.) Review of Skin Observation Tool dated 1/17/2020 revealed: Right and left arm bruising fading. Resident receives daily ASA (Aspirin). Skin frail and fragile. Left 3rd toe moist scab area 0.4 cm X 0.4 cm. Right and left shins scattered bruises fading. [MEDICATION NAME] dressing between all toes to promote dryness. d.) Review of Skin Observation Tool dated 1/24/2020 revealed: Right and left arm bruising-resolved does have 0.4 x 0.6 cm scab to area. Left 3rd toe moist scab area 0.3 cm x 0. 3cm. Right and left shins scattered bruises-resolved. [MEDICATION NAME] dressing between all toes to promote dryness. Buttocks reddened e.) Review of Skin Observation Tool dated 2/7/2020 revealed No scab to arm noted. [MEDICATION NAME] dressing between all toes to promote dryness with scabs between toes noted. No new areas of concern noted. f.) Review of Skin Observation Tool dated 2/14/2020 revealed Meglisorb dressing between toes. No other skin issues noted. g.) Review of Skin Observation Tool dated 2/21/2020 revealed Right arm with scattered bruises 13 x 7 cm- purple /pink. Left arm with fading brown bruise. Immeasurable. Review of the Quarterly MDS (MDS (Minimum Data Set-a federally mandated comprehensive assessment tool used for care planning) revealed Resident 24 was extensive assist with 2+ persons for bed mobility, transfer, and toilet unit. Resident 24 was extensive assist with one person for locomotion on and off the unit, dressing and personal hygiene. Review of the progress notes dated 11/14/2019 to 2/26/2020 revealed no documentation of resident running into objects with the wheelchair. It was documented that resident continues to be 1 assist with EZ Stand (mechanical lift to aide in transfers) for all transfers. Total assist with w/c mobility and is needing assist with all meals. This was documented for November, December, (MONTH) and February. Review of the undated care plan for Resident 24 revealed one undated handwritten entry of Resident 24 tending to bruise easily. There were no interventions listed on the care plan to prevent bruising for someone that tends to bruise easily. An interview on 2/27/20 at 1:00 PM with the DON (Director of Nursing) revealed that regarding the bruise on residents right arm there was no investigation of the bruise as to the root cause nor had the potential abuse been reported. The DON confirmed the documentation of the bruise was on the skin sheet and not in the progress note. When DON was asked if the DON had been informed of the 13 cm x 7 cm bruise on the right arm DON replied that no bruising had been communicated to the DON. DON stated further that Resident 24 bruises easily. Review of the Skin Observation Tools dated from 1/3/2020 through 2/21/2020 revealed that until 2/21/2020 the largest bruise Resident 24 had was 3 cm x 1 cm on 1/10/2020 and that the bruises for Resident 24's arms had resolved on 1/24/2020. For a resident with frail and fragile skin that bruises easily Resident 24 had no bruises from the arms from 1/24/2020 through 2/21/2020. Review of the ABUSE, NEGLECT, AND, MISAPPROPRIATION OF PROPERTY POLICY revealed the following: Abuse, Neglect and Misappropriation of Property Policy revealed for reporting and investigating of abuse as: The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State Law. Bath times and during AM/PM care are good times to be observant for unusual bruises, marks or injuries. The following may include, but not limited to possible indicators of abuse/neglect or misappropriation of property: [NAME] Burns, especially unusual location, pattern, or shape; B. Bruises and/or hematomas; C. Bilateral on arms (may indicate shaking, grabbing, rough handling); D. Bruises on inner arms/thighs; E. Bruises on top of the head; F. Clustered bruises on trunk from possible repeated striking; [NAME] Presence of old and new bruises at the same time as from repeated injuries; H. Bruises resembling an object or human hand; I. Bruises that do not resemble the explanation given for the cause; [NAME] Bruise of genitalia/rectum; K. Recent or sudden change in behavior; L. Unjustified fear or unwarranted suspicion; M. Evidence of restraints; N. Injuries of unknown source O. Fractures of unknown source P. Disappearance of personal property. Review of the ABUSE, NEGLECT, AND, MISAPPROPRIATION OF PROPERTY POLICY revealed under Reporting 1. All alleged cases of resident abuse, neglect, and misappropriation of resident's property will be reported to the Administrator or his/her designee. 2. The Administrator or his/her designee will immediately contact the proper authorities. Local law enforcement will be contacted as determined necessary by the Administrator or his/her designee.",2020-09-01
216,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,610,D,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.2(8) Based on observation, record review, and interview, the facility failed to investigate incidents of abuse for residents (Resident 24) 1 of 1 sampled resident. The facility census at the time of the survey was 30. Findings are: Review of documentation in Resident 24's EHR (Electronic Health Record) revealed Resident 24 had a bruise on the right arm that was 13 cm X 7 cm purplish/pink which documented on a Skin Observation Tool. An observation on 2/24/2020 at 4:39 PM of the area on Resident 24's right forearm arm the bruise was approximately the size of the human hand. Review of the admission status revealed an admission date of [DATE]. Review of Skin Sheets under the assessment tab revealed the following skins issues: a.) Review of Skin Observation Tool dated 1/3/2020 revealed Right arm bruise 2 cm X 2 cm. Left arm scattered bruises-3.2 x 1 cm. Right foot-3rd toe reddened on top. Left 3rd toe 0.4 cm X 0.4 cm. Right shin bruise 1 cm's 1 cm X 1 cm. and fading. Left shin 1.2 cm X 1 cm. No new skin issues noted. b.) Review of Skin Observation Tool dated 1/10/2020 Right arm bruise 2 cm X 2 cm. Left arm scattered bruises 3.2 x 1 cm. Right foot-3rd toe reddened on top. Left 3rd toe 0.4 cm's X 0.4 cm. Right shin bruise 1 cm X 1 cm X 1 cm. and fading. Left shin 1.2 cm X 1 cm. No new skin issues noted c.) Review of Skin Observation Tool dated 1/17/2020 revealed: Right and left arm bruising fading. Resident receives daily ASA (Aspirin). Skin frail and fragile. Left 3rd toe moist scab area 0.4 cm's X 0.4 cm's. Right and left shins scattered bruises fading. [MEDICATION NAME] dressing between all toes to promote dryness. d.) Review of Skin Observation Tool dated 1/24/2020 revealed: Right and left arm bruising-resolved does have 0.4 x 0.6 cm scab to area. Left 3rd toe moist scab area 0.3 cm x 0.3 cm. Right and left shins scattered bruises-resolved. [MEDICATION NAME] dressing between all toes to promote dryness. Buttocks reddened e.) Review of Skin Observation Tool dated 2/7/2020 revealed No scab to arm noted. [MEDICATION NAME] dressing between all toes to promote dryness with scabs between toes noted. No new areas of concern noted. f.) Review of Skin Observation Tool dated 2/14/2020 revealed Meglisorb dressing between toes. No other skin issues noted. g.) Review of Skin Observation Tool dated 2/21/2020 revealed Right arm with scattered bruises 13 x 7 cm- purple /pink. Left arm with fading brown bruise. Immeasurable. Review of the Skin Observation Tools dated from 1/3/2020 through 2/21/2020 revealed that until 2/21/2020 the largest bruise Resident 24 had was 3 cm x 1 cm on 1/10/2020 and that the bruises for Resident 24's arms had resolved on 1/24/2020. For a resident with frail and fragile skin that bruises easily Resident 24 had no bruises from the arms from 1/24/2020 through 2/21/2020. Review of the Quarterly MDS (MDS (Minimum Data Set-a federally mandated comprehensive assessment tool used for care planning) revealed Resident 24 was extensive assist with 2+ persons for bed mobility, transfer, and toilet unit. Resident 24 was extensive assist with one person for locomotion on and off the unit, dressing and personal hygiene. Review of the progress notes dated 11/14/2019 to 2/26/2020 revealed no documentation of resident running into objects with the wheelchair. It was documented that resident continues to be 1 assist with EZ Stand (mechanical lift to aide in transfers) for all transfers. Total assist with w/c mobility and is needing assist with all meals. This was documented for November, December, (MONTH) and February. Review of the undated care plan for Resident 24 revealed one undated handwritten entry of Resident 24 tending to bruise easily. There were no interventions listed on the care plan to prevent bruising for someone that tends to bruise easily. An interview on 2/27/20 at 1:00 PM with the DON (Director of Nursing) revealed that regarding the bruise on residents right arm there was no investigation of the bruise as to the root cause nor had the potential abuse been reported. The DON confirmed the documentation of the bruise was on the skin sheet and not in the progress note. When DON was asked if the DON had been informed of the 13 cm x 7 cm bruise on the right arm DON replied that no bruising had been communicated to the DON. DON stated further that Resident 24 bruises easily. Review of the ABUSE, NEGLECT, AND, MISAPPROPRIATION OF PROPERTY POLICY revealed the following: Abuse, Neglect and Misappropriation of Property Policy revealed for reporting and investigating of abuse as: The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State Law. Bath times and during AM/PM care are good times to be observant for unusual bruises, marks or injuries. The following may include, but not limited to possible indicators of abuse/neglect or misappropriation of property: [NAME] Burns, especially unusual location, pattern, or shape; B. Bruises and/or hematomas; C. Bilateral on arms (may indicate shaking, grabbing, rough handling); D. Bruises on inner arms/thighs; E. Bruises on top of the head; F. Clustered bruises on trunk from possible repeated striking; [NAME] Presence of old and new bruises at the same time as from repeated injuries; H. Bruises resembling an object or human hand; I. Bruises that do not resemble the explanation given for the cause; [NAME] Bruise of genitalia/rectum; K. Recent or sudden change in behavior; L. Unjustified fear or unwarranted suspicion; M. Evidence of restraints; N. Injuries of unknown source O. Fractures of unknown source P. Disappearance of personal property.",2020-09-01
217,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,641,D,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09B Based on observation, record review, and interview the facility failed to ensure that the Minimum Data Set Assessment (MDS) (a mandatory comprehensive assessment tool used for care planning) identified the resident's tobacco use for 1 resident (Resident 8) of 1 resident reviewed. The facility census was 30. Findings are: Observation on 2/25/20 at 8:10 AM revealed that Resident 8 exited the facility through the door by the facility chapel and removed a cigarette and lit it. Resident 8 smoked the cigarette and then extinguished the cigarette and disposed of the cigarette into the smoking receptacle. Record review of the Admission Record for Resident 8 revealed that the resident admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Record review of the Restorative Program Note (nurse's note) in the health record of Resident 8 dated 4/4/19 at 3:33 PM revealed that Resident 8 takes the wheelchair outside to smoke. Record review of the MDS assessment dated [DATE] revealed that question J1300 for resident current tobacco use was answered no. Interview on 2/27/20 at 11:34 AM with the facility MDS Coordinator (MDSC) confirmed that Resident 8 had a [DIAGNOSES REDACTED]. The MDSC confirmed that the resident tobacco use was not identified on the annual MDS assessment completed on 4/16/19 and that the MDS would be corrected.",2020-09-01
218,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,678,D,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC ,[DATE].09 Based on record review and interview the facility failed to ensure that the resident's change of Code Status (a resident's choice directing staff to either start CPR (cardiopulmonary resuscitation) or to withhold CPR if the resident stopped breathing and did not have a pulse) was updated on the physician orders [REDACTED]. This affected 1 resident (Resident 17) of 5 residents reviewed. The facility census was 30. Findings are: Record review of the Admission Record for Resident 17 revealed that the resident admitted to the facility on [DATE]. Record review of the facility form titled Code Status (a document containing the resident's choice directing staff to either start CPR or to withhold CPR if the resident stopped breathing and did not have a pulse) dated [DATE] revealed that Resident 17 selected a CPR code status for CPR to be performed. Record review of the facility form titled Code Status dated [DATE] revealed that Resident 17 changed the code status to I do not want CPR done. I want my doctor to order a DNR (Do Not Resuscitate) order. Record review of the Medication Review Report (physician's orders [REDACTED].>Interview on [DATE] at 12:57 PM with the facility Director of Nursing (DON) confirmed that Resident 17 had a code status form choosing to be resuscitated in the event of [MEDICAL CONDITION] dated [DATE] and that Resident 17 updated the code status choice to no CPR on [DATE]. The DON confirmed that the resident physician order [REDACTED].",2020-09-01
219,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,686,D,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility staff failed to perform wound care to prevent potential cross contamination and prevent infection for pressure ulcers and open [MEDICAL CONDITION] for Resident 29. This affected 1 sampled resident. The facility identified a census of 30 at the time of survey. Findings are: Review of Resident 29's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/31/2019 revealed an admission date of [DATE]. Resident 29 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 29 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Resident 29 had 1 unhealed Stage 3 ( Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer/injuries that was not present upon admission/entry or reentry. Resident 29 had other open [MEDICAL CONDITION] on the foot. Resident 29 received pressure ulcer/injury care and applications of ointments/medications other than to feet. Review of Resident 29's Wound-Weekly Observation Tool with an effective date of 2/24/2020 revealed Resident 29 had a facility acquired pressure ulcer to the right heel with a date acquired of 7/9/2019. Review of Resident 29's Skin Observation Tool dated 1/27/2020 revealed Resident 29's right heel closed with 0.3 cm (centimeter) by 0.3 cm scab area. Right heel with dry, frail, fragile skin. Left end of great toe with darkened scab area measuring 1.4 cm by 1.3 cm. Left third toenail bed dry-no drainage or redness. Right top of foot 0.3 cm by 0.3 cm reddened area. Review of Resident 29's History of Present Illness dated 12/19/2019 revealed the following: Resident 29 does have an open area on the right heel. It was closed, but now it has opened up again. Review of Resident 29's physician's orders [REDACTED]. Review of Resident 29's physician's orders [REDACTED]. Continue Praffo boot right foot at all times to offload. Continue to paint left toes with [MEDICATION NAME] BID (twice a day), wash with soap and water and dry. No outer dressing needed. Continue Prevalon boot to left foot at all times for offloading. Review of Resident 29's Care Plan dated 1/15/2020 revealed the following: I have a Stage 3 pressure injury on my heel. I have some dietary supplements to improve healing of ulcer. I have a stage 3 pressure ulcer on my right heel. Observation of Resident 29 on 2/26/20 at 9:40 AM revealed RN-I (Registered Nurse) with the DON (Director of Nursing) present completed wound care for Resident 29's feet. Resident 29 had a sign on their door Contact Precautions with a bag of PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection). RN-I removed Resident 29's socks and boots after donning gown and gloves and placed 2 wet washcloths, a hand towel, and 2 [MEDICATION NAME] swabs on a waterproof barrier on the over the bed table. Resident 29 had a black scabbed area to the right heel, a pink spot on the top of the right hallux (great toe), a black scabbed area on the left hallux and the nail bed of the 3rd toe of the left foot was scabbed. RN-I used a washcloth and started at the top of the right shin directly below the knee and washed the leg down the ankle to the foot then cleaned the pink and black areas on the right hallux and right heel. RN-I then used the same washcloth and started at the top of the shin on the left leg directly below the knee and washed down the leg around the ankle, over the foot then cleaned the black areas on the toes. RN-I then repeated the procedure with another wet washcloth. Interview with RN-I at this time revealed there was soap on the 1st wet washcloth and the 2nd wet washcloth was a rinse. RN-I then used a [MEDICATION NAME] swab and dabbed [MEDICATION NAME] on the black scab on the left hallux and the scab on the 3rd toe of the left foot. RN-I then applied lotion to Resident 29's legs, applied [MEDICAL CONDITION] wear, gripper socks, and then applied the protective boots on both feet. RN-I was observed with artificial nails with a french manicure design. Review of Resident 29's Order Summary Report dated 2/26/2020 revealed the following: Cleanse end of left great toe and 3rd toenail bed with soap and water. Apply [MEDICATION NAME] and leave open to the air two times a day for skin concerns with an active date of 2/26/2020. Lotion both feet. Monitor Skin concern: Monitor right heel daily every shift for skin care with an active date of 2/06/2020. Monitor Skin concern: left heel, bilateral toes with an active date of 10/02/2019. Wash great toe and 3rd toe and apply [MEDICATION NAME]. Leave open to air two times a day for wound care with an active date of 01/10/2020. Wash left great toe (end) with soap and water, then apply [MEDICATION NAME]. Leave open to air two times a day for wound care with an active date of 2/26/2020. Interview with the DON on 2/26/20 at 3:30 PM revealed the facility didn't have a wound care policy. They had a guideline. Interview with the DON on 02/26/20 at 3:48 PM revealed they trained their staff that if the wound is not open they are to go from top to bottom. The DON said Resident 29's wounds were not open so they were to go from top to bottom starting with the leg and working their way down. The DON reported that is the guideline per Lippincott (a publisher of nursing manuals). A copy of this guideline was requested. Review of the untitled and undated materials copied from an unidentified text book received from the DON regarding skin care revealed no documentation of the procedure to clean unhealed pressure ulcers or [MEDICAL CONDITION]. Observation of Resident 29 on 02/27/20 at 9:11 AM revealed RN-K measured Resident 29's foot wounds. On Resident 29's right heel was a long dark brown scab with surrounding redness. The wound bed measured 3.4 cm length by 3 cm wide. The dark brown area of scab formation in the wound bed was 0.3 cm. RN-K confirmed there was scab formation on the heel on the right foot, the hallux on the left foot and the 3rd toe on the left foot. The left hallux had a dark brown/black scab that measured 0.8 cm x 0.8 cm. RN-K revealed the area on the 3rd toe of the left foot was a nail bed that the toenail was removed. There was a scab area inside the nail bed which measured 0.7 cm x 0.4 cm. RN-K confirmed the areas were closed but not healed. Review of the undated Wound Care Reminders sheet revealed the following: Prepare dressing, hand sanitizer, gloves and chucks (barrier) and any other supplies prior to enter room. Follow hand washing protocol and glove. Remove old dressing if needed. Remove gloves and use hand sanitizer and apply new gloves. Measure per PUSH (Pressure Ulcer Scale for Healing) tool guide lines and put in a skin observation tool if needed. Apply new dressing and secure if needed. Follow hand washing protocol and remove and dispose of gloves per protocol. Chart in PCC (electronic health record) in a skin observation tool. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.17.1 (MONTH) 2019 revealed the following: Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable. A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a Stage 1 pressure injury. It should be coded as unstageable. ESCHAR TISSUE: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined. Stable eschar (i.e., dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heels serves as the body's natural (biological) cover and should only be removed after careful clinical consideration, including ruling out ischemia, and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws.",2020-09-01
220,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,692,E,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observation, interview, and record review; the facility staff failed to ensure fluids were in reach or ensure they were offered. This affected 3 of 3 sampled residents (Resident 20, 29, and 30). The facility identified a census of 30 at the time of survey. Findings are: [NAME] Review of Resident 20's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/28/2020 revealed an admission date of [DATE]. Resident 20 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 20 was cognitively intact. Resident 20 required extensive assistance from staff for transfers and locomotion. Resident 20 required supervision and 1 person physical assistance for eating (how resident eats and drinks). A wheelchair was used for a mobility device. Review of Resident 20's Care Plan dated 11/7/2019 revealed the following: I need a lot of help with all my transfers and cares. I need some assist with my wheelchair mobility at times. Interview with Resident 20 on 2/24/20 at 1:44 PM revealed they responded no when asked if they received enough to drink. Observation of Resident 20 at this time revealed they did not have any water or other fluids. There was no water observed in reach and there was no water pitcher or glass in the room. Resident 20 revealed they had not had a water pitcher since breakfast. Resident 20 stated It should be here and pointed to the tray table next to their recliner which they were sitting in. Resident 20's lips were dry with peeling skin. Review of Resident 20's Medical Record revealed no documentation of a fluid restriction or any indication of why Resident 20 would not be receiving fluids. Interview with Resident 20 on 2/24/20 at 4:16 PM revealed could not get to the sink without help. Observation of Resident 20's room on 2/25/20 at 8:18 AM, 2/26/20 at 8:12 AM, 2/26/20 at 8:49 AM, 2/26/20 at 9:21 AM, and 2/26/20 at 10:08 AM revealed there was no water pitcher or glass in the room. Observation of Resident 20 on 2/25/20 at 1:53 PM, 2/25/20 at 2:59 PM, and 2/26/20 at 8:12 AM revealed they were sitting in the lounge in their wheelchair. Resident 20 did not have anything to drink. On 2/26/20 at 7:50 AM an unidentified staff person was observed picking up the water pitchers and glasses from the residents' rooms. The staff member went into the rooms and picked up the pitchers and put them into tubs on a cart in the hall and wheeled it away. At 10:50 AM, an unidentified staff person was observed passing water pitchers and glasses to the residents, 3 hours after they picked up the water pitchers and glasses. B. Review of Resident 29's Quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 29 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 29 required extensive assistance from staff for transfer and limited assistance from staff for locomotion on and off the unit. Resident 29 required supervision and set up help for eating. A wheelchair was used for a mobility device. Review of Resident 29's Care Plan dated 1/15/2020 revealed Resident 29 needed assistance with ADLs (Activities of Daily Living). Review of Resident 29's Medical Record revealed no documentation of a fluid restriction or any indication of why Resident 29 would not be receiving fluids. Observation of Resident 29 on 2/25/20 at 8:08 AM, 2/25/20 at 1:55 PM, and 2/26/20 at 9:19 AM revealed they were in their room and they did not have anything to drink. There was a sign on the door Contact Precautions and This resident is to stay in their room today. C. Review of Resident 30's Quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 30 had no BIMS score as Resident 30 was rarely/never understood. Staff assessment for mental status revealed Resident 30 had short term and long term memory problems and severely impaired cognitive skills for daily decision making. Resident 30 required extensive assistance from staff for eating, bed mobility, transfer and was dependent upon staff for locomotion. Review of Resident 30's Care Plan dated 8/20/2019 revealed the following: I am unable to dine independently due to dementia. Record my food/fluid intake. I take my diet at assisted dining area. Extra fluids are offered by nursing every shift to increase fluid intake. Review of Resident 30's Medical Record revealed no documentation of a fluid restriction or any indication of why Resident 30 would not be receiving fluids. Interview with Resident 30's family member on 02/24/20 02:30 PM revealed Resident 30 never had a cup of water ever since Resident 30 had been in isolation for CRE (carbapenem-resistant [MEDICATION NAME]-antibiotic resistant bacteria) which started on 1/29/2020. Resident 30's family member revealed Resident 30 had to have Styrofoam since they were in isolation and they only brought them one cup if they brought one at all. Resident 30's family member revealed Resident 30 had a cup of water in their room one time when they visited in the evening and it was marked noon and no one had given Resident 30 a drink as the cup was still full. Resident 30's family member revealed Resident 30 needed assistance with drinking. Observation of Resident 30 on 2/25/20 at 8:08 AM, 2/25/20 at 1:58 PM, 2/26/20 at 7:55 AM, 2/26/20 at 8:11 AM, 2/26/20 at 8:49 AM, 2/26/20 at 9:18 AM, and 2/26/20 at 10:07 AM revealed they were in their room. There was a sign on the door Contact Precautions. No water or fluids were observed in the room. Observation of Resident 30 on 02/26/20 10:52 AM and 2/27/20 at 8:00 AM revealed they were in their room. There was a Styrofoam cup in the room that was not in reach of Resident 30. Review of the undated facility policy Hydration Protocol revealed the following: All residents will be offered fluids to meet their needs as determined by nutrition assessment. Extra fluids per resident's consistency are offered to every resident in their rooms every morning in a clean mug/glass and are refilled as often as resident wants and periodic through the day. Fluids are then offered to residents when staff is in resident's room if that resident is unable to help themselves. Documentation for these residents' fluids intake is done by nursing. Meal intake of fluids in the dining room, are documented by dietary; room trays are documented by nursing. Extra fluids given for: UTI/possible UTI (Urinary Tract Infection); S&S (signs and symptoms) of possible dehydration, or other needs. Review of the undated Water Pass Instructions revealed the following: Aide will go room to room and pick up dirty pitcher and cup. These will be placed either in tub or cart from dietary. Aide will fill water pitchers utilizing ice machine and place on cart from dietary. Aide will go room to room and place a clean water pitcher and glass in each room (CRE residents will receive paper products). The time that resident does not have a water pitcher in their room should be no more than 60 minutes. Interview with NA-C (Nurse Aide) on 2/25/20 at 3:40 PM revealed the staff were supposed to offer a drink to the residents every time they went into their rooms or when they requested. They were supposed to pass water every shift and as needed. Interview with the DON (Director of Nursing) on 2/27/20 at 11:07 AM revealed the facility staff were supposed to follow the hour guideline for providing fluids to the residents. One aide is supposed to pick up all the dirty water pitchers and glasses and then they passed new water pitchers and clean glasses. It did take some time, they did put in the policy that is shouldn't take more than an hour. The residents were to have water. If the residents were in isolation, the staff were supposed to put a cup of water in their room and then the residents were to receive extra fluids with meals.",2020-09-01
221,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,812,E,0,1,HGI711,"Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure that staff did not touch the eating surface of the plate and rims of drinking glasses when serving food to residents in the facility dining room. This affected 9 residents (Residents 8, 17, 4, 15, 26, 27, 10, 5, and 7). The facility census was 30. Findings are: Review of the Food Safety Code Preventing Contamination by Employees 3-301.11 Section 81-2,272.10* (Replaces 2013 Food Code 3-3-1.11 (B), (C), (D) and )E) Preventing Contamination from Hands)* (3) Except when washing fruits and begetables, food empoyees shall minimize bare hand and arm contact with exposed food. [NAME] Observation on 2/24/2020 at 11:32 AM of DA-A (Dietary Aide) revealed DA-A gave Resident 8 a glass the food from the serving tray and when doing so touched the rim of the glass by placing DA-A's bare contaminated hand over the top of the glass touching the drinking surface of Resident 8's glass. Observation on 2/24/2020 at 11:48 AM was of Resident 8 taking a drink from the contaminated glass where DA-A's hands had touched the glass when sitting it on the table. B. Observation on 2/24/2020 at 11:54 AM was of DA-A giving the tray of food to Resident 17. DA-A when placing the glass of orange juice on the table touched the rim of the glass by placing the bare hand over the top of the glass which touched the drinking surface of the glass. C. Record review of the Nebraska Food Code, Effective date 7/21/16, 81-2,272.10* (Replaces 2013 Food Code 3-301.11 (B), (C), (D) and (E) Preventing Contamination from Hands) * revealed: (3) Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. Observation on 2/24/20 at 11:33 AM revealed that Dietary Aide A (DA-A) picked up a small plastic cup of pickles from the tray on the top of the serving table hood with the thumb on the inside of the cup. DA-A picked up a bowl of coleslaw from the serving table with the thumb inside of the bowl. Observation on 2/24/20 at 11:39 AM revealed that Dietary Aide B (DA-B) picked up a plate of food with the thumb on the eating surface of the plate. DA-B served the plate to Resident 4 with the both thumbs on the eating surface of the plate. Observation on 2/24/20 at 11:40 AM revealed that DA-B picked up a plate of food with the thumb on the eating surface of the plate and served the plate of food to Resident 15. Observation on 2/24/20 at 11:51 AM revealed that Dietary Aide D (DA-D) grabbed a plate of food with the thumb on the eating surface of the plate. DA-D served the plate with the thumb on the eating surface of the plate to Resident 26. Observation on 2/24/20 at 11:54 AM revealed that DA-D grabbed a plate of food with the thumb on the eating surface of the plate and then served the plate to Resident 27. Observation on 2/24/20 at 11:40 AM revealed that DA-D grabbed a plate of food with the thumb on the eating surface of the plate and served the plate to Resident 10. Observation on 2/24/20 at 11:59 AM revealed that DA-D carried a plate of food with the thumb on the eating surface of the plate and served the plate of food to Resident 5. Observation on 2/24/20 at 12:00 PM revealed that DA-B carried a plate of food with the thumb on the eating surface of the plate and served the plate of food to Resident 7. Interview on 2/27/20 at 1:15 PM with the facility Food Services Supervisor (FSS) confirmed that the staff are not to pick up or handle plates or dishes with the bare hand touching the eating surfaces to prevent the potential for contamination.",2020-09-01
222,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,880,I,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility staff failed to prevent potential cross contamination by failing to follow contact precautions, failing to perform hand hygiene when indicated, failing to clean equipment used by multiple residents, and failing to ensure the facility policies for infection control, immunizations, and antibiotic stewardship were reviewed annually. The facility staff also failed to ensure that staff followed isolation precautions (the use of gloves, gowns, and hand washing to help stop the spread of germs from one person with a known infection to another) and to ensure that hand hygiene (hand washing) was performed when exiting the room of a resident under isolation precautions before entering the room of another resident. This had the potential to affect all of the facility residents. The facility identified a census of 30 at the time of survey. Findings are: [NAME] Interview with the ICC (Infection Control Coordinator) on 2/27/20 at 1:36 PM revealed the facility had 8 residents who had tested positive for CP-CRE (Carbapenem-resistant [MEDICATION NAME] (CRE) are [MEDICAL CONDITION] that that can cause serious infections and require interventions in healthcare settings to prevent spread according to the CDC (Centers for Disease Control)) and required contact precautions and 2 other residents who were discharged from the facility had also tested positive. Observation of the rooms belonging to Residents 29, 6, 14, 1, 30, 22, 31 and 29 on 2/24/20 at 4:05 PM revealed they had Contact Precautions signs and PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) on their doors. Review of the undated facility document Contact Precautions received from the DON (Director of Nursing) revealed the following: Perform hand hygiene before entering and before leaving room, wear gloves when entering room or cubicle, and when touching patient's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces, use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment between patients. Observation of ES-H (Environmental Services) on 2/25/20 at 11:58 AM revealed they were distributing personal clothing to Resident 14 and Resident 1 who shared a room. Contact Precautions were posted on the door. A sign posted on the door read must wear gloves and gown before entering room. ES-H donned gloves and took the clothes into the room, opened a drawer, and placed the clothing into the drawer before closing the drawer. Resident 14 and Resident 1 were present in the room. ES-H did not put a gown on. ES-H then took the gloves off, came out of the room and scrubbed hands with hand sanitizer. ES-H then took clothes to Resident 20, Resident 26, and Resident 7 who did not have contact precautions. ES-H then took clothes to Resident 28 at 02/25/20 at 12:02 PM who had contact precautions and PPE posted on their door. ES-H put gloves on, entered the room, opened the drawer and put the clothes in. ES-H did not have a gown on. ES-H then took the gloves off and used hand sanitizer that was in the dispenser outside the door. Resident 28 was present in the room. ES-H then took clothes to Resident 3, Resident 17, Resident 16, and Resident 21. They did not have contact precautions. On 2/25/20 at 12:06 PM, NA-F (Nurse Aide) took a Styrofoam container of food into Resident 28's room and put it on the wheeled walker platform in front of Resident 28 who was sitting in the recliner then did hand sanitizer and took food to Resident 16 who did not have contact precautions. NA-F was in close proximity to Resident 28 and their belongings and did not have a gown on. On 2/25/20 at 12:09 PM, ES-G brought plastic hangers out of the room belonging to Resident 14 and Resident 1. There was a sign on the door Contact Precautions and PPE. ES-G was wearing gloves and did not have on a gown. ES-G handled the outside of a large white plastic bag marked for CRE hangers with the gloved hands, placed the hangers in the bag, then went back into the room and discarded the gloves. The bag was hanging on the end of a rolling clothes rack that had personal clothing on it that was out in the hall. Resident 14 and Resident 1 were present in the room. At 2/25/20 at 12:10 PM, ES-G had gloved hands and brought hangers from Resident 29's room and placed them in the bag marked for CRE hangers by handling the outside of the bag with the gloved hands. Resident 29 also had a sign on the door Contact Precautions and PPE. ES-G had gloves on and no gown. Resident 29 was present in the room. ES-G then proceeded to push the cart down the hall. The clothes were touching ES-G's smock. ES-G then took clothes into Resident 4's room on 2/25/20 at 12:15 PM then into Resident 2's room. Resident 4 and Resident 2 did not have Contact Precautions on their door. ES-G brought the hangers out of Resident 2's room and hung them on the rack. On 2/25/20 at 12:16 PM ES-G then took clothes in to Resident 5 and Resident 25. Their clothes had also been touching ES-G's smock. On 2/25/20 at 12:17 PM the bag marked for CRE hangers was touching the clothing belonging to Resident 27 and Resident 24 who did not have contact precautions. ES-G was also observed using bare hands when putting the clothes into the closets. On 2/25/20 at 12:19 PM ES-G hung a T shirt on the handrail outside Resident 6's door and it was touching the floor. On 2/25/20 at 12:20 PM ES-G donned gloves and took the T-shirt into Resident 6's room then brought hangers out and put them in the bag marked for CRE hangers by handling the bag with the same gloves. On 2/26/20 at 8:15 AM NA-F was observed carrying a pile of linens (sheets, pillowcases) down the hall up against their uniform. NA-F took the pile of linens into Resident 5's room and put some of the linen on the bed which was stripped. NA-F then took the remainder of the linens still carrying them up against their uniform into Resident 4's room. Interview with LHS (Laundry Housekeeping Supervisor) on 02/27/20 at 11:37 AM revealed the facility staff were supposed to be leaving the hangers in the rooms of residents who have contact precautions until they found a proper procedure for sanitizing them before they brought them out of the room. LHS confirmed they were looking for a disinfectant they could use the clean the hangers. The LHS revealed the facility staff should not be touching the resident clothing to their own clothing when they are passing clothing. If a clothing item fell on the floor or touched the floor the staff should have taken it back to the laundry to wash it. The LHS confirmed that the observations with laundry deviated from their expectations. Review of the undated Policy for Passing linens revealed no documentation of clothing not touching the staff clothing or items should be re-laundered if dropped on the floor or touch the floor. No documentation that staff should not be taking the hangers out of the rooms who had residents in isolation/contact precautions. There was also no documentation that staff should not be taking the same linens from room to room. Review of the facility policy Hallway Policy dated 3/7/2017 revealed the following: Linen carts-load your cart, pass linen and put cart away. B. Observation of the facility bath house on 02/26/20 at 1:52 PM revealed a Penner Cascade jetted tub with a lift chair. NA-E with the DON (Director of Nursing) present proceeded to clean the tub. The DON said they were done with baths for the day so they used a different cleaning procedure as all of the residents used the tub and the residents with CRE received the last baths of the day. NA-E set a timer for 10:45 seconds, dispensed the disinfectant in about 1 1/2 gallons of water into the bottom of the tub, then started wetting the surfaces. Everything was finally wet with 8:47 left on the clock. NA-E then proceeded to use a brush to scrub the tub with Penner disinfectant on the inside of the tub. NA-E said they cleaned the inside of the tub with the Penner disinfectant that was dispensed into the bottom of the tub and NA-E used a spray bottle of the Penner disinfectant the keep the surfaces wet. NA-E said the tub surface had to stay wet with the Penner disinfectant for 10 minutes. NA-E said they would use MicroKill wipes to clean the outside of the tub. NA-E did not put the sprayer or the spray hose into the tub and clean it. NA-E focused on the left side of the tub and did not consistently keep the right side of the tub wet. NA-E only scrubbed the underside of the lift seat that was in the tub 3 times. NA-E did not run the jets on the tub. NA-E said they did the procedure twice so after the 10 minute timer went off, NA-E started over again. This time NA-E put the sprayer into the tub and put the disinfectant on it with the scrub brush but NA-E did not spray the hose on the outside of the tub with the disinfectant. NA-E did not have the sprayer hose wet with disinfectant and the surfaces of the tub were not wet the full 10 minutes. NA-E demonstrated where the disinfectant came out of the floor of the tub, not the jets. NA-E said they did not run the jets when cleaning the tub. At 2:15 PM the DON said they don't have to run the disinfectant through the jets. After NA-E cleaned the tub NA-E wiped the outside of the tub and the sprayer hose with a MicroKill wipe. Observation of the tub of MicroKill wipes read it had a 1 minute wet set time. The surface did not stay wet for the full 1 minute. It was dry in 10 seconds. NA-E also wiped from the floor to the top of the tub when NA-E cleaned the outside of the tub. NA-E then wiped the cabinets which did not stay wet and the paper towel holder. NA-E then sprayed the shower chair with the Penner disinfectant 2 times but it did not stay wet 10 minutes. There was also a commode tub sitting on the shower chair which was not sprayed at all. NA-E then took their gloves off, took another pair of gloves out of the box, laid them on the sink, did hand hygiene with hand sanitizer and then put the gloves on. This was at 2:17 PM. Review of the undated The System Cleaning for whirlpool tubs revealed the following: press and hold the disinfect button #1 located on the left side of the tube. As the button is held down, the properly mixed cleaning solution is running through and disinfecting the pump and motor. Release the button after you see solution coming out of both jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. For aqua-air tubs: press and hold the disinfect button #1 located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. Use a long-handled brush to thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Disinfect the seat by reattaching it to the lift and positioning it over the tub. Use the brush to scrub its surfaces with the remaining solution. Allow for proper disinfectant contact time (Usually 10 minutes or as recommended by the disinfectant manufacturer) and rinse the seat. Replace the seat on the Penner Transfer. Repeat the disinfecting procedure on the wet portions of the lift's upper arm and latching mechanism. Remove the plug from the drain. For Whirlpool tubs, spray water from the shower sprayer into the back outlet until clear water appears from the inlet. Repeat this procedure with the front outlet. Rinse the tub's interior surfaces thoroughly with the shower sprayer. For Aqua-Air tubs spray water from the shower sprayer to rinse out most of the disinfectant solution. Then press and hold the rinse button (32) until you see clear water (not soapy) coming out of the air jets. Release the rinse button. Finish rinsing the interior surfaces of the tub with the shower sprayer. Start the air blower by pushing the Aqua-air button #7. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. Stop the air blower by again pushing the Aqua-Air button #7. There was a picture of the tub on the document. Observation of the facility tub on 2/26/20 at 4:40 PM with the ICC revealed the tub not have any outlets and had a button for the air jets. The ICC confirmed the tub in the tub room looked similar to the tub on the document indicated as an Aqua air jet tub. Observation of the facility tub on 2/26/20 at 4:43 PM with the DON revealed the DON said it was a Cascade side entry tub and thought it looked like an Aqua air tub as there were not outlets. Review of the untitled facility documents identified by the DON as the bathing records for (MONTH) 2019 through (MONTH) 2020 revealed documentation all of the facility residents received a bath during the timeframe of the outbreak of CP-CRE, (MONTH) 2019 to the present. Review of the Penner Disinfectant Cleaner dated 7/7/2011 revealed the following: To disinfect inanimate, hard, non-porous surfaces add 2 ounces of per gallon of water. Apply solution. Allow to remain wet for 10 minutes. Review of the undated Medline Micro-Kill One Germicidal Wipes revealed the following: Exposure time for Escherichia coli and [DIAGNOSES REDACTED] pneumoniae is 1 minute at room temperature. Requested documentation of the first case of CP-CRE from the DON. On 2/27/20 at 9:17 AM Resident 31 tested positive for CRE on 12/9/2019 when they were hospitalized . Resident 31 returned to the facility on [DATE] and had been in strict contact isolation since then. The DON also provided a list of residents who tested positive for CP-CRE (Carbapenemase Producing Carbapenem-Resistant [MEDICATION NAME]-an antibiotic resistant bacteria) and the dates: Resident 29 on 12/27/2019 [DIAGNOSES REDACTED] pneumoniae; Resident 6 on 12/27/2019 eschericia coli; Resident 14 on 1/9/2020; Resident 1 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 30 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 22 on 2/12/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 28 on 2/12/2020. Interview with the DON on 2/27/20 on 11:07 AM revealed Resident 31 took a shower and had their own shower chair in their room as Resident 31 was CRE positive. Resident 21 took a shower and Resident 21's was the shower chair that was in the bath house that NA-E had sprayed twice and it had not remained wet for the full 10 minutes. The DON revealed that if a resident wanted a shower, the staff just put them in the tub and used the shower attachment. Otherwise all of the other residents received a tub bath. The DON revealed they did not know if the staff were allowed to hold resident clothing and linens up against their uniforms or smocks. The DON revealed the expectation was that the staff were supposed to take linens and fill their cart. If they were going to leave it in the hallway they had to cover it. When they were going into the room they were supposed to grab everything for that resident depending on the resident and they were supposed to take 2-4 towels and washcloths. If they took linen into one room they could take it out of that room and take it into another resident's room. If they took linen into one resident's room and didn't need it had to be laundered and not used for another resident. The DON revealed the staff could not take the linen into another resident's room. The staff were allowed to keep the laundry hampers in the hall during am and pm cares so they were not dragging soiled linens down the hall. The DON confirmed that NA-F should not have entered resident rooms with the linen after they had taken the linen into another resident's room; when NA-F crossed the plane of the resident's room with the linen it should not have been taken into another residents room. That is why the facility had carts. Based on contact precautions, as long as they are not going to touch the residents (at first they were strict but they were running out of PPE) so they looked at the standard of care for contact precautions as long as they weren't going to do any direct resident contact for dropping off meals they did not have to wear a gown. Review of the undated untitled modified contact precautions provided by the DON: Contact isolation-any time you are going to come into contact with the resident or the residents belongings you must wear a (sic) isolation gown. The only time that you do not need to wear isolation gowns is: if you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in to do any of these things you must: Do hand hygiene: wash your hands or use hand sanitizer. Apply gloves. Make sure that you or your clothing does not touch the resident or the residents belongings. Deliver what you need to or do what you need to do. Remove gloves. Hand hygiene: wash with soap and water or use hand sanitizer. Interview with the DON on 2/27/20 at 12:55 PM revealed they did not have documentation of communication with ICAP/ASAP (state agencies responsible for infection surveillance when outbreaks of communicable diseases occur in facilities) when they modified the contact precautions. The DON revealed the Administrator made the decision to do the modified (no gown) contact precautions based on the contact precautions information they had. The DON pointed out the statement on the contact precautions document: Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. The DON revealed the facility did not have a procedure in place if the staff did not wear a gown, entered a CP-CRE room and got coughed on or inadvertently contaminated their uniform. The DON revealed that the equipment and surfaces needed to be wet for the amount of time per the recommendations for the Penner Disinfectant and the Micro-Kill wipes. The DON confirmed NA-E should have performed hand hygiene before touching the gloves and the wet times were not long enough on the tub, shower chair, sprayer and sprayer hose, and the cabinets. Interview with the DON on 2/27/2020 at 1:37 PM revealed they didn't know how or when the first resident had CP-CRE or how long it could have been spread. The DON confirmed they had residents who initially were negative for CP-CRE and then were positive at a later time while they were residing in the facility. On 2/27/20 at 2:27 PM the ICC provided the list of residents who were initially negative and then had positive CP-CRE tests while they were in the facility: Resident 14 tested negative 12/27/2020 then tested positive 1/9/2020. Resident 1 tested negative 1/15/2020 then tested positive 1/29/20. Resident 30 tested negative on 1/15/2020 then tested positive 1/29/20. Resident 22 tested negative on 1/29/20 then tested positive 2/12/20. Resident 28 tested negative on 1/29/20 then tested positive 2/12/20. There was no documentation any of these residents were out of the facility in the time frames which indicated the residents were in the facility when they contracted the CP-CRE. C. Review of the facility policy Influenza, Prevention and Control of Seasonal dated 8/11/2015 revealed no documentation it had been reviewed annually. Review of the undated facility policy Infection Prevention and Control Policy and Procedures revealed no documentation it had been reviewed annually. Review of the facility policy Antimicrobial Stewardship Program dated 11/16/2017 revealed no documentation it had been reviewed annually. Interview with the DON on 2/27/20 at 2:28 PM confirmed there was no documentation the facility policies had been reviewed annually. D. An observation of the contact isolation precautions for Resident 6 revealed that a sign on gold paper and placed on Resident 6's door stated anyone entering the room must wear a gown and gloves at all times. Also on a pink sign were instruction for putting on PPE (Personal Protective Equipment) which was complete hand hygiene, apply gown, mask, goggles, or face shield and gloves. An observation on 2/24/2020 at 12:46 PM of ES-H (Environmental Services) delivering laundry into the isolation room for Resident 6 revealed that ES-H cleansed hands with hand sanitizer and walked into the room without applying a gown. An interview on 2/24/20 at 1:00 PM with ES-H revealed that the laundry staff because those staff don't come into contact with the residents only have to wear gloves into the room. An interview on 2/24/20 at 1:07 PM with ES-J revealed the type of PPE worn depends on the job you're doing at the time. Laundry staff only have to wear a pair of gloves into the room since there was no contact with the resident. Housekeeping need to wear a gown, gloves and booties into the isolation rooms. ES-J stated the staff have been doing this forever and are frazzled. Working with the Health Department and getting all kinds of instruction was overwhelming. D. Observation on 2/25/20 at 8:21 AM of NA-E who was taking a breakfast meal to Resident 6 revealed that NA-E was wearing only gloves into the room. NA-E after doing unobserved hand hygiene in the restroom because this surveyor could not get on the PPE (Personal Protective Equipment) in time, went into Resident 23's room and informed Resident 23 that the bath for this resident was ready. NA-E did not complete hand hygiene before going into Resident 23's room. NA-E then went around the room touching the closet door and dresser drawers gathering clothing for Resident 23 to put on after the bath. Review of a Sign at nurses' station that states: Midwest Covenant Home- * Contact Isolation-Any time you are going to come into contact with the resident or the residents belongings you must wear a isolation gown. *The only time that you do not need to wear isolation gowns is: 1. If you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in for these few things you must: a. Do hand hygiene wash your hands or use hand sanitizer b. apply gloves c. Make sure that you or your clothing does not touch the resident or the residents' belongings d. Deliver what you need to or do what you need to do. e. Remove gloves f. Hand hygiene wash with soap and water or use hand sanitizer. There was no documentation or education on the posting or anywhere in the facility to instruct staff what the process was or what to do if the staff not wearing a gown were touched by a resident or the residents personal items came into contact with the staff or the staff 's clothing. Observation on 2/27/20 at 11:39 AM of ES-H (Environmental Services) entering the isolation room for Resident 6 revealed ES-H reached into the pocket of ES-H uniform and removed a pair of gloves and applied them without doing hand hygiene. ES-H then entered the room without putting on an isolation gown. An interview on 2/27/20 at 1:24 PM with the DON (Director of Nursing) revealed the DON did not know what the precautions were if the staff touched items in the room without gloves on or if the resident touched the staff who did not have a gown on. The staff person then would be contaminated and if leaving the room would potentially contaminate everyone the staff person came into contact with. DON stated the staff are being instructed if the staff find out the resident needs something more than just answering the call light. The staff need to remove the gloves. Sanitize the hands and put a gown on then help the resident. Observation on 2/27/20 at 1: 42 PM of the sign outside Resident 22's room a yellow sign on the door that states When entering this room please wear a gown, gloves and mask at all times. Resident 22 had just returned from the hospital around 5:00 PM on 2/26/20 with a [DIAGNOSES REDACTED]. Observation on 2/27/20 at 1:50 PM of RN-K (Registered Nurse) entering the room for Resident 22 revealed RN-K did hand hygiene and applied gloves, gown was applied and a face mask. RN-K then turned off the nebulizer machine (machine used to administer aerosol medication) for Resident 22. Observation on 2/27/20 at 1:57 PM NA-C (Nurse Aide) getting Resident 22 ready to take to the bath revealed NA-C completed hand hygiene with hand sanitizer before applied gloves and a gown before entering the room. NA-C went about the room touching the closet door, the residents' bedside table, and the recliner that the resident was sitting in. Touching the items in the room contaminated the gloves worn by NA-C. NA-C was not wearing a face mask while in the residents' room and NA-C was within 2 feet of Resident 22. Resident 22 stated Resident 22 had to go to the restroom. NA-C got the isolation lift from the hallway by the door to Resident 22's Room and touched the lift without removing the gloves and doing hand hygiene after touching items in the room. This contaminated the handles of the lift. NA-C shut the door to take Resident 22 to the restroom. After 5 minutes NA-C opened the door and placed the contaminated lift in the hallway. NA-C then proceeded to assist Resident 22 out of the room in Resident 22's contaminated wheelchair down the hallway. NA-C was wearing the same gloves that were worn to push the lift into the hallway to push the wheelchair down the hallway. NA-C was pushing the wheelchair and pulling the lift contaminated lift that hadn't been cleaned from the hallway behind them. Resident 22 was brought down the hallway, by other residents, in the contaminated wheelchair that was in residents' room. Wheelchair was not wiped down and resident was not wearing a mask or gown. Resident 22 was wearing the same clothes Resident 22 had been wearing this morning. The door to the bath house was open and NA-C went inside with Resident 22, the contaminated wheelchair and contaminated lift which contaminated the bath house. Review of the undated CRE positive procedure for going to designated activity the process was to: cleaning the resident wheelchair (including wheels and high-touch surfaces like handles), putting on clean clothes; clean resident hands; use reasonable distance from others when positioning the residents'; paper copies of supplies (thrown away after use, i.e. song book); push to activity and push back when done. An interview on 2/27/20 at 2:15 PM with MA-L (Medication Aide) revealed that it is staff preference as to what you want to wear for mask, gown or gloves when entering Resident 22's room. Observation on 2/27/20 at 3:04 PM of Resident 22 sitting at the nurses' station within 3 to 4 feet of the other residents at the activity. Resident 22 was sitting in the same wheelchair that Resident 22 had been taken to the bath house in. Resident 22 was not wearing a mask. When other residents or staff wanted to go down the South hallway they would have to walk within 2 feet of the residents from contact isolation rooms. An interview on 2/27/20 at 3:34 PM with RN-K (Registered Nurse) revealed that Resident 22 was not coughing much at this time and Resident 22 was receiving nebulizer breathing treatments and hopefully would start to cough up some of the secretions from the lungs. Review of the CDC (Centers for Disease Control and Prevention) article Healthcare-associated Infections revealed that the Healthcare Facilities should- Ensure precautions are implemented for CRE (Carbapenem-resistant [MEDICATION NAME] ) colonized or infected patients. These include: *Whenever possible, place patients currently or previously colonized (Some people have germs on or in their body, but those germs do not cause an infection (when germs enter the body, often through medical devices like ventilators, intravenous catheters, urinary catheters, or wounds caused by injury or surgery) or infected with CRE in a private room with a bathroom and dedicate noncritical equipment (e.g., stethoscope, blood pressure cuff) to CRE patients. *Have and enforce a policy for using gown and gloves when caring for patients with CRE. *Have and enforce policies for healthcare personnel hand hygiene before and after contact with patient or their environment, and increase emphasis on hand hygiene on a unit caring for a patient or resident with CRE. *Healthcare personnel should follow standard hand hygiene practices, which include use of alcohol-based hand sanitizer or, if hands are visibly soiled, washing with soap and water. *When a patient with an unusual type of carbapenemase-producing CRE is identified in your facility, work with public health to prevent spread, including following guidance to assess for ongoing transmission. F. Record review of the history and physical documentation by the physician for Resident 31 dated 2/9/20 revealed that the resident had a urine lab test confirming that the resident's urine contained Carbapenem-resistant [MEDICATION NAME] (CRE) [DIAGNOSES REDACTED] (a type of bacteria that has become resistant to carbapenem, a class of antibiotic used to kill bacteria). Observation on 2/25/20 at 2:45 PM revealed that Nursing Assistant C (NA-C) entered the room of Resident 31 without putting on personal protective equipment (PPE) (protective clothing such as gown, gloves, or mask used to protect the wearer's body from infection). Resident 31 was in isolation precautions (requiring the use of gloves, gowns, and hand washing when in the resident room to help stop the spread of germs from one person with a known infection to another) and disposable PPE was available in a holder hanging on the resident's door for staff use. NA-C exited the room of Resident 31 carrying linens and did not perform hand hygiene. NA-C then carried linens into the room of Resident 3. Interview on 2/27/20 at 12:57 PM with the facility Director of Nursing (DON) confirmed that staff are required to wash the hands with soap and water or with alcohol based hand rub when exiting a resident room.",2020-09-01
223,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2020-02-27,883,D,0,1,HGI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to maintain documentation they educated Resident 1 and/or Resident 1's representative regarding the risks and benefits of the influenza immunization and failed to have written permission to administer the influenza immunization to Resident 1. This affected 1 of 5 sampled residents. The facility identified a census of 30 at the time of survey. Findings are: Review of Resident 1's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 11/25/2019 revealed an admission date of [DATE]. Resident 1 had no BIMS (Brief Interview for Mental Status) score as Resident 1 was rarely/never understood. Staff assessment for mental status revealed short term and long term memory problems and severely impaired cognitive skills for daily decision making. Influenza vaccine was received. Review of Resident 1's MAR (Medication Administration Record)/TAR (Treated Administration Record) for (MONTH) 2019 revealed documentation Resident 1 received an influenza immunization injection on 10/7/2019. Record Review of Resident 1's Medical Record revealed no documentation Resident 1 or their representative were educated on the risks and benefits of the influenza immunization and there was no documentation permission was received from Resident 1 or their representative to administer the influenza immunization. Interview with ICC (Infection Control Coordinator) on 2/27/20 at 10:45 AM revealed they were unable to locate the education and permission form for Resident 1's influenza immunization. Interview with the DON (Director of Nursing) on 02/27/20 at 12:55 PM confirmed they were unable to locate the education and permission form for Resident 1's influenza immunization. Interview with ICC on 2/27/20 at 1:36 PM confirmed they were supposed to get permission from the residents and/or resident representative before giving influenza immunizations. Review of the facility policy Influenza, Prevention and Control of Seasonal dated 8/11/2015 revealed the following: The Infection Control Coordinator will promote and administer seasonal influenza vaccine. Unless contraindicated, all residents and staff will be offered the vaccine. There was no documentation that education regarding the risks and benefits of the influenza immunization would be given and permission obtained from the resident or the resident representative would be obtained.",2020-09-01
224,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-06-14,689,D,1,0,1ZPS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, interview, and record review; the facility staff failed to provide supervision to prevent accidents for 2 of 3 sampled residents. This affected Residents 1 and 2. The facility identified a census of 38 at the time of survey. Findings are: [NAME] Review of Resident 1's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/20/2018 revealed an admission date of [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 8 out of 15 possible which indicated Resident 1 had moderately impaired cognitive skills. Resident 1 required supervision with assistance from one staff person for transfers, walk in room and corridor, and locomotion on and off unit. Review of Resident 1's Morse Fall Scale dated 6/7/2018 at 5:40 PM revealed a score of 65 which indicated Resident 1 was at a High Risk for falling. Review of Resident 1's Progress Notes dated 6/5/2018 revealed Resident 1 was found on the floor outside their bathroom door and was transported to the hospital. Blood was noted coming from the head and Resident 1 complained of leg and head pain. Resident 1 was kept in the hospital due to a fracture in the spine. Review of Resident 1's Progress Notes dated 6/7/2018 revealed Resident 1 returned to the facility from the hospital at 1:00 PM. Resident 1 was then found sitting on the floor in their room at 6:32 PM. Resident 1 was noted to be confused this shift and talking with people in the room who were not present. Record review of Resident 1's Care Plan dated 6/7/2018 revealed Resident 1 required assistance from staff for transfers. Staff were to do visual checks on Resident 1 every 2 hours and encourage the resident to call for assistance. Interview with the DON (Director of Nursing) on 6/14/2018 at 2:38 PM revealed Resident 1 was to use the call light to call staff for assistance with transfers. The DON revealed that visual checks every 2 hours was adequate. Interview with Resident 1 on 6/14/2018 at 11:00 AM revealed Resident 1 was disoriented to time, place, and situation and could not convey use of the call light to get assistance. B. Review of Resident 2's Admission MDS dated [DATE] revealed Resident 2 was admitted to the facility on [DATE]. Resident 2 had a BIMS score of 9 which indicated Resident 2 had moderately impaired cognitive skills. Resident 2 required extensive assistance of 2 staff for transfer, walk in room, locomotion on and off the unit, and toilet use. Resident 2 had a fracture related to a fall in the 6 months prior to admission. Review of Resident 2's Morse Fall Scale dated 4/2/2018 revealed a score of 75 which indicated Resident 2 was at a very high risk for falls. Review of Resident 2's Progress Notes dated 4/11/2018 revealed documentation Resident 2 self-transferred at 2:08 PM. Re-educated importance of using call light. At 3:03 PM, Resident 2 was documented transferring self into and out of wheelchair to the bed several times today. Education was given. At 9:30 PM, Resident 2 attempted to stand up from wheelchair and then at 11:34 PM Resident 2 was found sitting on the floor in their room in front of the commode. Resident confused and got up without assist and did not use call light. When reminded to call for assist and not get (up) by self-stated did not know that. Reminded resident to not get up without assistance and showed (gender) call light. No other interventions were documented as implemented. Review of Resident 2's progress notes revealed Resident 2 had falls documented as follows: 4/11-resident was sitting on the floor in room in front of commode at 11:20 PM 4/22-resident was found lying on floor beside bed at 12:30 AM. Resident very confused. Resident received large skin tear right elbow and also abrasion left shoulder. 5/3-resident found on the floor in the dining room at 1:05 PM. Resident states they hit their head. Resident stated that (gender) was trying to get up after finishing their coffee. 6/3-resident got up out of the recliner in the Gathering Area without assistance from staff. Resident fell to the floor at 2:33 AM 6/10-at 10:19 AM resident noted to be on the floor in the gathering place beside the recliner where (gender) was sitting. Resident was transferred to the hospital for 2 lacerations to the head. Review of Resident 2's Care Plan dated 4/10/2018 revealed no documentation of supervision being provided to prevent Resident 2 from falling after Resident 2 was observed attempting to transfer self without calling for assistance on 4/11/2018. Interventions implemented were body pillow while in bed. Remind resident to call for assist despite documentation that Resident 2 did not remember to use the call light for assistance. Interventions added on 4/22/2018 for night shift do 1 hours checks from bedtime to morning with baby monitor in room with receiver were marked off the care plan.",2020-09-01
225,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,550,E,0,1,7KXJ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (6) Based on observation, interview, and record review; the facility staff failed to maintain the residents' dignity by standing while feeding a resident, entering a resident's room without knocking and requesting permission to enter, and failing to ensure a resident was not exposed. This affected 3 of 35 residents who were seated in the dining room (Residents 3, 34, and 14). The facility identified a census of 39 at the time of survey. Findings are: [NAME] Observation of the facility dining room on 11/15/18 at 8:32 AM revealed NA-A (Nurse Aide) was standing next to Resident 3 at the dining room table. NA-A gave Resident 3 a bite of food out of a bowl. NA-A did not sit down to feed Resident 3 in order to interact with Resident 3 or have eye contact with Resident 3. Interview with the DON (Director of Nursing) on 11/20/18 at 3:14 PM revealed the facility staff were supposed to be seated when they were feeding the residents, and it was part of the staff resident rights training. B. Observation of Resident 34's room on 11/14/18 at 2:15 PM revealed an unidentified staff person walked in without knocking and waiting for permission to enter. Resident 34 was sitting in their recliner in their room and was visible from the doorway. Resident 34 was alert and able to grant permission for staff to enter their room if it was requested. Interview with the DON on 11/20/18 at 3:15 PM confirmed staff should knock before they enter a resident's room. It was part of their resident rights training. C. An observation on 11/14/18 at 2:55 PM revealed Resident 14 sitting in the living room area with jean pants pulled up to the upper thighs and Resident 14 had the right buttock and bare skin of the upper thigh was visible from the side and back of Resident 14's wheelchair. An observation on 11/15/18 at 5:24 PM revealed Resident 14 sitting in the Dining Room for dinner sitting at the table with 3 other residents and Resident 14's right buttock and bare skin of the upper thigh was visible from the side and back of Resident 14's wheelchair. Review of Resident 14's Care Plan revealed that Resident 14 required 2 assist to transfer with the EZ stand lift (a mechanical lift to assist with transfers) at all times and with wheelchair mobility. An interview on 11/19/18 at 12:31 PM with the DON (Director of Nursing) revealed that there was no policy for dignity and treating the residents with dignity is a part of the overall quality of nursing care.",2020-09-01
226,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,584,E,0,1,7KXJ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A (1) Based on observation, interview, and record review; the facility staff failed to maintain resident living areas in a clean manner by failing to clean the bathroom exhaust fan covers; and failed to maintain resident living areas in good repair by failing to ensure wood trim on the dining room pass through was not splintered. This affected 6 of 18 residents whose rooms were inspected during the survey (Residents 4, 38, 29, 25, 34, and 12) and had the potential to affect 1 wandering resident (Resident 12) who could potentially use the pass through for support while walking. The facility identified a census of 39 at the time of survey. Findings are: [NAME] Observation of the facility dining room on 11/19/18 at 10:29 AM revealed a pass through opening from the hall into the dining room that was trimmed with wood. The trim on the lower right portion of the pass through opening was splintered. Resident 12 was observed walking around the dining room and the halls holding on the the walls and hand rails for support. B. Environmental tour of the facility with the LHS (Laundry & Housekeeping Supervisor) and the ESS (Environmental Services Supervisor) on 11/19/18 at 10:33 AM revealed the following: Observation of the bathroom exhaust fan covers for Residents 4, 38, 29, 25, 34, and 12 revealed they were covered with gray debris. The LHS confirmed at this time the bathroom exhaust fan covers were soiled and the staff needed to clean them on a more regular basis. The splintered wood trim around the dining room pass through was also observed by the ESS during the Environmental tour. Interview with the facility Administrator on 11/19/18 at 11:37 AM revealed the bathroom exhaust fan covers were soiled and staff were expected to clean them. The Administrator reported that there was no documentation that cleaning the exhaust fan covers was on any type of cleaning schedule. Review of the undated Environmental Services Daily Agenda revealed no documentation of cleaning the bathroom exhaust fan covers. Review of the undated Housekeeping Cleaning Schedule identified by the Administrator as the old cleaning schedule revealed the following: Monthly: vents-ceiling vents, use backpack vacuum to clean vents. Check and clean air conditioner vents as needed. Interview with the facility Administrator on 11/19/18 at 12:40 PM revealed the facility did not have a specific policy regarding monitoring the pass through trim for wear.",2020-09-01
227,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,606,D,0,1,7KXJ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility failed to maintain 4 of 5 personnel files with evidence the NA (Nurse Aide) registry was checked for adverse findings prior to employment, failed to ensure staff working did not have a criminal conviction involving theft on their record prior to employment, and failed to ensure personnel files contained evidence that prospective employees had not been found guilty of abuse, neglect, exploitation or misappropriation. This affected 5 of 10 new staff hired by the facility in the past 4 months. The facility identified a census of 39 at the time of survey. Findings are: [NAME] Review of DA-B's (Dietary Aide) personnel file with a DOH (Date of Hire) of 10/5/2018 revealed a conviction for theft dated 5/7/2018. There was no documentation the NA registry was checked for adverse findings prior to employment. B. Review of the personnel file for NA-C with a DOH of 8/27/2018 revealed no evidence of APS/CAN (Adult Protective Services/Child Abuse & Neglect), NSP SOR (Nebraska State Patrol Sex Offender Registry), or NA registry checks. C. Review of the personnel file for ES-D (Environmental Services) with a DOH of 10/6/2018 revealed no evidence of APS/CAN, Nebraska State Patrol SOR, or NA registry checks. D. Review of the personnel file for NA-E with a DOH of 7/17/2018 revealed no evidence of Criminal background check, APS/CAN, or NSP SOR checks. E. Review of the Personnel file for AA-F (Activity Aide) with a DOH of 9/29/2018 revealed no evidence of Criminal background check, NSP SOR, or NA registry checks. Interview with the Administrator on 11/19/2018 at 4:40 PM confirmed the personnel files did not contain evidence the NA registry, NSP SOR, APS/CAN Registry was checked for adverse findings for DA-B, NA-C, ES-D, NA-E and AA-F. The Administrator confirmed no knowledge DA-B had a conviction of theft on their criminal record. Interview with the facility Administrator on 11/19/2018 at 4:50 PM revealed the facility had not completed NA registry checks for staff who were not nurse aides. The Administrator confirmed that DA-B, NA-C, ES-D, and AA-F had been working in the facility and providing care to the residents. Review of the undated facility policy Abuse, Neglect, and Misappropriation of Property revealed the following: Screening: (facility) will complete a check of the following for all potential employees, prior to the start of their employment. Criminal background check via the Nebraska State Patrol, Adult Central Registry of Abuse & Neglect, Child Central Registry of Abuse & Neglect, Nurse Aide/Medication Aide Registry, State board of licensors/registry (license status verification), Previous/current employers or other reference. Evidence of all of the above checks, will be maintained in the employee's file in the Business office. (Facility) will not employ or continue to employ anyone that has a history of documented abuse, neglect, or misappropriation of property. Potential Employees: Employees that have gone through the interview process that (facility) would like to hire, but cannot until the results listed above have been completed and are in the employee's file.",2020-09-01
228,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,607,E,0,1,7KXJ11,"LICENSURE REFERENCE NUMBER 12-006.04A3b Based on interview and record review, the facility failed to implement the facility policy for screening prospective applicants prior to employment. This affected 5 of 5 personnel files reviewed of the 10 facility staff hired in the past 4 months. The facility identified a facility census of 39 at the time of survey. Findings are: Review of the undated policy Abuse, Neglect, and Misappropriation of Property revealed the following: Screening: (Facility) will complete a check of the following for all potential employees, prior to the start of their employment: Criminal background check via the Nebraska State Patrol, Adult Central Registry of Abuse & Neglect, Child Central Registry of Abuse & Neglect, Nurse Aide/Medication Aide Registry, State board of licensors/registry (license status verification), Previous/current employers or other reference. Evidence of all of the above checks, will be e maintained in the employees file in the Business office. (Facility) will not employ or continue to employ anyone that has a history of documented abuse, neglect, or misappropriation of property. Potential Employees: Employees that have gone through the interview process that (facility) would like to hire, but cannot until the results listed above have been completed and are in the employee's file. Review of the personnel file for DA-B (Dietary Aide) with a DOH (Date of Hire) 10/5/2018 revealed no evidence of the Nebraska State Patrol SOR (Sex Offender Registry) check of NA (Nurse Aide) Registry. Review of the personnel file for NA-C with a DOH of 8/27/2018 revealed no evidence of APS/CPS (Adult Protective Services/Child Protective Services), Nebraska State Patrol SOR, or NA registry checks. Review of the personnel file for ES-D (Environmental Services) with a DOH of 10/6/2018 revealed no evidence of APS/CPS, Nebraska State Patrol SOR, or NA registry checks. Review of the personnel file for NA-E with a DOH of 7/17/2018 revealed no evidence of Criminal background check, APS/CPS, NE State Patrol SOR checks. Review of the Personnel file for AA-F (Activity Aide) with a DOH of 9/29/2018 revealed no evidence of Criminal background check, NE State Patrol SOR, or NA registry. Interview with the facility Administrator on 11/19/2018 at 5:20 PM confirmed the personnel files did not contain evidence the background and registry checks were completed. The facility Administrator confirmed all 5 staff members had been working in the facility.",2020-09-01
229,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,623,D,0,1,7KXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.05 (5) Based on interview and record review, the facility failed to notify the Ombudsman (a person appointed by the state who advocates for residents' rights) when Resident 5 was transferred to the hospital for a facility initiated discharge. This affected 1 of 1 sampled residents. The facility identified a census of 39 at the time of survey. Findings are: Review of Resident 5's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) Discharge Tracking Record dated 8/2/2018 revealed Resident 5 was transferred to the hospital for an unplanned discharge. Review of Resident 5's MDS Entry Tracking Record revealed Resident 5 returned to the facility on [DATE]. Review of Resident 5's Progress Notes revealed Resident 5 was transferred to the hospital on [DATE] for evaluation after a fall with injury. There was no documentation the State Ombudsman was notified Resident 5 was transferred to the hospital. Interview with the facility Administrator on 11/20/18 at 4:08 PM revealed the State Ombudsman was not notified Resident 5 was transferred to the hospital.",2020-09-01
230,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,641,D,0,1,7KXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B(1) Based on record review and interview, the facility staff failed to code the MDS (Minimum Data Set-a federally mandated comprehensive assessment tool used to develop a resident's care plan) to reflect the PASRR (Pre-admission Screening and Resident Review, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) [DIAGNOSES REDACTED]. The facility census was 39. Findings are: Review of Resident 14's MDS dated [DATE] under Section A 1500 for this section check all conditions related to possible MI (Mental Illness) ID/DD (Intellectual Disability/Developmental Disability) no diagnoses marked. In Section I of the MDS for Resident 14 dated 1/2/18 the [DIAGNOSES REDACTED]. Review of Resident 14's medical diagnoses revealed the [DIAGNOSES REDACTED]. Review of Resident 14's PASRR level I screen dated 4/9/2009 revealed the [DIAGNOSES REDACTED]. An interview on 11/19/18 at 4:48 PM with MDS (MDS Coordinator) confirmed that the MDS dated [DATE] for Section A did not contain the same [DIAGNOSES REDACTED].",2020-09-01
231,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,689,D,1,1,7KXJ11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, interview, and record review; the facility staff failed to ensure Resident 38's oxygen tank was safely stored away from a heat source and secured to prevent it from falling over. This had the potential to affect 1 of 1 sampled residents (Resident 38). The facility identified a census of 39 at the time of survey. Findings are: Interview with Resident 38 on 11/14/18 at 1:34 PM revealed the resident went outside the facility to smoke. Resident 38 reported they had to remove their oxygen tank from the back of their wheelchair. which was contained in a bag before they could take the wheelchair outside when they went out to smoke. Observation of Resident 38 on 11/15/18 at 12:21 PM revealed Resident 38 wheeled themselves down the hall in their wheelchair to the exit by the activity room. Resident 38 stood up from the wheelchair, removed the oxygen tank from the back of the wheelchair, propped the oxygen tank against the wall next to a heating unit. Then Resident 38 wheeled themselves out the back door of the facility. The oxygen tank was not secured to keep it from potentially falling. Resident 38 proceeded to smoke while sitting in the wheelchair outside. Observation of the oxygen tank on 11/15/18 at 12:38 PM with the facility Administrator revealed the oxygen tank was propped up against a wall heating unit. Interview with the facility Administrator on 11/15/18 at 12:50 PM confirmed there was power going to the wall heating unit. Interview with the DON (Director of Nursing) on 11/20/18 at 3:11 PM confirmed the oxygen tank needed to be secured. Review of the facility policy Oxygen Storage Protocol dated 6/2012 revealed the following: When used by a resident the oxygen tank needs to be secured to wheelchair or two wheeled cart so the oxygen tank is ready for use. When in storage room must be in rack to prevent falling. Not to be stored by active heat sources. All storage locations are labeled with signs.",2020-09-01
232,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,761,E,0,1,7KXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E4 Based on observation, interview, and record review; the facility staff failed to label insulin and glucose controls with the date they were opened to ensure they would be discarded within the required time frame. This had the potential to affect 10 of 10 sampled residents who had blood sugar monitoring machines (Residents 37, 4, 25, 15, 9, 13, 24, 3, 29, and 19) and 1 of 3 residents who had insulin stored on the medication cart (Resident 37). The facility identified a census of 39 at the time of survey. Findings are: [NAME] Observation of the facility medication room on 11/20/18 at 10:10 AM with MA-G (Medication Aide) revealed each resident had their own blood glucose testing machine on a rolling cart with drawers. In the top drawer of the cart were 2 bottles of Assure Dose glucose controls (solution used to check the accuracy of the glucose monitoring machines) with the seals missing- evidence the bottles had been opened. There was one bottle for high and one bottle for low. Neither bottle was marked with the date the bottle was opened. The directions on both bottles read use within 90 days of opening. Residents who had glucose monitoring machines, on the cart in the medication room, were Resident 4, Resident 25, Resident 37, Resident 15, Resident 9, Resident 13, Resident 24, Resident 3, Resident 29, and Resident 19. Interview with the DON (Director of Nursing) on 11/20/18 at 10:34 AM confirmed there was no documentation of when the bottles of control solution were opened. The DON confirmed the staff were supposed to mark the date they were opened on the bottles. B. Observation of the medication cart on 11/20/18 at 10:48 AM revealed a bottle of [MEDICATION NAME] 70/30 insulin with Resident 37's name on it, that was not marked with the date it was opened. The [MEDICATION NAME] cover was missing, indicated it had been opened. The items on the medication cart were stored at room temperature. Interview with the DON 11/20/18 at 10:48 AM confirmed the nursing staff were supposed to mark the insulin bottles with the date they were opened. Review of Resident 37's Medication Review Report dated 11/20/2018 revealed an order for [REDACTED]. Review of Resident 37's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed the [MEDICATION NAME] 70/30 insulin was administered to Resident 37. Review of the undated facility policy Pharmaceutical Services revealed the following: The expiration date is required on all non-unit dose containers. Review of the Nursing (YEAR) Drug Handbook revealed the following directions for 70/30 insulin: Once opened or unopened vial has been stored at room temperature, stability is 28 days.",2020-09-01
233,MIDWEST COVENANT HOME,285062,"P O BOX 367, 615 EAST 9TH STREET",STROMSBURG,NE,68666,2018-11-20,880,E,0,1,7KXJ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E5 Based on observation, interview, and record review; the facility failed to store medications on the medication cart to prevent potential cross contamination. This had the potential to affect 7 of 25 residents whose medications were stored on the medication cart (Residents 37, 36, 9, 32, 5, 31, and 1). The facility identified a census of 39 at the time of survey. Findings are: Observation of the medication cart for north and east halls with MA-G (Medication Aide) on 11/20/18 at 10:10 AM revealed nose spray, inhalers, topical creams and eye drops were in the same drawers in contact with each other in the medication cart for Residents 37, 36, 9, 32, 5, 31, and 1. Interview with ADON (Assistant Director of Nursing) on 11/20/2018 at 10:18 AM revealed the eye drops, topical creams, nose sprays, and inhalers were to be separated by dividers in the drawers. Review of the undated facility policy Pharmaceutical Services revealed medications should be stored in compartments within the storage area and should be segregated by resident. External medication (ointments, creams, eye medications, suppositories, etc.) will be stored in a drawer on the medication cart separate from the internal medications.",2020-09-01
234,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,583,D,0,1,TTUV11,"Licensure Reference Number 175 NAC 12-006.16C2 Based on observations and interviews, the facility failed to ensure one unsampled resident's information (Resident #36) wasn't in view of others. Census: 60 residents. Sample: 25 residents An observation on 07/01/19 between 12:50 PM and 1:10 PM revealed the 300 med cart was unattended beside the nurses station with the computer screen left open to resident eMar (electronic medication administration record). Medical information for Resident #36 was visible and easily accessible to the public. LPN-E was at the nurses station on the phone. RN-K, the nurse responsible for the 300 med cart, was down the hallway in the room of Resident #36. RN-K came to nurses station, walked past the open coputer on the 300 med cart and entered the med room located around the corner from the nurses station. RN-K returned to the nurses station, walked past the 300 med cart with medical information for Resident #36 visible to the public, back down the hallway. RN-K returned with Resident #36 to the nurses station, ance again, walking past the open computer with visible resident information. The administrator, came out of a resident room on 300 hall and walked to nurses station area, walking past the 300 med cart with the open computer with information for Resident #36 visible to the public. An interview on 07/01/19 at 01:10 PM with RN-K confirmed the computer on the 300 med cart was left open to the eMar and was unattended with medical information for Resident #36 visible to the public. An interview on 07/01/19 at 01:10 PM with the administrator verified that the computer on the 300 med cart was left open to the eMar and was unattended with medication information for Resident #36 visible to the public.",2020-09-01
235,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,641,B,0,1,TTUV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record reviews and interviews the facility failed to ensure MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans): 1) recorded the receipt of insulin injections for one sampled resident (Resident 22); 2) recorded the receipt of an influenza vaccination administered in the facility for one sampled resident (Resident 13); and 3) record the actual dates for the receipt of influenza vaccinations for two sampled residents (Residents 33, and 51) and one non-sampled resident (Resident 23). Facility census was 60. Sample size was 25 current residents. Findings are: [NAME] Record review of Resident 22's Admission Record printed on 7/1/19 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 22's (MONTH) 2019 Medication Administration Record [REDACTED]. Record review of Resident 22's MDS assessments revealed a Quarterly review assessment was completed on 1/11/19. Examination of the assessment reveled in the medication section the resident received injections on 7 of the last 7 days but in the section for Insulin the assessment recorded the resident had not received any insulin injections over the last 7 day period. Interview with the Medical Records Coordinator, LPN (Licensed Practical Nurse)-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 22's quarterly MDS on 1/11/19 failed to record the insulin injections received by the resident during the reference period of the MDS. B. Record review of Resident 13's Admission Record printed on 7/1/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 13's Quarterly review MDS completed on 3/30/19 revealed in the section entitled Influenza vaccination that the resident had not received an influenza in the facility for this year's influenza season (fall of (YEAR) through winter 2019). The reason recorded for not receiving the vaccination in the facility was Received outside of this facility. Record review of an Immunization Report for Resident 13 printed on 7/1/19 revealed the resident consented to an influenza vaccination and was administered an influenza vaccine in the facility on 10/16/2018 by LPN-[NAME] Interview with the Medical Records Coordinator, LPN-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 13 received an influenza vaccine in the facility on 10/16/2018 and the quarterly MDS on 3/30/19 had inaccurately documented the resident received the vaccination at an outside facility. C. Record review of Resident 33's Admission Record printed on 7/1/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 33's Quarterly review MDS completed on 4/29/19 revealed the resident received in influenza vaccination at the facility on 11/12/2018. Record review of Resident 33's Immunization Report dated 7/1/2019 revealed the resident received an influenza vaccination administered by the Memory Support Unit Coordinator, LPN-C on 10/12/18. Interview with the Medical Records Coordinator, LPN-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 33 received an influenza vaccination on 10/12/18 and the quarterly MDS 4/29/19 had recorded the wrong date of the receipt of the vaccination. D. Record review of Resident 51's Admission Record printed on 7/1/19 revealed the resident was admitted on [DATE]. Record review of Resident 51's Quarterly review MDS completed on 5/31/19 recorded the resident received influenza vaccination on 10/4/2016. Record review of Resident 51's Immunization Report dated 7/1/2019 revealed the resident consented to and was administered an influenza vaccination by LPN-A on 10/12/2018. Interview with the Medical Records Coordinator, LPN-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 51 received an influenza vaccination at the facility on 10/12/18 and the quarterly MDS on 5/31/2019 had recorded the wrong date of the current immunization. E. Record review of Resident 23's Admission Record printed on 7/1/19 revealed the resident was admitted on [DATE]. Record review of Resident 23's Annual MDS completed on 4/10/19 recorded the resident received influenza vaccination on 10/13/2017. Record review of Resident 23's Immunization Report dated 7/1/2019 revealed the resident consented to and was administered an influenza vaccination by LPN-A on 10/12/2018. Interview with the Medical Records Coordinator, LPN-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 23 received an influenza vaccination at the facility on 10/12/18 and the quarterly MDS on 4/10/2019 had recorded the wrong date of the current immunization.",2020-09-01
236,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,657,D,0,1,TTUV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C1c Based on observation, record reviews, and interviews, the facility failed to update care plans to reflect changes in care related to 1. UTIs (urinary tract infections) for one sampled resident (Resident 43) and 2. an abscess for one sampled resident (Resident 44). Facility census was 60. Sample size was 25. Findings are: [NAME] On 6/26/19 at 9:13 AM during an interview, Resident 43 reported having frequent urinary tract infections with symptoms causing discomfort and expressed concern that nothing was being done for it. Resident 43 also revealed having recently had pills for this concern but stated this had not helped much. On 6/27/19 at 2:17 PM, Resident 43 reported continued discomfort related to having a urinary tract infection but also reported having started taking a new medication for this and expressed hope this would provide relief soon. Review of the Medication Administration Record [REDACTED]. The same record indicated that [MEDICATION NAME] (an antibiotic commonly used to treat UTIs) had been started at 9:55 PM on 6/26/19 and was scheduled to be given twice a day until 7/6/19. The Care Plan for Resident 43 contained interventions to monitor for signs and symptoms of UTI but did not include any information regarding actual UTIs in (MONTH) or the use of antibiotics to treat this condition. On 6/27/19 at 3:53 PM, an interview with RN (Registered Nurse)-A who served as the facility's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used to develop resident care plans) coordinator verified that the Care Plan for Resident 43 had not been updated regarding the resident's UTIs in (MONTH) or the use of antibiotics to treat this condition. B. On 6/26/19 at 2:47 PM, an interview with LPN(Licensed Practical Nurse)-D revealed that Resident 44 had recently developed an abscess near the anal area which was being kept lightly packed with guaze tape and covered with a dressing to keep the wound clean. The packing was being changed every other day at bed time and the dressing was replaced when it became soiled or loose. RN-D clarified that Resident 44 recently had a similar area on the left inner buttock directly across from this area which was treated for [REDACTED]. On 6/27/19 at 9:38 AM, NA(Nurse Aid)-G and NA-H stated that open areas on Resident 44's buttocks had been an ongoing concern and verified that the current abcess was on the right buttock. NA-G and NA-H verified that it was their responsibility to keep the area clean and to report if the dressing became soiled to the nurse on duty. On 7/01/19 at 10:46 AM an interview with Resident 44 revealed that the abcess on the right inner buttock was not painful. Resident 44 expressed confidence that staff were caring for this abcess appropriately as there had been a previous area on other side which had healed. On 7/01/19 at 1:06 PM, LPN-E accompanied this surveyor to the tub room to observe the wound on Resident 44's buttocks. NA-F assisted Resident 44 to stand while LPN-E opened the area to reveal a small slit about 0.5 cm long on the inner aspect of the right buttock which had a narrow strip of gauze tape hanging from the wound. The gauze had areas of bright red drainage on it, but no purulent drainage was visible at the time of this exam. LPN-E verified that no purulent drainage had been noted since the abcess had been drained by the physician on 6/21/19. The Care Plan for Resident 44 showed potential for skin breakdown related to [MEDICAL CONDITION], fragile skin, immobility, and history of pressure ulcer to coccyx, 5/27/19 history of resident picking at skin, 5/29/19 red raised area to upper abdomen, and 6/20/19 open area to left gluteal cleft. The Care Plan did not reflect the current abcess on the resident's right buttocks. On 7/01/19 at 3:04 PM, LPN-A who worked in Medical Records verified that the Care Plan for Resident 44 had not been updated to reflect the abscess on the right buttock which was currently being treated.",2020-09-01
237,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,676,D,0,1,TTUV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews, and interviews, the facility failed to provide further assessment to identify causal factors and determine if referral for specialized rehab or restorative nursing was warranted for one sampled resident (Resident 22) with a decline in walking ability. Facility census was 60. Sample size was 25 current residents. Findings are: Record review of Resident 22's Admission Record printed on 7/1/19 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Observations of Resident 22 at breakfast and noon meal times on 6/25; 6/26; 6/27; 7/1; and 7/2/19 revealed the resident mobilized from the resident's room to the dining room independently per wheelchair. The resident was not observed walking to meals on those days. Interviews with Resident 22 on 6/26/19 beginning at 10:21 a.m. and on 7/1/19 at 11:04 a.m. revealed the resident's primary mode of getting to meals, toileting, and going to activities was per wheelchair. The resident acknowledged having walked more in the past and stated was on a routine therapy but due to the gout pain and deformities of the toes it became harder to walk, so the resident transferred to wheelchair and other surfaces but did not walk in the room or corridor to meals or activities. The resident confirmed not being approached about a further therapy evaluation or restorative program, but would be agreeable to this to determine if the resident could walk better. Record review of Resident 22's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed an Annual assessment was completed on 4/10/19 and a Quarterly review assessment was completed on 1/11/19. Comparison of these assessments revealed on 1/11/19 the resident was assessed as walking in the room and corridor under staff supervision, oversight, encouragement, or cueing. The 4/10/19 assessment recorded the resident's walking in the room or corridor did not occur during the previous 7 day period. The MDS also recorded the resident had not received any Physical or Occupational Therapy during the assessment period (4/4 through 4/10/19), nor had the resident received any Restorative Nursing program during the assessment period. The assessment recorded the resident had received Physical Therapy which ended on 2/14/2019 and Occupational Therapy which ended on 3/22/19. Record review of a CAA (Care Area Assessment- additional assessment documentation based on triggered problem areas from the MDS) revealed a problem area of ADL (Activities of Daily Living including walking ability) Functional/Rehabilitation Potential triggered for Resident 22 based on the 4/10/19 annual assessment. The CAA documentation identified the resident was at risk for complications of immobility. The CAA summary statement recorded the resident required assistance with ADLs at times and was unaware of limitations. There was nothing in the ADL CAA summary identifying a decline in the resident's walking ability, causal factors for the decline, or any needed therapy or restorative nursing referrals. The CAA recorded that Therapy could be referred to PRN (as needed). Record review of Resident 22's therapy documentation revealed a Physical Therapy discharge summary indicating the resident ended physical therapy treatment on 2/14/2019. The document recorded at the time of discharge from therapy the resident's current level of functioning included walking 10 feet, and walking 50 feet with two turns. The current level of resident functioning for this task was Supervision or the provision of assistance intermittently for the resident to complete these tasks. Interviews with direct care staff regarding Resident 22's care and treatment: - Evening shift LPN (Licensed Practical Nurse)-D on 6/26/19 at 2:55 p.m. revealed the resident was basically independent with cares, rarely complained of pain. Mobilizes per wheelchair independently. - NA (Nurse Aide)-L, evening shift employee, and NA-M primarily a night shift employee on 6/26/19 at 3:10 p.m. revealed the resident uses call light if needing assistance. Mobilizes per wheelchair, does not walk to meals or in room on their shifts, transfers self from wheelchair to other surfaces unless needing help with the resident's catheter. - NA-N, day shift employee, on 7/1/19 at 10:09 a.m. revealed the resident was basically independent except catheter care. NA-N stated the resident was not walking like before due to pain to knees and back. Interview with the RA (Restorative Nursing Aide)-0 on 7/1/19 at 11:31 a.m. verified Resident 22 was not referred to restorative or therapy related to the decline in walking ability. RA-0 stated the resident had previously been on a restorative program but often refused and was discharged . Interview with the Medical Records Coordinator, LPN-A on 7/2/19 beginning at 11:00 a.m. confirmed Resident 22 experienced a decline in walking ability from supervised walking in the room and corridor to not walking as evidenced by MDS assessments conducted on 1/11/19 and 4/10/19. LPN-A verified there was no documentation in the CAA information or resident's medical record explaining further an evaluation of the resident's decline to determine causal factors and whether or not the resident should be referred to therapy or Restorative Nursing for further screening.",2020-09-01
238,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,684,D,0,1,TTUV11,"Licensure Reference Number: 175 NAC 12-0006.9D2 Based on observations, record reviews, and interviews, the facility failed to identify and assess treatment to one sampled resident (Resident 19) who had both feet sunburned. Current sample size was 25. Facility census was 60. Findings are: Observation on 06/25/19 at 10:00 a.m. Resident 19 was sitting in the dining area in the locked unit. The tops of Resident 19's feet were exposed and both right and left feet were bright red as if sunburned. Resident interview on 06/25/19 Resident 19 reported that both feet were sunburned from getting to much sun over the weekend. Resident 19 also verified that staff did not place any sun block on the feet and this is why they sunburned. Resident 19 stated that no treatment had been provided to address the sunburn on both feet. Record review on 07/01/19 09:43 AM There was no documentation in progress notes identifying Resident 19's sunburn on both feet, no skin assessment identifying that Resident 19 had a sunburn on both feet and no care planning addressing treatment and interventions. Record review 07/01/19 last skin assessment completed on 07/01/19 only revealed a bruise on Resident 19's abdomen and nothing on having both feet sunburned. Facility Policy on non-pressure skin conditions states Non-Pressure skin conditions will be assessed and measured every 7 days or more frequently if indicated, until resolved. This did not occur and was not identified in any records for Resident 19's sunburned feet. Staff interview on 07/01/19 at 09:44 a.m. LPN(Licensed Practical Nurse)-C Unit Coordinator verified not being aware of Resident 19's sunburned feet. LPN-C Unit Coordinator Confirmed that no skin assessments or documentation of any kind had been completed on Resident 19's sunburned feet. Staff interview on 07/01/19 at 10:04 a.m. Administrator verified the resident had a sunburn on both feet and staff did not identify this and no assessment or care planning were developed to address Resident 19's sunburned feet.",2020-09-01
239,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,689,E,0,1,TTUV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record review, and interviews, the facility failed to ensure an oxygen concentrator was shut off during periods of being unattended for one sampled resident (Resident 49). The failure could potentially oxygenate the resident's room increasing the hazard of fire; Facility census was 60. Sample size was 25. Findings are: [NAME] Record review of Resident 49's Admission Record printed on 7/1/2019 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Interview and observation with Resident 49 on 6/26/19 at 10:00 a.m. revealed the resident used oxygen continually per oxygen concentrator when in the room and per tank when out of the room. Observations of Resident 49's oxygen concentrator revealed the following observations on 6/25/19: - at 2:00 p.m. the resident was out of the room, the oxygen concentrator was running set at two liters of oxygen delivery. The concentrator was unattended. - at 3:30 p.m. Resident 49's room mate reported the resident left for an appointment. The resident was out of the room, the oxygen concentrator was running set at two liters of oxygen delivery. The concentrator was unattended Record review of Resident 49's electronic Progress Notes revealed an entry on 6/25/19 at 1:55 p.m. that recorded the resident was out of the facility at an appointment accompanied by staff. Interview on 6/25/19 at 3:50 p.m. with direct care staff NA (Nurse Aide)-I and NA-H verified Resident 49's oxygen concentrator was left on while unattended for the duration of the resident's appointment. Observations on 7/1/19 at 8:00 a.m. through 8:35 a.m. revealed Resident 49 was in the dining room eating breakfast while the resident's oxygen concentrator remained on at 2 liters per minute delivering oxygen in the resident's room while unattended. Interview with the DON (Director of Nursing) on 7/1/19 at 8:37 verified Resident 49's oxygen concentrator was left on delivering oxygen in the room while the resident was in the dining room and the concentrator was unattended.",2020-09-01
240,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,801,F,0,1,TTUV11,"Licensure reference Number: 175 NAC 12-006.04D2a Based on record reviews and interview, the facility failed to ensure the Dietary Manager had the credentialing to meet the regulatory requirements for the position. This had the potential to affect all residents. Facility Census was 60. Findings are: Record review of the Dietary Manager's employee record verified the Dietary Manager didn't have the regulatory required training to meet the required credentials. Staff interview on 06/27/17 at 09:06 a.m. Dietary Manager verified not having the required credentials for the Dietary Manager Position. The Dietary Manager reported being enrolled in a food service management course that would be completed within a year. Staff interview on 07/01/19 at 11:00 a.m. Administrator verified the Dietary Manager did not have the required credentials for the Dietary Manager Position.",2020-09-01
241,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,812,F,0,1,TTUV11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observations, and interviews, the facility failed to: 1) Prevent build up of dirt and debris on all ceiling vents located in the kitchen located over food preparation areas, and 2) Clean the dirt and debris off the ceiling located next to the hood over the stove and over the food prep areas. These failures had the potential to affect all residents. Facility census was 60. Findings are: [NAME] 06/25/19 at 10:37 a.m. Kitchen observation revealed that all ceiling vents located in the kitchen located over food preparation areas had dirt and debris located on them. 06/27/19 at 09:06 a.m. Kitchen observation revealed that all ceiling vents located in the kitchen located over food preparation areas had dirt and debris located on them. 06/27/19 at 09:08 a.m. Staff interview Dietary Manager verified there was dirt and debris located on all the vents located in the kitchen ceiling located over food preparation areas. 07/01/19 at 11:00 a.m. Staff interview Administrator verified there was dirt and debris located on all the vents located in the kitchen ceiling located over food preparation areas. Review of the 7/21/16 version of the Food Code, based on the United States Food and Drug Administration food Code and used as an Authoritive reference for the food service sanitation practices, revealed the following: 6-5-1.14(A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt and other materials. B. 06/25/19 at 10:37 a.m. Kitchen observation revealed the main kitchen ceiling by the hood over the stove and food preparation area had dirt and debris located on it. 06/27/19 at 09:06 a.m. Kitchen observation revealed the main kitchen ceiling by the hood over the stove and food preparation area had dirt and debris located on it. 06/27/19 at 09:08 a.m. Staff interview Dietary Manager verified there was dirt and debris located on the main kitchen ceiling located by the hood over the stove and food preparation area. 07/01/19 at 11:00 a.m. Staff interview Administrator verified there was dirt and debris located on the main kitchen ceiling located by the hood over the stove and food preparation area. Review of the 7/21/16 version of the Food Code, based on the United States Food and Drug Administration food Code and used as an Authoritive reference for the food service sanitation practices, revealed the following: 4-601.11 Equipment, Food-Contact Surfaces, NonFood-Contact Surfaces, and Utensils. (C) NONFOOD-CONTACT SURFACES of equipment shall be kept free of an accumulation of dust, dirt, residue, and other debris.",2020-09-01
242,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,909,D,0,1,TTUV11,"Licensure Reference Number: 175 NAC 12-006.18B3 Based on observations and interviews, the facility failed to ensure that the bed canes were tight and functioning for one sampled Resident (Resident 16). Sample size was 25 current residents. Facility census was 60. Findings are: Observation on 06/25/19 at 03:12 p.m. Resident 16's bed had two bed canes located on it and both bed canes were loose to the touch. Observation on 06/27/19 at 09:45 a.m. Resident 16 was sitting on the bed and attempted to use the bed cane for support in transferring and Resident 16 almost fell forward as the bed cane was loose. Record review on 06/27/19 Work History Report only identified that beds were checked monthly but it is not specific as to what resident beds are looked at and reviewed. Resident Interview on 06/27/19 at 09:23 a.m. Resident 19 verified the bed canes had been loose for sometime now and was not sure if they had been checked by staff. Staff Interview on 06/27/19 at 09:52 a.m. Administrator and Maintenance Supervisor verified the bed canes located on Resident 19's bed were both loose and required tightening or replacing the bed canes completely.",2020-09-01
243,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2019-07-02,925,F,0,1,TTUV11,"Licensure Reference Number: 175 NAC 12-006.18A(4) Based on observations, and interviews, the facility failed to clean out one light fixture of dead insects in the main kitchen. All Residents could be affected. Facility Census was 60. Findings are: 06/25/19 at 10:37 a.m. Large Kitchen observation identified one light fixture with dead insects located in it. The Light fixture was located on the kitchen ceiling in front of the the stove hood. 06/27/19 at 09:06 a.m. Large Kitchen observation identified one light fixture with dead insects located in it. The Light fixture was located on the kitchen ceiling in front of the the stove hood. 06/27/19 at 09.08 a.m. Staff interview with Dietary Manager verified there were dead insects in the light on the ceiling in front of the stove hood located in the main kitchen. Dietary Manager confirmed the lights should have been cleaned out. 07/01/19 at 11:00 a.m. Staff interview with Administrator verified there were dead insects located in the light on the ceiling in front of the stove hood in the main kitchen.",2020-09-01
244,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,164,D,0,1,7J6I11,"Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations, record review and interview; the facility failed to ensure that privacy was provided during medical procedures for one sampled resident (Resident 21). The facility census was 46 with five residents sampled for observations of medication administration. Findings are: Observations on 7/10/17 at 11:10 AM revealed Resident 21 seated in the recliner in room. Further observations revealed LPN (Licensed Practical Nurse) - A obtained a blood sugar reading without closing the door or utilizing the privacy curtain. LPN - A also administered an injection into the resident's abdomen without providing privacy. Further observations revealed staff members and residents walking in the hallway by the resident's room while these procedures were done. Review of the facility procedure Subcutaneous Injection, dated 5/19/17, revealed the following including: . Provide privacy . Interview with the Director of Nursing on 7/11/17 at 1:00 PM confirmed that the nurses were to provide privacy for the residents during care and medical procedures.",2020-09-01
245,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,280,E,0,1,7J6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews: the facility failed to: 1) include a Nurse Aide in developing resident care plans for two sampled residents (Residents 15 and 53); 2) update one sampled resident's care plan (Resident 46)to remove problems and interventions related to isolation procedures which had been discontinued; and 3) update one sampled resident's care plan (Resident 7) to remove interventions pertaining to therapies which had been discontinued. Facility census was 46. Findings are: [NAME] Record review of Resident 15's Admission Record printed on 7/10/17 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 15's Care Plan revealed the current care plan with goals through 7/24/17 was developed and updated following a quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) on 4/24/17. Review of the care plan document, the resident's electronic medical record and chart revealed no documentation that a Nurse Aide was included in the development of the resident's care plan. B. Record review of Resident 53's Admission Record printed on 7/10/17 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 53's Care Plan revealed the current care plan with goals through 7/24/17 was developed following a quarterly MDS assessment on 4/24/17. Review of the care plan document, the resident's electronic medical record and chart revealed no documentation that a Nurse Aide was included in the development of the resident's care plan. Record review of a facility document listing the interdisciplinary team members involved in developing care plans revealed the team consisted of: The MDS Coordinator, RN (Registered Nurse)-J; the facility Social Service Director; the facility Life Enrichment Coordinator (Activities Director); and the Certified Dietary Manager. Interview with RN-J, the MDS Coordinator on 7/12/17 at 11:25 a.m. confirmed that Residents 15 and 53 had care plan revisions developing the current care plans following MDS assessments on 4/24/17. RN-J verified that nurse aides familiar with resident care were included in the MDS assessments but were not included in the team developing the resident's care plan. Licensure Reference Number 175 NAC 12-006.09C1c C. Observations of Resident 46's room revealed no isolation equipment or supplies. Review of the Care Plan, goal date 7/24/17, revealed that the resident had a history of [REDACTED]. Further review revealed approaches including instruct family/visitors/caregivers to wear disposable gown and gloves during physical contact with the resident. Discard in appropriate receptacal (sic) and and wash hands before leaving room, Instruct visitors to wear disposable gloves and gown when in residents (sic) room and to wash hands before leaving room and CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry with reocurring(sic) infectious process as indicated. Interview with LPN (Licensed Practical Nurse) - E, Infection Control Nurse, on 7/12/17 at 10:45 AM confirmed that the resident was no longer in contact isolation and the care plan needed to be revised to remove the approaches listed above. D 7/10/2017 2:12 PM Record review of the care plan revealed that Resident (7) was recieving Physhical Therapy and Occupational Therapy from the facility. 7/10/2017 2:20 PM interview with Restorative Nurse (I) confirmed that Resident (7) care plan was not updated Therapies had been discontinued several months ago and Resident (7) has been in restorative therapy for months. 7/10/2017 2:25 PM Restorative Nurse (I) updated Resident (7) care plan to reflect current status infront of me.",2020-09-01
246,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,281,D,0,1,7J6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on record reviews and interview, the facility failed to follow physician orders [REDACTED]. The facility census was 46 with 16 current sampled residents. Findings are: Review of Resident 59's Report of Consultation, dated 5/30/17, revealed that the resident's right heel ulcer was evaluated and new treatment orders were received. Further review revealed an order to follow up 1 month. Review of the resident's medical record, including physician orders [REDACTED]. Interview with LPN (Licensed Practical Nurse) - E, Unit Coordinator, on 7/11/17 at 10:30 AM confirmed that a follow up appointment was not made as ordered by the physician. Interview with the Director of Nursing on 7/11/17 at 1:00 PM confirmed that a follow up appointment to evaluate the resident's right heel wound should have been made as ordered by the physician.",2020-09-01
247,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,323,E,0,1,7J6I11,"Licensure Reference Number 175 NAC 12-006.09D7a Based on observations, record review and interview; the facility failed to ensure that chemicals were secured on the SCU (Special Care Unit) to reduce the risk of accidental exposure or injury for 10 residents identified as confused and wandering and at risk (Residents 10, 51, 28, 20, 39, 49, 68, 34, 27 and 44). The facility census was 46 with 13 residents residing on the SCU. Findings are: Observations on 7/6/17 at 9:00 AM, during the initial tour of the facility, revealed an unlocked utility room cupboard on the SCU which contained two spray bottles of Power Bolt cleaner. Interview on 7/6/17 at 9:00 AM with LPN (Licensed Practical Nurse) - B, Unit Coordinator, confirmed that the cupboard was to be locked to reduce the risk of accidental exposure and injury for 10 residents who were confused and wandered in the unit. Interview with the Director of Nursing. on 7/6/17 at 9:15 AM, confirmed that the chemicals were to be locked and secured on the SCU to protect the confused and wandering residents. Review of the MSDS (Material Safety Data Sheet) for Power Bolt Power Cleaner revealed the following including: Signs and Symptoms of Overexposure: Eyes: Causes eye irritation. Symptoms may include redness and pain. Skin: Caused mild skin irritation. Symptoms may include redness. Ingestion: (MONTH) cause mouth, throat and stomach irritation. Symptoms may include nausea, vomiting and diarrhea. (MONTH) also cause Central Nervous System effects including headache, dizziness and weakness. Inhalation: High concentrations of vapor or mist may cause nose, throat and respiratory tract irritation. Symptoms may include coughing. High concentrations of vapor or mist may also cause Central Nervous System effects including headache, dizziness and nausea.",2020-09-01
248,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,367,D,0,1,7J6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.11A3 Based on observations, record reviews, and interviews; the facility failed to ensure that Resident (59) received a diet as ordered by the physician. Facility census was 46 and 16 residents were sampled. Findings are: On 7/06/2017 at 11:45 AM interview with Cook F revealed Resident 59 was on a mechanical soft diet. Observation on 7/6/2017 at 11:45 AM revealed Cook F followed the diet cards and served Resident 59 a mechanical soft diet. On 7/11/2017 at 1:30 PM observation in the dining room revealed Resident 59 eating a chicken leg. Interview with the Dietary Manager at this time revealed Resident 59 didn't like their food ground up so the cook just gave the resident meat that wasn't ground up. Interview on 7/11/2017 at 1:32 PM with Cook G revealed that Resident 59 had 2 eggs over easy, 2 pieces of toast, 2 sausage and 2 bacon for breakfast. Observation of the breakfast meal of 7/11/17 at 7:45 AM revealed that Cook G did not serve Resident 59 a mechanical soft diet. Cook G stated that Resident 59 didn't like meat ground up so the didn't grind the meat. Observation on 7/11/2017 at 1:35 PM of the Resident 59's meal card revealed that Resident 59 was on a mechanical soft diet. Interview on 7/12/2017 at 8:37 AM with Resident 59 revealed The cooks are supposed to grind up my food but I don't like it that way. Review of the speech therapy telephone doctor's order, dated 2/13/2017, revealed that the speech therapist recommended a mechanical soft diet due to a swallow dysfunction. Review of the doctor's telephone order, dated 2/22/2017 revealed, an order for [REDACTED]. Review of the readmission orders [REDACTED]. Interview 7/12/2017 at 1:26 PM with the Dietary Manager confirmed that the diet card was not updated with the current diet order. Interview with the dietary manager confirmed that the cooks did not provide the resident's diet as ordered by the doctor.",2020-09-01
249,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,371,F,0,1,7J6I11,"Licensure Reference Number 175 NAC 12-006.11.E Based on observations and interviews; the facility failed to serve food in a manner to prevent foodborne illness. Census was 46. Sample size was 46. Findings: On 7/11/2017 at 12:15 PM observation revealed Employee H in the Dining Room putting fingers on the rims of the glasses of water, juice and tea while serving them to residents . On 7/12/2017 at 12:10 PM observation revelaed Employee H in the Dining room serving drinks of water, tea and juice with fingers around the rim of the glasses. On 7/12/2017 at 1:23 PM Interview with the Dietary Manager confirmed that serving drinks with your fingers on the rims of the glasses was not sanitary. On 7/6/2017 at 11:55 AM observation revelaed Cook F did not wash hands with soap before serving lunch. On 7/11/2017 at 7:55 AM observation revealed Cook G cutting up a banana, touching toast, and preparing an egg sandwich with bare hands and Cook G did not wash hands. Cook G did not wear gloves when touching the ready to eat food. On 7/12/2017 at 1:25 PM Interview with the Dietary Manager confirmed that it was not sanitary to touch food that was served directly to the residents without hand washing. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and Used as an authoritative reference for food service sanitation practices, revealed the following: 3-301.11 Preventing Contamination by Employees (A) Food employees shall wash their hands as specified under 2-301.12 81-2,272.10* (Replaces 2013 Food Code 3-301.11 (B), (C), (D), and (E) Preventing Contamination from Hands) (1) Food employees shall wash their hands as specified in the Nebraska Pure Food Act. (2) Food Employees shall be trained to wash their hands as specified in the act. (3) Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. This may be accomplished with the use of suitable utensils such as deli tissue, spatulas, tongs, single use gloves, or dispensing equipment. (4) Food employees not serving a highly susceptible population may contact exposed, ready to-eat-food with there bare hands if they have washed their hands as specified in the act prior to handling the food.",2020-09-01
250,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,425,E,0,1,7J6I11,"Licensure Reference Number 175 NAC 12--006.10A2 Based on observations, record reviews and interview; the facility failed to ensure that 1) the prescription labels were compared to the medication orders at least three times before medications were administered to reduce the risk for errors for five residents observed (Residents 21, 22, 44, 65 and 17) and 2) follow up was done when routine morning medications were refused for three days for one sampled resident (Resident 46). The facility census was 46 with five residents sampled for observations of medication administration and five residents sampled for medication review. Findings are: [NAME] Observations on 7/10/17 at 11:10 AM revealed LPN (Licensed Practical Nurse) - A, prepared to administer an insulin injection for Resident 21. LPN - A compared the prescription label with the medication order on the MAR (Medication Administration Record) one time, prepared the medication and then placed the medication back into the drawer on the medication cart. LPN - A administered the medication and then documented the medication administered on the MAR. Observations on 7/10/17 at 11:20 AM revealed LPN - A prepared to administer an eye drop for Resident 22. LPN - A compared the prescription label with the order on the MAR one time and administered the medication. LPN - A returned to the medication cart, placed the medication back into the drawer and documented the medication administered on the MAR. Observations on 7/10/17 at 11:40 AM revealed LPN - B prepared to administer an eye drop for Resident 44. LPN - B compared the prescription label with the order on the MAR one time and administered the medication. LPN - B returned to the medication cart, placed the medication back into the drawer and documented the medication administered on the MAR. Observations on 7/11/17 at 7:30 AM revealed LPN - C prepared to administer 16 medications for Resident 65. LPN - C removed the medications from the medication cart drawers and compared each prescription label with the order on the MAR one time, poured the medications and then placed the medications back into the medication cart. LPN - C administered the medications and returned to the medication cart and documented the medications administered on the MAR. Observations on 7/11/17 at 8:00 AM revealed LPN - D prepared to administer 9 medications for Resident 17. LPN - D removed the medications from the medication cart drawers, compared each prescription label with the orders on the MAR and poured the medications. LPN - D checked the prescription label with the orders on the MAR a second time and placed the medication containers back into the medication cart. LPN - D administered the medications and returned to the medication cart and documented the medications administered on the MAR. Review of the facility policy and procedure Administering Medications, revised (MONTH) 2012, revealed the following including: Policy Interpretation and Implementation . 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Interview with the Director of Nursing on 7/11/17 at 1:00 PM confirmed that the nurses were to follow the medication administration procedure and compare the prescription label with the medication order at least three times before the medications were administered to reduce the risk for errors. B. Review of Resident 46's Medication Administration Record, dated (MONTH) (YEAR), revealed that the resident refused the routine morning medications as ordered on (MONTH) 8, 9, 10. The medication refused included Cipro (antibiotic), Claritan (antihistamine), Digoxin (heart medication for atrial fibrillation), D-Mannose Powder (urinary tract infection), Feosol (iron supplement), Metoprolol (atrial fibrillation), Multivitamin (supplement), Lasix (diuretic for heart failure), Namenda (dementia), Voltaren Gel (pain), Ensure (supplement) and Potassium Chloride (supplement). Further review revealed no documentation of the reason why the medications were refused, later attempts to offer the medications or that the resident was monitored to identify potential adverse effects from not receiving the medications as ordered. Interview with the Director of Nursing on 7/12/17 at 10:00 AM confirmed that the nurses were to document the reason why the medications were refused, attempt to offer the medications again at a later time. Further interview confirmed that the nurses should monitor and document the resident's condition to identify potential adverse effects from not taking the medications as ordered.",2020-09-01
251,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,431,E,0,1,7J6I11,"Based on observations, record reviews and interviews; the facility failed to ensure that 1) prescription labels matched the current MEDICATION ORDERS FOR [REDACTED]. The facility census was 46 with five residents sampled for medication administration observations and several residents with medications stored in the medication room. Findings are: Licensure Reference Number 175 NAC 12-006.12E7 [NAME] Observations on 7/10/17 at 11:10 AM revealed LPN (Licensed Practical Nurse) - A prepared to administer a Novolog injection for Resident 21. Review of the Novolog prescription label revealed instructions to administer 15 units at noon, 12 units in the evening and 12 units in the morning. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed an order to administer Novolog per sliding scale (specific dose for the blood sugar range). Review of the Medication Review Report, dated 6/28/17, revealed an order dated 5/11/17, for the Novolog per sliding scale. Interview with LPN - A on 7/10/17 at 11:10 AM confirmed that the prescription label did not match the current order on the MAR. B. Observations on 7/10/17 at 11:20 AM revealed LPN - A prepared to administer Prednisone eye drops for Resident 22. Review of the Prednisone prescription label revealed instructions to administer one drop four times a day to operative eye (s). Review of the MAR, dated (MONTH) (YEAR), revealed orders to administer one drop to the left eye four times a day. Review of the Medication Review Report, dated (MONTH) 11, (YEAR), revealed an order dated 6/21/17, for PrednisoLone one drop in the left eye four times a day. Interview with LPN - A on 7/10/17 at 11:15 AM confirmed that the prescription label did not match the order on the MAR. C. Observations on 7/10/17 at 11:40 AM revealed LPN - B prepared to administer Brimonidine eye drops for Resident 44. Review of the Brimonidine prescription label revealed instructions to administer one drop to affected eye (s) three times a day. Review of the MAR, dated (MONTH) 2107, revealed orders to administer one drop to both eyes three times a day. Review of the Medication Review Report, dated (MONTH) 11, (YEAR), revealed an order dated 5/10/17, for Brimonidine eye drops with instructions to administer one drop in each eye three times a day. Interview with LPN - B on 7/10/17 at 11:40 AM confirmed that the prescription label did not match the order on the MAR. Interview with the DON (Director of Nursing) on 7/11/17 at 1:00 AM confirmed that the prescription labels needed to match the current orders to reduce the risk of errors. Licensure Reference Number 175 NAC 12-006.12E1 D. Observations on 7/11/17 at 9:00 AM revealed the SSD (Social Services Director) asked LPN - C, Charge Nurse, for the door code to access the medical records stored in the locked medication room. LPN - C verbally gave the SSD the door code and the SSD entered the medication room. Further observations revealed an unlocked refrigerator which contained injectable prescription medications for several residents. Interview with the DON on 7/11/17 at 10:00 AM confirmed that only medication nurses were to have access to the medication room to ensure the security of the medications.",2020-09-01
252,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2017-07-12,501,D,0,1,7J6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.03 (2) Based on interviews and record reviews, the facility failed to consult the Medical Director for involvement in resolving questioning and clarification in a dispute with a medical practitioner pertaining to an antibiotic medication ordered for one sampled resident (Resident 59). Sample size was 16 current residents. Facility census was 46. Findings are: Record review of Resident 59's Admission Record printed on 7/10/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Interviews with a NP (Nurse Practitioner) on 7/11/17 at 4:10 p.m. and 7/12/17 at 1:15 p.m. revealed the NP worked at a local clinic and Resident 59 was a patient at the clinic. The NP described a concern that on 5/23/17 the NP reviewed a urinalysis report faxed to the clinic regarding Resident 59. The NP was the on-call provider for Resident 59 and faxed an order back to the facility on [DATE] with instructions to [MEDICATION NAME](an antibiotic medication). The NP described the facility faxed back a culture report and questioned whether the NP wished to continue the antibiotic. The NP's nurse contacted the facility and instructed the facility to initiate the antibiotic and a conversation ensued between the NP's nurse and facility nurse in which the NP described the facility nurse reported refusal to follow the order. The NP stated being handed the phone and speaking with the facility DON (Director of Nursing). The NP stated the facility was refusing to order the medication and a conversation ensued in which the facility failed to initiate the order. The NP described that the facility then contacted another provider at the clinic attempting to over-ride the NP's order and that this provider informed the facility they do not mess with other provider's orders. Record review of Resident 59's medical record chart revealed the following: - A urinalysis report collected on 5/22/17 was faxed to the clinic on 5/22/17. The NP documented a handwritten reply on 5/23/17 with an order to start treatment [MEDICATION NAME] milligrams every 12 hours for 7 days. The order was faxed to the facility on [DATE] at 11:15 a.m. - A urinary culture report received at the facility on 5/24/17 at 12:44 p.m. was then faxed to the clinic on 5/24/17 at 1:15 p.m. with handwritten note asking No growth (urinary infective organisms) after 48 hours. Do you still want to [MEDICATION NAME] q (every) 12 hours x (for) 7 days? - Indterdisciplinary Progress Notes for 5/24/17 recorded in the resident's records revealed at 1:00 p.m. LPN (Licensed Practical Nurse)-D notified the clinic and left a message to clarify orders pertaining to Resident 59's urinalysis and culture results and was awaiting a response. - Interdisciplinary Progress Notes on 5/24/17 at 2:20 p.m. recorded by the facility DON revealed the DON spoke with the NP related to culture and sensitivity results and recorded the NP wanted to start an antibiotic. The RN (Registered Nurse) questioned the order related to no growth of organisms and received an order to re-culture the urine. There was nothing documented in the resident's record pertaining to what information was conveyed to the NP or whether the NP clarified whether or not to start [MEDICATION NAME]. There was nothing documented in the resident's record indicating the facility Medical Director was consulted to intervene and assist in determining the best course of action pertaining to the resident's condition. Interview with the facility DON on 7/12/17 at 1:33 p.m. verified the facility received orders for Resident 59 on 5/24/17 from the NP to initiate a series [MEDICATION NAME] on a preliminary urinalysis test collected on 5/22/17. The DON acknowledged following receipt of the resident's culture report of the urinalysis on 5/24/17 the facility asked the NP for clarification whether to continue [MEDICATION NAME] not. The DON verified documenting in the Interdisciplinary Progress notes on 5/24/17 that the DON spoke with NP and the facility questioned the order. The DON nothing was documented regarding the details of the conversation and whether or not the NP continued to order the medication. The DON verified the order [MEDICATION NAME] not initiated by the facility and no order to rescind the order was received. The DON confirmed the facility Medical Director was not consulted to intervene, clarify, or assist in determining the course of action to treat the resident.",2020-09-01
253,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,623,D,0,1,EHQ211,"Licensure Reference Number 175 NAC 12-006.05 Based on record reviews and interview, the facility failed to notify the resident or resident's representative in writing as required when transferred to the hospital for one current sampled resident (Resident 54). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's Nursing Note, dated 1/17/18, revealed that the resident was admitted to the hospital for Pneumonia and a Urinary Tract Infection. Review of the Nursing Note, dated 4/27/18, revealed that the resident was transferred to a hospital at 3:30 PM for assessment and evaluation of behaviors. Review of the Nursing Note, dated 7/25/18, revealed that the resident was transferred to a hospital for evaluation of neck and shoulder pain. Interview with the Social Services Director on 8/23/18 at 9:45 AM confirmed that the resident was transferred to the hospital as stated above. Further interview revealed that the resident or the resident's representative was not notified in writing as required of the transfers, including the reason, to the hospital.",2020-09-01
254,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,637,D,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B1 (2) Based on record reviews and interview, the facility interdisciplinary team failed to either complete a significant change MDS (a federally mandated comprehensive assessment identifying significant changes in the resident's status to aid in developing resident care planning) assessment or acknowledge changes with documentation supporting why the team chose not to complete the significant change in status assessment for one sampled resident (Resident 10). Facility census was 53. Sample size was 22 current residents. Findings are: Record review of Resident 10's Admission Record printed on 8/21/18 revealed the resident was admitted to the facility on [DATE]. Record review and comparisons of Resident 10's MDS assessments revealed the following declines in the resident's condition between the Quarterly review MDS on 6/5/18 and a Quarterly review MDS on 3/6/18: - The resident's ability to dress self declined from Supervision in (MONTH) to Limited assistance- resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance with one staff member assisting the resident in the activity. - The resident's ability to toilet declined from Limited assistance in (MONTH) to Extensive assistance- resident involved inactivity, staff provide weight bearing support with one staff member assisting the resident in the activity. - The resident's Personal Hygiene ability declined from Supervision in (MONTH) to Extensive assistance in (MONTH) with one staff member assisting the resident in the activity. - The resident's Urinary Continence declined from Always continent in (MONTH) to Occasionally incontinent (less than 7 episodes in 7 days) in June. - The resident's weight declined from 175 pounds recorded in the resident's Admission MDS assessment on 12/7/17 to 155 pounds in June. This calculated as a significant weight loss of 10% or greater in a six month period. - The MDS failed to record the resident's six month loss as a significant weight loss on the 6/5/18 quarterly assessment. Record review of Resident 10's electronic medical record including progress notes revealed there was no documentation by the interdisciplinary team acknowledging having reviewed the resident's declines in assessment items from the 3/6/18 MDS and the 6/5/18 MDS. There was no documentation by the team recording why the team chose to do an abbreviated quarterly review assessment rather than a significant change assessment as directed in the RAI (Resident Assessment Instrument manual with instructions on determining the type of MDS assessment to be completed) manual. Interview with the MDS Coordinator, RN (Registered Nurse)-E on 8/23/18 at 12:45 p.m. confirmed Resident 10's Quarterly review MDS assessments on 3/6/18 and 6/5/18 revealed changes in the resident's condition. RN-E verified the resident declined in ability to dress, use the toilet, and perform personal hygiene tasks, declined in urinary incontinence, and experienced a significant weight loss of 20 pounds since the admission MDS on 12/7/17 and the quarterly assessment on 6/5/18. RN-B also verified the interdisciplinary team had not documented any acknowledgement of these declines during the 6/5/18 review or documented decision making regarding completing a quarterly assessment rather than a significant change in status assessment. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (a procedural manual instructing staff on how to determine the correct type of MDS assessment to be used) Version 1.14 (MONTH) (YEAR). For the manual section entitled Guidelines for Determining a Significant Change in a Resident's Status instructions direct staff: The final decision regarding what constitutes a significant change in status must be based upon the judgment of the IDT (Interdisciplinary Team) . However, staff must note these transient changes in the resident's status in the resident's record . The manual goes on to further instruct staff when a Significant Change in Status MDS is appropriate if there is a Decline in two or more of the following: . Any decline in an ADL (Activities of Daily Living- includes dressing, toileting, personal hygiene) physical functioning area where a resident is newly coded as Extensive assistance . Resident's incontinence pattern changes . Emergence of unplanned weight loss problem (10% change in 180 days) .",2020-09-01
255,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,641,D,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record review and interviews, the facility failed to record a significant weight loss on a quarterly review MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment for one sampled resident (Resident 10). Facility census was 53. Sample size included 22 residents. Findings are: Record review of Resident 10's Admission Record printed on 8/21/18 revealed the resident was admitted to the facility on [DATE]. Listed among the medical [DIAGNOSES REDACTED]. Record review of physician assessments of the resident revealed on 4/18/18 the physician increased the resident's diuretic medication for [MEDICAL CONDITION]. A note by the physician on 6/2/18 recorded the resident's [MEDICAL CONDITION] had improved. Record review of Resident 10's MDS assessments revealed the following: - Admission assessment on 12/7/17 recorded Resident 10's weight at 175 pounds. - Quarterly assessment on 6/5/18 recorded Resident 10's weight at 155 pounds. Further review of the MDS section entitled Weight Loss the facility recorded No or unknown regarding resident weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Interview with the facility RD (Registered Dietitian) on 8/21/18 at 4:05 p.m. confirmed Resident 10 had lost significant amount of weight since admission. The RD attributed the drop in weight to being on duplicate diuretics to reduce the amount of fluid and [MEDICAL CONDITION] being retained by the resident. Interview with the MDS Coordinator, RN (Registered Nurse)-E on 8/23/18 at 12:45 p.m. verified Resident 10's Admitting MDS recorded the resident's weight at 175 and a quarterly on 6/5/18 recorded the resident's weight at 155 pounds. RN-E confirmed calculation of the weight loss in this six month period was 11.43%. RN-E verified the quarterly MDS on 6/5/18 failed to record that a significant weight loss occurred and that the weight loss section of the MDS was incorrectly coded. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (a manual with instructions on how to accurately record MDS assessment items) Version 1.14 (MONTH) (YEAR). With reference to coding Weight Loss the rationale for the section describes Weight loss can result in debility and adversely affect health, safety, and quality of life . For persons with a large volume (fluid) overload, controlled and careful diuresis can improve health. The instructions in calculating weight loss in 180 days direct staff to Start with the resident's weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight. Calculating the weight loss by the above formula resulted in a weight of 157.5 pounds. The resident's weight on 6/5/18 was 155 pounds which was less than the resulting figure indicating the resident lost 10% or more. The Coding instructions for the weight loss item direct staff to Code 1, yes on physician prescribed weight-loss regimen: if the resident has experienced a weight loss of . 10% or more in 180 days as a result of any physician ordered diet plan or expected weight loss due to loss of fluid with physician orders [REDACTED].",2020-09-01
256,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,656,D,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C Based on interviews and record reviews, the facility failed to develop a care plan problem with goals and interventions to relieve one sampled resident's (Resident 12) seasonal allergies. Facility census was 53. Sample size included 22 current residents. Findings are: Interview with Resident 12's FM (Family Member) on 8/12/18 at 8:21 a.m. revealed the FM had noticed Resident 12 developing seasonal allergies in the form of runny nose and congestion. The FM stated the resident generally developed these symptoms around the same time each year and was currently ordered a medication to help with the symptoms. Record review of Resident 12's Admission Record printed on 8/21/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 12's Medication Administration Record [REDACTED]. Record review of Resident 12's Care Plan printed on 8/22/18 revealed there was no Focus problem, Goal, or interventions on the care plan addressing the resident's seasonal allergies and daily use of an [MEDICATION NAME] medication. Interview with the unit coordinator, LPN (Licensed Practical Nurse)-G on 8/23/18 at 10:24 a.m. confirmed Resident 12 was experiencing seasonal allergy symptoms and was ordered a daily dose of [MEDICATION NAME] for the allergies. LPN-G verified the resident's care plan had not developed a problem, goals, or interventions related to the resident's allergy symptoms.",2020-09-01
257,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,684,D,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D2c Based on observations, record reviews and interviews, the facility failed to asses and provide care to an abrasion and bruising for two current sampled residents (Resident 39 and Resident 46). The facility census was 53 with 22 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 39 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation on 8/21/18 at 9:06 a.m. and 8/23/18 at 11:38 a.m., revealed Resident 39 was sitting in the recliner in the room and was wearing a short sleeve shirt. Resident 39 had bruises on the left hand and a small purple dime size bruise on the left forearm. Resident interview on 8/21/18 at 9:06 a.m. revealed that Resident 39 reported hitting left arm in the door way while propelling the wheelchair. Record review on 8/23/18 identified there were no progress notes, no assessments and no care plan that addressed the bruising on Resident 39's left hand and left forearm. Staff interview on 8/23/18 at 12:06 p.m. with RN (Registered Nurse)-F verified that Resident 39 had bruising on the left hand and left forearm and reported not being aware of the bruising on Resident 39. RN-B reported there was no documentation or assessments completed on Resident 39's bruised left hand and forearm. Staff interview on 8/23/18 at 12:06 p.m. with the Administrator verified that Resident 39 had bruising to the left hand and left forearm that had not been identified, assessed or treated. B. Review of the Admission Record revealed that Resident 46 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Allergic Rhinitis Due to Pollen. Observation on 8/21/18 at 8:45 a.m. identified a large bruise and abrasion to Resident 46's right forearm. Observation on 8/23/18 at 11:11 a.m. identified Resident 46 had a large deep purple bruise with abrasion on the right forearm. Interview on 8/23/18 at 11:11 a.m. Resident 46 reported not knowing how the bruise was obtained on the right arm. Staff Interview on 8/23/18 at 11:11 a.m. with LPN (Licensed Practical Nurse)-A verified that Resident 46 had a large bruise and abrasion on the right forearm. LPN-A reported not knowing how Resident 46 had obtained the bruise and LPN-A reported not knowing that Resident 46 even had the bruise. Staff interview on 8/23/18 at 11:15 a.m. LPN (Licensed Practical Nurse)-C stated not being aware of the bruise and abrasion on the right forearm of Resident 46. LPN-c verified this bruise and abrasion had not been identified and no charting, no assessments and no care planning had occurred on this injury. Staff interview on 8/23/18 at 11:29 a.m. with the Administrator and DON verified Resident 46 had a bruise and abrasion to her right forearm and no documentation or treatment had been completed. Administrator reported this would be addressed immediately.",2020-09-01
258,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,689,G,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b (3 and 4) Based on record reviews and interview, the facility failed to ensure that interventions were in place to prevent recurrent falls with injuries including a cervical fracture with ongoing pain and multiple abrasions with pain for one current sampled resident (Resident 54). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's care plan, goal date 8/20/18, revealed that the resident had a history and potential for falls related to a history of self transfers and self ambulation, confusion, impaired gait and balance, incontinence, antidepressant and diuretic medications, was unaware of safety needs, weakness, difficulty in walking, refusal of cares and physical and verbal aggression and agitation at times. Further review revealed a focus area, dated 8/20/18, which stated that the resident sustained [REDACTED]. Other focus areas included that the resident had cognitive impairment related to both short term and long term memory troubles and the resident required assistance with activities of daily living including transfers and toileting. Interventions listed on 7/4/18 revealed that the resident often self transfers, attempts to self ambulate and will often transfer self to the bathroom unassisted. Review of the Progress Notes revealed the following including: - 7/24/18 at 7:20 PM The staff found the resident on the floor at the foot of the bed. The resident stated was going to the bathroom. The resident complained of neck and shoulder pain and refused to go to the hospital for evaluation. The resident was educated on the use of the call light; - 7/25/18 at 1:35 PM The resident was sent to the to physician for evaluation of severe neck and shoulder pain almost unbearable; - 8/2/18 at 11:00 AM The resident was readmitted from the hospital with a [DIAGNOSES REDACTED].; - 8/4/18 at 1:08 PM The resident transferred self back to bed after breakfast and staff gave frequent reminders to call for assistance, the resident required extensive assistance of two staff for all transfers; 6:47 PM The resident attempted to self transfer multiple times this shift; - 8/10/18 at 1:23 PM The provider changed pain medications from routine to as needed; - 8/14/18 at 11:10 AM The resident was unable to use legs to stand up correctly in sit to stand lift, full body lift used at this time; - 8/17/18 at 1:27 PM The nurse witnessed the resident slip to the floor from the bed, the resident frequently attempts self transfers, no injuries noted; - 8/19/18 at 2:58 PM The resident was observed on the floor at 1:15 PM, the resident stated tried to get into bed, did not use the call light for assistance. The resident was transported to the emergency room via ambulance for evaluation. The resident returned to the facility at 6:45 PM and was treated for [REDACTED]. - 8/20/18 at 3:00 PM The resident is very confused and has been attempting to self transfer since 2:00 PM, 9:48 PM The resident had been attempting multiple times to self transfer this shift and is very confused and does not call for help; - 8/21/18 at 3:50 AM The resident was confused and was observed attempting to get up from bed, legs hanging out over the side of the bed. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident received [MEDICATION NAME] as needed for pain related to the cervical fracture 17 times from 8/11/1- 8/20/18 for pain rated 4-7 on the 0-10 pain scale with 0 indicating no pain and 10 the worst possible pain. The resident rated pain at 4 three times, 5 seven times, 6 three times and 7 four times. Review of the facility Fall Scene Investigation Reports revealed the following including: - 7/24/18 Initial Cause (s) of the fall? The resident did not call for assistance to go to the bathroom, knocked the wheelchair over, still did not call for help and then attempted to self transfer to the bathroom. Interventions to prevent future falls and verify implementation were encourage the use of the call light, educate on the use of the call light every time staff enters room and possible placement of a fall alarm. IDT (Interdisciplinary Team) interventions added to the care plan related to the event and observe to verify implementation: 1. Place anti -tip device on the wheelchair. 2. Have therapy evaluate transfer and determine if a trapeze would be appropriate for repositioning. 3. Offer to move the bed against the wall to open up room if the residents wants to self transfer. - 8/17/18 Initial cause(s) of the fall? Bed positioning and frequent attempts to self transfer. Interventions to prevent future falls and verify implementation: Care plan update, will not position the bed with both the head and foot elevated at the same time. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Staff to monitor bed position with each encounter and reposition bed if both foot and head elevated. 2. Remove turn sheet when not in use. - 8/19/18 Initial cause(s) of fall? Attempted to self transfer. Interventions put into place to prevent future falls and verify implementation: Provider ordered transport to the hospital emergency room per ambulance for assessment. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Schedule pain medications. 2. Document pain levels two times a day and report to provider if not adequate. Review of the Non -Pressure Skin Condition Records, dated 8/23/18, revealed the following skin injuries related to the fall on 8/19/18: - Digits to the left foot have multiple abrasions in various stages of healing and pain; - Digits to the right foot have abrasions to all digits except the fifth digit. Abrasions in various stated of healing and pain; - Entire left knee is reddened, several abrasions in various shapes and sizes inside the reddened area and pain; - Entire right knee is reddened with several abrasions in various sizes and shapes throughout the reddened area and pain. Interview with the Director of Nursing on 8/23/18 at 10:35 AM confirmed that the resident had a history of [REDACTED]. Further interview confirmed that fall interventions in place were not effective to prevent self transfers and subsequent falls with injuries.",2020-09-01
259,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,690,D,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (1 and 2) Based on record reviews and interviews, the facility failed to 1) further assess an identified decline in urinary continence (ability to control urination) to include potential causal factors, the need for further assessment or referral and to develop a plan to maintain or restore bladder continence or to prevent further decline and 2) follow up with identified symptoms of a UTI (Urinary Tract Infection) to ensure that the resident's needs were met for one current sampled resident (Resident 50). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 50's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 5/1/18, revealed that the resident was continent of bladder. Review of the MDS, dated [DATE], revealed that the resident was frequently incontinent of bladder with seven or more episodes of urinary incontinence but at least one episode of continent voiding. Interview with RN (Registered Nurse) - E, MDS Coordinator, on 8/23/18 at 9:15 AM confirmed that the resident had a decline in urinary incontinence during the MDS assessment period. Further interview confirmed that there was no documentation that there was further assessments to include potential causal factors or the need for further assessment or a referral. RN - [NAME] confirmed that there was no plan developed to maintain or restore urinary continence or to prevent further decline. Review of the resident's Progress Notes, dated 8/8/18 at 12:43 PM, revealed a suspected urinary tract infection, urine is noted to be cloudy and foul smelling, fluids encouraged throughout the shift and the resident had no complaints of pain with urination. Further review revealed no further documentation related to the resident's symptoms of a urinary tract infection. Interview with the Director of Nursing on 8/23/18 at 11:15 AM confirmed that the resident was treated with an antibiotic series for a urinary tract infection in (MONTH) (YEAR). Further interview confirmed that the nurses were to complete and document follow up assessments of the resident's symptoms of infection for at least three days or until resolved to ensure that the resident's needs were met.",2020-09-01
260,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,730,E,0,1,EHQ211,"Based on record reviews and interview, the facility failed to ensure that an annual performance evaluation was completed as required for one of five nursing assistants personnel files reviewed. The facility census was 53 with the potential to effect residents on one hallway assigned to the nursing assistant. Findings are: Review of NA (Nursing Assistant) - H's personnel file revealed a hire date of 9/16/16. Further review revealed no annual performance review completed. Interview with the Administrator on 8/23/18 at 7:40 AM confirmed that there was no annual performance evaluation in the personnel file as required. Further interview revealed that the nursing assistants are assigned to one hallway per shift to provide care for the residents.",2020-09-01
261,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,740,D,0,1,EHQ211,"Licensure Reference Number 175 NAC 12-006.09D6 Based on record reviews and interview, the facility failed to document adverse behaviors to include identification of causal factors, interventions implemented and the resident's response to the interventions for one current sampled resident (Resident 54) to ensure that the resident's needs were met. The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's Behavior/Intervention Monthly Flow Record, dated (MONTH) (YEAR), revealed that the resident had behaviors including attempts to hit staff, anger outbursts, combative and foul language. Further review revealed that the resident had five episodes of behaviors on the day shift on 8/4/18, four episodes on 8/5/18 and two episodes on 8/19/18. Further review revealed on 8/4/18 and 8/5/18 the resident was redirected and refer to the nurses's notes and on 8/19/18 refer to the nurse's notes. On 8/5/18 during the evening shift, the resident had 6 episodes of behaviors, was redirected and a back rub given with a negative response. Review of the Progress Notes revealed the following documentation of behaviors including: - 8/4/18 at 6:47 PM Resident attempted self transfers multiple times this shift, requested door be closed and the nurse stated that we can't close your door because you won't call for help and you are walking on your own. The resident became very agitated; - 8/5/18 at 1:15 PM Required a great deal of redirection when attempted to refuse cares, cursed and struck out at staff; 9:41 PM The nurse attempted to assess wound under the neck collar and the resident tried to hit the nurse, was agitated and called the nurse names. The resident attempted to hit staff and called the staff names; - 8/6/18 at 7:59 PM Resident tried to hit the nurse when attempting to assess the wound under the neck brace, resident agitated and called the nurse names; - 8/19/18 at 2:58 PM Resident observed on the floor. Refused to allow staff to obtain vital signs, pulled the blood pressure cuff off and cursed at staff, grabbed the thermometer probe and tried to break it in half. Interview with the Director of Nursing on 8/23/18 at 10:45 AM revealed that the nurses were to document the number of episodes of behaviors on the the daily behavior flow record and then document the specific behaviors in the progress notes. Further interview confirmed that the progress notes should include the specific behaviors, identification of precipitating or causal factors, interventions used to manage the behaviors and the resident's response to the interventions to ensure that the resident's needs were met.",2020-09-01
262,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,755,E,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12E1b Based on observation, record reviews, and interviews, the facility failed to ensure the on-coming shift and off-going shift staff members sign narcotic narcotic accountability documents ensuring both staff verify the change of shift narcotic counting is accurate for 3 sampled residents (Residents 50, 54, and 105) and 2 non-sampled residents (Residents 7 and 41) with controlled substances (narcotics) secured on the 300 wing medication storage cart. Facility census was 53. Sample included 22 current residents. Findings are: Observations on 8/22/18 at 7:45 a.m. revealed LPN (Licensed Practical Nurse)-C was passing medications to residents from the 300 unit's medication cart. Record review of Individual Resident's Controlled Substance Record forms from the 300 unit medication cart revealed the following: - Resident 7's record revealed on 8/22/18 at 6:00 a.m. one staff member (LPN-I) signed off the change of shift narcotic count of 7 tablets of [MEDICATION NAME]. There was no co-signature on the form verifying the accuracy of this count at the 6:00 a.m. shift change. - Resident 41's record revealed on 8/22/18 at 6:00 a.m. one staff member (LPN-I) signed off the change of shift narcotic count of 37 tablets of [MEDICATION NAME] and 10 topical patches of [MEDICATION NAME]. There was no co-signature on the form verifying the accuracy of these counts at the 6:00 a.m. shift change. - Resident 50's record revealed on 8/22/18 at 6:00 a.m. one staff member (LPN-I) signed off the change of shift narcotic count of 21 tablets of [MEDICATION NAME]. There was no co-signature on the form verifying the accuracy of this count at the 6:00 a.m. shift change. - Resident 54's record revealed on 8/22/18 at 6:00 a.m. one staff member (LPN-I) signed off the change of shift narcotic count of 43 tablets of [MEDICATION NAME]; 61 tablets of [MEDICATION NAME] (2.5 milligram strength); and 8 tablets of [MEDICATION NAME] (5 milligram strength). There was no co-signature on the form verifying the accuracy of this count at the 6:00 a.m. shift change. - Resident 105's record revealed on 8/22/18 at 6:00 a.m. one staff member (LPN-I) signed off the change of shift narcotic count of 31 tablets of [MEDICATION NAME]. There was no co-signature on the form verifying the accuracy of this count at the 6:00 a.m. shift change. Interview with LPN-C on 8/22/18 at 7:45 a.m. confirmed the 300 unit Individual Resident's Controlled Substance Record for narcotics kept on the 300 unit cart for Residents 7, 41, 50, 54, and 105 had not been co-signed by LPN-C as the on-coming staff at the change of shift on 8/22/18 at 6:00 a.m. to ensure the accuracy of the counting by two individual staff members. Record review of the facility policy for Controlled Substances revised (MONTH) of 2012 revealed instructions for the policy's Interpretation and Implementation which recorded instructions that Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Interview with the Director of Nursing Services on 8/23/18 at 2:30 p.m. revealed the facility staff were expected to count controlled substances with the off-going and on-coming staff members at change of shift, and the Individual Resident's Controlled Substance Record should be signed by both staff at the time the count was verified as accurate.",2020-09-01
263,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,758,D,0,1,EHQ211,"**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 follow pharmacist recommendation to monitor resident behavior when administering [MEDICATION NAME] (antidepressant medication) for one sampled resident (Resident 18) Facility census was 53. Sample size was 22. Findings are: Record review of Resident 18's Admission Record printed on 8/21/2018 showed a [DIAGNOSES REDACTED]. An Admission Medication Regimen Review was completed by the facility's pharmacist on 6/12/18 which indicated Residents receiving psychoactive medications should have on-going behavior monitoring, Diagnosis, targeting behaviors identified, and side effect monitoring. Med(s) to be monitored: [MEDICATION NAME]. Record review of Behavior/Intervention Monthly Flow Record forms for June, July, and (MONTH) of (YEAR) showed no monitoring was done related to the continued use of [MEDICATION NAME]. Current MAR (Medication Administration Record) indicated Resident 18 was receiving [MEDICATION NAME] 40 mg at 8:00 AM each morning which was started on 6/20/2018. On 8/23/2018 at 8:15 AM in an interview, the DON (Director of Nursing) acknowledged there had not been ongoing monitoring for use of [MEDICATION NAME] for Resident 18. The DON examined and acknowledged pharmacy recommendation of monitoring for this drug and stated that it was missed.",2020-09-01
264,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,803,D,0,1,EHQ211,"Licensure Reference Number 175 NAC 12-006.11A2 Based on record reviews and interviews, the facility failed to consistently provide preferred food for one current sampled resident (Resident 44). The census was 53 with 22 current sampled residents. Findings are: Interview with Resident 44 on 8/21/18 at 10:20 AM revealed had lost some weight since admission to the facility. Further interview revealed that the resident had requested gluten free bread and products which was provided for awhile and then was not provided as requested. Review of the care plan, goal date 8/31/18, revealed that the resident preferred a vegetarian, gluten free diet, Further review revealed that the resident was at risk for potential impaired nutritional status related to poor food intake secondary to personal preference for gluten free/organic diet. Interventions included determine food preferences as needed. Interview with the Dietary Manager on 8/22/18 at 3:00 PM revealed that the resident had requested and was provided a gluten free diet but later accepted regular food products. The Dietary Manager was not aware that the resident still would like to have gluten free products and stated that the gluten free products could be provided for the resident. Further interview revealed that the resident's diet card did not include information about the resident's preference for gluten free foods.",2020-09-01
265,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,812,F,0,1,EHQ211,"Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interviews, the facility failed to date and label open bag of chicken wings, prevent and repair cracking ceiling to remove a compromised, punctured can of pineapple, clean the ceiling vent/fan from dirt and debris and dispose of single use gloves and provide hand hygiene during meal service on the Special Care Unit. All residents could be affected. Facility census was 53 and current sampled residents was 22. Findings are: [NAME] Kitchen observation on 08/20/18 at 6:30 p.m. revealed one open bag of chicken wings located in the freezer had not labeled or dated. Staff interview on 08/22/18 at 10:20 a.m. with the Dietary Manager verified the bag of chicken wings located in the freezer was opened and had not been labeled or dated. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 3-201.11(C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food Labeling, 9 CFR 317 labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.17 and 3-202.18. B. Kitchen Observation on 8/20/18 at 6:30 p.m. and 8/22/18 at 7:20 a.m. ceiling had a large crack above the food preparation areas. Staff interview on 8/22/18 at 10:20 a.m. with the Dietary Manager verified the ceiling in the kitchen had a large crack which could lead to potential cross contamination of the food should debris fall into the food. Review of the 07/21/16 version of the food Code, based on the United States Food and Drug Administration Code an used an authoritive reference to the food services sanitation practices, revealed the following: 6-2-01.11 Cleanability, floors, Walls, and Ceilings. Except as Specified under 6-201.14 and except anti-slip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and EASILY CLEANABLE. C. Kitchen observation on 8/21/18 at 7:23 a.m. and 8/22/18 at 7:20 a.m. there was a bent and punctured can of pineapples located in the pantry. Staff Interview on 8/22/18 at 10:20 a.m. with the Dietary Manager verified there was a bent and punctured can of pineapples located in the pantry that should have been removed. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Code and used an authoritive reference to the food service sanitation practices, revealed the following: 3-202.15 Food packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to Adulteration or potential contaminants. D. Kitchen observation on 8/20/18 at 6:30 p.m., 8/21/18 at 7:23 p.m. and 8/22/18 at 7:20 p.m. revealed build up of dirt and debris on the ceiling vents located throughout the ceiling of the kitchen. Staff interview on 8/22/18 at 10:20 a.m. with the Dietary Manager verified the ceiling vents in the kitchen were covered in dirt and debris and reported that they should have been cleaned. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Autoritive reference for the food service sanitation practices, revealed the following: 6-5-1.14(A) Intake and exhaust air ducts shall be cleaned and filters changed they are not a source of contamination by dust, dirt and other materials. E. Kitchen observation on 8/22/18 at 11:50 a.m. revealed that DC (Dietary Cook)-F was not wearing gloves and did not use a kitchen utensil to remove the fish patties from the oven sheet. DC-F used bare hands to grab the tin foil and pull up all the fish at once trying to dump then in a serving container, as DC-F did this DC-F's hands touched some of the fish patties an then the foil fell back and the fish touched the counter top and the oven mitts causing to cross contaminate the fish. Staff Interview on 8/22/18 at 11:50 a.m. Dietary Manager confirmed that DC-F touched the foil and the fish with bare hands and how the tin foil fell back and touched the counter and the oven met cross contaminating the baked fish. The Administrator reported that DC-F should have used a kitchen utensil to remove the fish one by one as to not contaminate the fish they were serving for the day or could have used gloves. Review of the 7/21/2016 version of the Food Code, based on the Unite States Food and Drug Administration Food Code and Used as an Authoritive reference for the food service sanitation practices, revealed the following: 81-2,272.10(3) Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. this may be accomplished with the use of suitable utensils such as deli tissue, spatulas, tongs, single use gloves, or dispensing equipment. F. Dining room and kitchenette meal service continual observation on the locked Special Care Unit of the facility was conducted on 8/21/18 from 7:15 a.m. through 9:15 a.m. During the observation, DS (Dietary Staff)-J was observed setting up, preparing, and delivering breakfast meals for the 16 residents residing on the Special Care Unit. DS-J was observed wearing a pair of plastic disposable gloves at the beginning of the observation at 7:15 a.m. and was observed wearing the same pair of disposable gloves throughout the breakfast meal service ending at 9:15 a.m. During the observations, DS-J was observed touching cabinet handles, refrigerator handles, utensils and containers, touching residents, and placing hands on the resident tables. All these activities could cause potential cross-contamination. In addition, DS-J was observed removing grapes from stems touching the grapes with the potentially contaminated gloves; and touching strawberries with the potentially contaminated gloves while cutting the strawberries up on a counter. Dining room and kitchenette meal service continual observation on the locked Special Care Unit of the facility was conducted on 8/21/18 from 12:30 p.m. to 12:45 p.m. for the noon meal service. DS-J was again observed with disposable gloves on at the beginning of the observation through 12:45 and was again observed touching tablecloths, delivering food items on plates, opening microwave handles, and touching utensils while wearing the same pair of disposable gloves throughout. Interview with the Dietary Manager on 8/23/18 at 12:20 p.m. confirmed that disposable gloves were to be used during kitchen and dining procedures for one task only and then disposed and hands were to be washed after disposal. The Dietary Manager confirmed the observation on 8/21/18 at 12:30 p.m. to 12:45 p.m. while DS-J was observed wearing the same pair of disposable gloves throughout the observation and potentially cross-contaminating the gloves by touching surfaces, utensils, and handles. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-304.15 Gloves, Use Limitation. (A) If used, Single-Use gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose and discarded when damaged or soiled, or when interruptions occur in the operation.",2020-09-01
266,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,842,D,0,1,EHQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.16B (1) Based on record reviews and interview, the facility failed to complete behavior monitoring records on each shift for 2 sampled residents (Residents 1 and 12). Facility census was 53. Sample size included 22 current residents. Findings are: [NAME] Record review of Resident 1's Admission Record printed on 8/21/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 1's Behavior/Intervention Monthly Flow Record for (MONTH) of (YEAR) revealed the evening shift staff had not completed the form monitoring resident behaviors of Crying and Aggression on 8/3/18 and 8/4/18. B. Record review of Resident 12's Admission Record printed on 8/21/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 12's Behavior/Intervention Monthly Flow Record for (MONTH) of (YEAR) revealed the evening shift staff had not completed the form monitoring resident behaviors of Crying; Anger outburst with cares; and Frequent up and down Restlessness on 8/3/18 and 8/4/18. Interview with the Special Care Unit manager, LPN (Licensed Practical Nurse)-G on 08/23/18 at 10:24 a.m. verified the Behavior/Intervention Monthly Flow Records for Resident 1 and Resident 12 were not completed by the evening shift staff on 8/3/18 and 8/4/18.",2020-09-01
267,HIGHLAND PARK CARE CENTER,285063,"P O BOX 950, 1633 SWEETWATER",ALLIANCE,NE,69301,2018-08-23,880,D,0,1,EHQ211,"Licensure Reference Number: 175 NAC 12-006.17B Based on observations and interview, the facility failed to ensure C-PAP (Continuous Positive Air Pressure device to help with sleep apnea) equipment was cleaned and stored to prevent potential cross-contamination; and ensure opened containers of distilled water were labeled with the date opened for one sampled resident (Resident 21). Facility census was 53. Sample size was 22. Findings are: On 8/21/2018 at 9:50 AM while in room of Resident 21, observed C-PAP face mask laying on table, not covered or contained. A bottle of distilled water was also on the table. This bottle had been opened and was about half empty but did not have date on it to indicated when it was opened. On 8/21/2018 at 11:45 AM returned to Resident 21's room and observed that C-PAP face mask and a bottle of distilled water remained as seen earlier. Black storage bag was on table but C-PAP equipment had not been placed into bag to prevent possible cross-contamination. On 8/22/2018 at 10:15 AM again observed C-PAP face mask and black bag on table in Resident 21's room, and mask was not being stored in bag. A bottle of distilled water was also still on table and did not have any date marked to indicate when it was opened. On 8/22/2018 at 1:45 PM returned to Resident 21's room and observed C-PAP mask, black bag, and bottle of distilled water remained on table as observed earlier in day. On 8/22/2018 at 1:55 PM LPN (Licensed Practical Nurse)-A who served as Infection Control coordinator for the facility accompanied surveyor to Resident 21's room and verified the C-PAP should be wiped clean daily and should be stored in black bag which was laying on table next to face mask. LPN-A also verified that all bottles of distilled water should be dated when opened and acknowledged that the bottle on Resident 21's table did not have a date to indicate when it had been opened at the time of interview.",2020-09-01
268,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,578,E,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] Based on record review and interview, the facility failed to ensure that the residents advanced directives were included in the Comprehensive Care Plan. This had the potential to effect all Residents in the facility. The facility census was 35. Record review of Resident #5s medical chart revealed, a Durable Power of Attorney dated [DATE], a Declaration of Living Will dated [DATE] and a Declaration of Intent for Life Sustaining Measures dated [DATE]. Record review also revealed a Comprehensive Care Plan dated [DATE] with no documentation of advanced directives. Record review of Resident #8s medical chart revealed, a Nebraska Power of Attorney for Health Care dated [DATE] and a Declaration of Intent for Life Sustaining Measures dated [DATE]. Record review also revealed a Comprehensive Care Plan dated [DATE] with no documentation of Advanced Directives. Record review of Resident #10s medical chart revealed. A Durable Power of Attorney dated [DATE] a Power of Attorney for Health Care dated [DATE] and a Living Will dated [DATE] and a Declaration of Intent for Life Sustaining Measures dated [DATE], Record review also revealed a Comprehensive Care Plan dated [DATE] with no documentation of Advanced Directives. On [DATE] at 1:48 PM an interview with the MDS Coordinator revealed that they do not put advanced directives on care plans. B. Record review of the Care Plan with a goal target date of [DATE] revealed; Advanced Directives were not addressed in the Comprehensive care plan. Record review of the Advanced Directives dated [DATE] revealed; Resident 28's preference was not to have CPR (Cardiopulmonary Resuscitation a medical procedure involving repeated compression of a residents chest performed in an attempt to restore circulation and breathing of a person who has had a [MEDICAL CONDITION]) initiated if the heart stopped. Resident 28's preference was to have nutrition and hydration provided through a tube which would be inserted into the nose leading to the stomach if the resident should stop eating. An interview on [DATE] at 01:59 PM with MDS coordinator confirmed that the Advanced Directives are not on the Comprehensive Care Plan, this was not placed on care plans.",2020-09-01
269,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,584,E,0,1,MX7V11,"Licensure and Reference Number 175 NAC 12-006.18A(1) Based on observation, interview and record review the facility failed to ensure the vent fans in the resident restrooms were free of dust, this had the potential to affect 4 resident rooms, rooms numbered; 502, 503, 505, and 508, and the facility had 28 rooms. The facility census was 35. On 03/05/19 at 10:25 AM an observation revealed a brown fuzzy substance on the restroom vents in room #s 502, 503, 505, and 508. On 03/05/19 at 10:25 AM an interview with the Maintenance Director, confirmed the vents in the resident restrooms in rooms; 502. 503, 505, and 508 were covered in a brown fuzzy substance. On 03/05/19 at 10:27 AM an interview with the housekeeper on 500 hall confirmed the vents were covered with a brown fuzzy substance and should be cleaned, the housekeeper also revealed the vents are cleaned once or twice a year. On 03/05/19 at 12:00 PM an interview with Administrator / Housekeeping Director revealed; there is no routine cleaning schedule for the resident restroom vent fans, and the vent fans should be cleaned when dirty.",2020-09-01
270,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,641,D,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview the facility failed to ensure that the MDS (The Long-term 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 resident in a Medicare or Medicaid-certified long term care facility) was accurately coded to reflect the Swallowing/Nutritional Status for weight loss for one resident (Resident 25)of 2 sampled residents. The facility census was 35. Findings are: Record review of Resident 25 weights revealed; on 08/13/2018 at 11:46AM was 169.4 lbs. (Pounds) and on 02/21/2019 at 11:12AM Resident 25 weighed 150.2 lbs. and had a weight loss of 11.33% in 6 months. Record review of MDS (Minimum Data Set- an assessment used to develop a person centered comprehensive plan of care for the resident) Annual assessment dated [DATE] revealed; Section K Swallowing/Nutrition Status revealed; Resident 25 had no loss of 5% or more in the last month or loss of 10 % or more in the last 6 months. Record review of Progress note from Dietary dated 02/19/2019 at 12:51PM Revealed; o Resident's 25's current weight was149.lbs. , had stabilized, same as 30 days, but remained 10% below weight 180 days ago. Record review of Nutritional assessment dated [DATE] at 10:26AM Resident 25 had a decrease of 22 lbs. or 13% weight loss in 90 days. Interview with Dietary Manager on 03/04/19 at 03:12 PM confirmed that the MDS dated [DATE] was coded incorrectly for Section K and Resident 25 had an 11 percent weight loss in 180 days.",2020-09-01
271,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,689,E,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006 18.E4 Based on observation, record review and interview; the facility failed to ensure chemicals were secured to prevent the potential for accidental exposure for 2 residents( Residents 87 and 34) identified as self mobile with wandering behaviors. The facility failed to ensure hot equipment was not accessible to residents with cognitive impairment. This had the potential to affect 5 residents( Residents #15, 17, 22, 23, and 186) of 7 residents that reside on the memory care unit. The facility census was 35. Findings are: [NAME] Observation on 03/04/19 at 02:25 PM reveled one utility room on the 200 hall that was unlocked. The under the sink cabinet was unlocked and contained the following chemicals: - Empty 409 Cleaning container. - One gallon of Bleach. - One 32 ounce bottle of Lime -A- Way. - Spray Disinfectant cleaner 8 ounce bottle. - Spray Bathroom cleaner and Disinfectant 450 ml bottle - Aerosol Stainless Steel cleaner can - Aerosol Garage Door Lube can. - Mop bucket with mop and dirty water also noticed in cleaning closet. Observation on 03/04/19 at 2:30 P.M. Revealed a clean linen closet on the 200 hall that was unlocked. The top shelf had a full container of Germicide wipes in plain site. Interview on 03/04/19 at 3:25 P.M. with the facility Administrator, confirmed that the 200 hall utility room was unlocked and the lock on the cabinet under the sink was not working. The Administrator confirmed the cabinet contained chemicals which could be considered hazards to residents that had exhibited wandering behavior as they could open the cabinet and have immediate access to chemicals. The Administrator agreed mop bucket and dirty water should not be in an unlocked room. The Administrator confirmed that all chemicals should be kept in a locked cabinet. Interview on 03/04/19 at 3:27 P.M. with the Administrator confirmed that the 200 hall clean linen closet contained Germicidal wipes on top shelf in plain site and agreed they should be removed from an unlocked area. Record review of a Facility Safety Policy (no date) related to chemicals revealed the following : - Chemicals, cleaners, etc. shall be stored as instructed on the container. - Chemicals shall be stored in locked rooms/cabinets/carts when not in use. Record Review of Material Safety Data Sheets (MSDS) with varying dates revealed the following safety hazard information: - Clinging Lime -a-way: causes severe [MEDICAL CONDITION] eye damage, may cause respiratory irritation if inhaled, may [MEDICAL CONDITION] mouth, throat and stomach if ingested. - Disinfectant cleaner: Harmful in contact with skin, causes serious eye irritation - Germicidal disposable wipes: serious eye damage, eye irritation - Stainless steel cleaner and polish: (MONTH) be fatal if swallowed and enters airways, causes eye irritation - Garage door lubricant: causes serious eye damage,May be fatal if swallowed and enters airways - Clorox automatic toilet bowel cleaner: Harmful if swallowed, causes severe [MEDICAL CONDITION] eye damage, may cause an allergic skin reaction - Clorox Germicidal Bleach: Danger corrosive, harmful if swallowed, may cause severe irritation or damage to eyes, skin and mucous membranes. - 409 Cleaner: causes mild irritation of eyes and skin. B. Interview on 3/4/19 at 3:30 PM with The Director of Nursing (DON) revealed that Resident 87 and 34 were identified as self mobile with wandering behavior. C. Record review of Resident 87's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/27/19 revealed that Resident 87 was moderately cognitively impaired, had disorganized thinking present and exhibited wandering behaviors 4-6 days per week. Record review of Resident 87's Comprehensive Care Plan ( a interdisciplinary team plan for resident care) (CCP) dated 2/18/19 revealed that a Wanderguard ( device used to alert staff to wandering behavior) was placed to Residents 87 left wrist on 2/27/19 due to excessive exit seeking behaviors. Observation on 03/04/19 at 2:33 P.M. Revealed Resident 87; walked down the 200 hallway and checked doors. Resident 87 went in to room [ROOM NUMBER] ( not Resident 87's room) and proceed to lay on the bed. D. Review of Resident 34's undated Face Sheet revealed the date of admission 5-15-18 and [DIAGNOSES REDACTED]. Review of Resident 34's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) of severely impaired cognition. The resident required supervision with ambulation. Observation on 3-5-19 at 3:27 PM revealed the resident wandered in the halls. MA-F (Medication Aide) redirected the resident from ambulating down the 100 hallway and returned to the TV solarium. Review of Resident 34's Careplan revealed the resident wore a wandergard and wandered the halls. The resident normally took redirection from others. Observation on 2-27-19 at 10:48 AM revealed a housekeeping cart was parked outside of the room of 306. Hskp-G (Housekeeper) was in the room and the housekeeping cart was not within the line of site of the housekeeper. The cabinet door to the cart had the key in the lock and the door was open. Inside the cabinet was several bottles of liquid chemicals: bottle of 409 spray cleaner, bottle of urine deodorizer, and bottle of glass cleaner. Hskp-G came out of the resident room and interview with Hskp-G revealed the door to the cabinet was to be kept locked at all times. Hskp-G obtained supplies from the cabinet, shut the door and locked it, but left the key in the lock and returned back to the resident's room. The housekeeping cart was not within site of Hskp-G as it was not parked in the doorway of the room Hskp-G was in. A few minutes later Hskp-G came back out into the hall and entered the housekeeping cart again, shut the door and locked it, but again left the key in the lock of the door, then returned back to the resident's room. At the time of this observation, there were no residents in the 300 hall. Interview on 3-5-19 at 2:03 PM with the ADM (Administrator) confirmed the housekeeping cart cabinets were to be locked without the key in the lock when the cart was not within the line of vision of the housekeeping staff. E. Observation on 03/05/19 at 07:47 AM of the steam table that had been delivered to the Memory Unit and plugged into the wall across the room approximately 20 foot from dining room table. The dietary staff then left the Memory Care Unit. Observation on 03/05/19 at 08:03 AM of the MA (Medication Aide) F left the common area with the steam table plugged into the wall. The MDS (Minimal Data Set- A comprehensive assessment tool used to develop a person centered plan of care) Coordinator left the Memory Unit. Residents 17, 22, 23, 28 were seated at the table. Observation on 03/05/19 at 08:06 AM of the MA had returned to the common area. Observation on 03/05/19 at 08:07 AM of Resident 25, who had ambulated to the common area with a night gown on. The MA had taken Resident 25 to her room to get dressed, and left the common area where the steam table remained plugged into the wall. Residents 28, 23, 22, 15, 17 were seated at the table when the MA left the area. Observation on 03/05/19 at 08:10AM of Resident 186 ambulated to the dining table unassisted and sat down. Observation on 03/05/19 at 08:13AM of the MA who had returned to the common area. Interview on 03/05/19 at 08:23AM with MA confirmed that the steam table that was plugged in and the temperature was 154.7 and that it would have burned a resident if they had touched it. MA confirmed that there was no staff present to monitor the steam table when the MA had assisted Resident 25 with ADL's (Activities of Daily Living- Dressing, Brushing hair, teeth, and toileting). An interview on 03/05/19 at 10:33 AM with the DON (Director of Nurses) confirmed; that leaving the steam table unattended would be a safety concern. The DON reported that the staff probably left the area because the residents were seated at the dining room table. The DON confirmed that residents on the memory care unit are ambulatory. Record review of Resident 15 Face Sheet with admission date of [DATE] for [DIAGNOSES REDACTED]. Record Review of the MDS Quarterly assessment dated [DATE] revealed; Staff Assessment for Mental Status, Section C 1000 Resident 15 had severely impaired cognitive skills for daily decision making. Section [NAME] Behavior E0200 verbal behavior directed at other for Resident 15 had occurred 1-3 days. Resident 15 had rejected care 1-3 days. Section E0900 for Wandering revealed; Resident 15 had not exhibited wandering. Section G 0110 Functional status revealed; Resident 15 required supervision with set up for locomotion on/off the unit, in the room and corridor. Section G 0300 for Balance during Transition and walking revealed; not steady but able to stabilize without staff for walking, surface to surface transfers. Record review of the Care plan for Resident 15 revealed; a Care Plan for Cognitive loss/Dementia, with a start date of 10/31/18 and a target goal date of 04/16/19, documented Resident 15's need for reminders and cues due to dementia and Resident 15 had antipsychotic medications. A Care plan for falls, with a start date of 5/22/18 and a goal date of 05/16/19 revealed; Resident 15 was a high fall risk and ambulated and transferred with a walker. Record review of Resident 17's Face Sheet with an admission date of [DATE] for [DIAGNOSES REDACTED]. Record review of MDS Annual assessment dated [DATE] revealed; Staff Assessment for Mental Status, Section C 1000 Resident 17 had severely impaired cognitive skills for daily decision making. Section E0900 Wandering revealed that the Resident 17 had not exhibited wandering. Section G Functional Status revealed G0110 ADL's walking on the unit and in the room required one person with limited assistance. Section G0300 Balance during transition and walking Resident 17 had not been steady but able to stabilize on own for moving from seated to standing, walking, turning around and surface to surface transfers Record review of Care Plan Care Plan for falls with a start date of 04/26/16 and a target date of 04/30/2019 revealed; Resident 17 was a high fall risk related to dementia. Resident 17 transferred and ambulated with stand by assist at times. The Care Plan for Cognition loss/Dementia dated 8/23/18 revealed; Resident 17 was forgetful, and had restlessness which required verbal cues at meal times. An observation on 03/05/19 at 11:05 AM of Resident 17 who ambulated with a walker unassisted to the dining table from the recliners in front of the TV which was approximately 30 feet. The MA F helped Resident 17 to sit at table. Record review of Face Sheet with admission date of [DATE] for [DIAGNOSES REDACTED]. Record review of Resident 22's Annual MDS dated [DATE] revealed; Resident 22 had a BIMS (Brief interview for Mental Status- an assessment used to assess memory impairment) was 09 and indicated moderately impaired for decision making Section [NAME] Wandering E0900 revealed; Resident 22 had not exhibited wandering. Section G Functional Status ADL's revealed Resident 22 was independent with ambulation on the unit and needed supervision with ambulation off the unit. Section G0300 Balance and transfers revealed Resident 22 was steady at all times with ambulation and transfers. Record review of Care Plan for Cognitive loss/dementia, with a start date of 2/13/19 and a target goal date of 5/7/19 revealed; Resident 22 needed reminders during the day, at times attempted to get out of the unit. Resident 22's Care Plan for fall with a start date of 9/4/18 and a target goal date of 5/7/19 revealed; Resident 22 was a high risk for falls related to dementia. Resident 22 ambulated without any devices. Record Review of Face Sheet with an admission date of [DATE] revealed; Resident 23 had [DIAGNOSES REDACTED]. Record review of MDS Quarterly assessment dated [DATE] revealed; Section C Staff Assessment for Mental Status, Section C 1000 Resident 17 had moderately impaired cognitive skills for daily decision making. Section [NAME] Wandering revealed that Resident 23 had exhibited wandering 1-3 days out of 7 days. Section G Functional Status ADL's revealed Resident 23 was supervised with set up help for ambulation on the unit and off the unit. Section G0300 Balance and transfers revealed Resident 23 was steady at all times with ambulation and transfers. Record review of Care Plan Cognitive loss/Dementia for with a start date of 11/20/18 with a Target date of 05/0719 revealed; Resident 23 had poor memory and needed reminders daily from staff. Resident 23 Care Plan for Falls with a start date of 8/28/18 and a goal date of 5/7/19 revealed; Resident 23 was a high risk for falls related to dementia and ambulated independently without assistance. Record review of the Face Sheet for Resident 186 with an admission date of [DATE] revealed; [DIAGNOSES REDACTED]. Disorder, recurrent, unspecified, Anxiety disorder, unspecified, and Unspecified age-related cataract-bilateral. Record review of the BIMS assessment dated [DATE] for Resident 186 revealed; Resident 186 score was 04 and indicated severe cognitive impairment. Record review of the Baseline Care Plan dated 2/28/19 revealed; Resident 186 was independent with transfers without an assistive device. The Baseline Care Plan did not address cognitive impairment.",2020-09-01
272,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,700,D,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observations, record reviews, and interviews, the facility failed to review the risks and benefits of bed rails to the resident and/or legal representative, failed to obtain consent to use bed rails, failed to attempt to use other alternatives prior to installing the bed rail, and failed to assess the resident for risk of entrapment from bed rails prior to installation on one resident (Resident 2) out of 1 resident sampled. The facility census was 35. Findings are: Record review of Resident 2's undated Face Sheet revealed the [DIAGNOSES REDACTED]. Review of Resident 2's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-27-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated Resident 2 had moderate impairment of cognition. The resident required extensive of assist of two staff with bed mobility, transfers, dressing, and toileting. The resident did not walk during the assessment period. Observation on 2-27-18 at 3:30 PM of Resident 2's bed revealed the bed had a bed rail on the outside edge at the HOB (head of bed) only. The other side of the bed was against the wall and did not have a bedrail. The mattress on the bed had a gap between the uncompressed mattress and the bedrail which measured 3.5 inches. Review of Resident 2's Careplan dated 12-17-18 revealed the resident had an assist handle on the right side of the bed to help the resident with transfers and repositioning. Review of the medical record revealed absence of a bedrail assessment and absence of a consent form. Interview on 2/28/19 at 2:44 PM with the DON (Director of Nursing) confirmed the facility did not complete siderail/bedrail assessments on residents with siderails or assist bars and therefore Resident 2 did not have a bedrail assessment completed. The DON confirmed the facility did not complete consent forms for any of the siderails/assist bars, did not document interventions tried or reason why the bed rails were the least restrictive device used for the resident. Observation on 2/28/19 at 2:55 PM with the DON of the residents room and bed revealed the mattress continued with the same gap between the bedrail and the uncompressed mattress. Observation of the bed frame at the HOB to hold the mattress in place was absent and the DON confirmed a mattress holder should have been on the bed. Interview on 02/28/19 at 2:49 PM with the ADM (Administrator) confirmed the facility did not perform regular inspection of all bed frames, mattresses, and bedrails to identify areas of entrapment.",2020-09-01
273,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,756,D,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 174 NAC 12-006.12B Based on record review and interview, the facility failed to ensure the drug allergies [REDACTED]. The facility census was 35. Findings are: Review of undated Face Sheet revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the electronic medical record on the undated Face Sheet revealed the allergies [REDACTED]. Review of the paper chart revealed an allergy sticker across the front of the resident's medical record with the allergy sticker listed cephalosporins, latanoprost, [MEDICATION NAME], and [MEDICATION NAME] (pain medication). Interview on 03/05/19 at 11:50 AM with the MDS-C (Minimum Data Set Coordinator) confirmed the electronic medical record list of cephalosporins, lantaprost, [MEDICATION NAME], and [MEDICATION NAME] would be the current list of allergies [REDACTED]. MDS-C reviewed the most recent H/P (history and physical) and the H/P did not list the [MEDICATION NAME] as an allergy. MDS-C could not explain where the [MEDICATION NAME] allergy came from. Later in the day on 3-5-19, MDS-C provided 2 forms, the Admission Notification and Clarification form dated 08/27/15 which listed Resident 1's allergies [REDACTED]. Interview on 03/05/19 at 2:06 PM with MDS-C revealed MDS-C attempted to enter [MEDICATION NAME] into the electronic medical record but the program would not accept it. When MDS-C entered it as ketoralac (the generic name for [MEDICATION NAME]) the program accepted it so the MDS-C felt the discrepency resulted from a glitch in the computer system.",2020-09-01
274,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,770,E,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E4 Based on observation, record review, and interviews, the facility failed to ensure glucose (blood sugar) test strips were not expired for 3 residents (Residents 1, 88, and 30) out of 3 sampled. The facility census was 35. Findings are: Observation on [DATE] at 12:08 PM revealed RN-E (Registered Nurse) performed a blood glucose check using the Assure Platinum test strips on Resident 88. Review on [DATE] at 3:07 PM of the Assure Platinum test strip bottle for Resident 88 revealed the bottle was opened and did not have an opened date documented on the bottle. Review of Residents 1 and 30's glucose test strip bottles revealed the bottles were opened and also did not have a date the bottles were opened documented on the bottles. Review of the Assure Platinum Test Strips instructional insert revealed to date the bottle and use within 3 months, or the manufacturer expiration date on the bottle, whichever comes first. Interview on [DATE] at 3:08 PM with LPN-J (Licensed Practical Nurse) revealed the manufacturer's expiration date listed on the bottle was the expiration date the facility used. Residents 1, 30, and 88 had manufacturer expiration dates listed as [DATE]. LPN-J revealed the date the test strip bottles were opened were documented in the control book log, but staff only review that log anytime a new bottle was opened and therefore the nurse using the test strips would not know the date the bottle was opened since it was not documented on the bottle. LPN-J denied knowledge of the instructions listed on the bottle stating the test strips expired 90 days after the bottle was opened.",2020-09-01
275,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,812,F,0,1,MX7V11,"Licensure Reference Number 175 NAC 12-006.11 E Based on observation and interview, the facility failed to maintain equipment in a clean, sanitary manner to prevent the potential for food borne illness as evidenced by: air ventilation and ceiling ventilation systems covers with reddish substance that resembled rust and a fuzzy gray substance that resembled dust present, peeled paint on the ceiling near lights, peeled and missing non-slip black tile floor surfaces, fuzzy gray substance present on the fan that blew air toward the clean dish area, fuzzy gray substance on the ventilation fans in the walk in cooler. The facility staff failed to ensure that hair restraints fully enclosed all hair in a manner to prevent potential contact with food. This had the potential to affect 34 residents that ate food prepared in the facility kitchen. The facility census was 35. Findings are: [NAME] Equipment: Observation on 03/04/19 between 10:45 AM and 11:25 AM with the DM revealed the following concerns with sanitation of equipment and surfaces: - Return air ventilation system covers for the air conditioner had a reddish substance that resembled rust and a fuzzy gray substance that resembled dust present on the exterior of the covers. - Ceiling ventilation system covers had a reddish substance that resembled rust and a fuzzy gray substance that resembled dust present on the exterior of the covers. - Paint on the ceiling surrounding the light fixtures was peeled and missing in places in the food preparation area and above the stove. - Non-skid black floor tiles were peeled off and absent in front of the stove and dish wash area which created a non-cleanable surface. - Small white fan above the clean dish area had a fuzzy gray substance present. The fan blew air toward the clean dish area. - Walk in refrigerator had a fuzzy gray substance present on the ventilation system fans. Interview on 03/04/19 at 11:25 AM with the DM confirmed the concerns with sanitation of the air conditioning ventilation system covers, the ceiling ventilation covers, paint on the ceiling, non-skid floor tiles, fans in the dish area and the walk in refrigerator. The DM agreed that those items needed to be cleaned and repaired. B. Hair restraints: Observation on 02/27/19 between 9:10 AM and 09:24 AM in the facility kitchen revealed the Dietary Manager (DM) and Dietary Aide (DA) C wore hair restraints that did not contain all hair with hair exposed at the sides and back of the hair restraint. Observation on 03/04/19 between 10:45 AM and 11:25 AM revealed the DM and DA C were in the food preparation area with hair restraints that did not fully contain all hair. The hair was coming out of the sides and back of the hair restraint Observation on 3/5/19 between 9:25 AM and 9:50 AM revealed the DM and DA D moved throughout the kitchen area with hair exposed and not fully restrained in the hair nets. Record review of a facility policy on Employee Sanitary Practices (no date) revealed that all employees shall wear hair restraints to prevent hair from contacting exposed food. C. Interview on 03/04/19 at 11:52 AM with Registered Nurse (RN) [NAME] identified that 34 residents ate food prepared in the facility kitchen. D. Record review of the Nebraska Food Code 2-402.11 revealed that food employees shall wear hair restraints such as hats, hair coverings, or nets, beard nets, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. Record review of the Nebraska Food Code 4-602.12 revealed that non food contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues.",2020-09-01
276,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,880,F,0,1,MX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 174 NAC 12-006.17 Based on observation, record review, and Inteview, the facility failed to ensure that hand hygiene and gloving during resident care procedures were performed in a manner to prevent the potential cross contamination for 3 residents (Residents 1, 5, and 88) out of 3 residents sampled; and failed to store clean linens inches above the floor in the linen storage closets in halls 100 and 300. This had the potential to affect all residents in the facility. the facility failed to ensure that hand hygiene and gloving during resident care procedure's were performed in a manner to prevent the potential cross contamination for residents # 5, 1, and 88. and failed to store clean linens 6 inches above floor in the linen storage closets in hall 100 and 300 this had the potential to affect all residents in the facility. The facility census was 35. Findings are: [NAME] Review of Resident 1's undated Face Sheet revealed Resident 1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-13-19 revealed the resident had a stage 2 pressure ulcer (per the MDS manual: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). ) Interview on 3-4-19 at 2:56 PM with the MDS-C (MDS Coordinator) revealed the resident's pressure ulcer on the heel began on 8-24-18. The resident had been evaluated by the Physician several times at a wound clinic and the wound was healing but very slowly. Observation on 03/04/19 at 10:09 AM revealed RN-E (Registered Nurse) performed wound care to Resident 1's left heel pressure ulcer in the resident's room while the resident was in bed. RN-E had brought wound supplies into the room on a cart from the medication supply room. RN-E entered the resident's room, then washed the top of the cart with a disinfectant wipe. Without first performing hand hygiene, RN-E applied gloves to both hands then proceeded to clean a pair of scissors with a Super Sani Plus disinfectant wipe. Without changing gloves, RN-E used the scissors to remove the rest of the old wound dressing from Resident 1's right leg. RN-E cleansed the wound, then changed gloves without performing hand hygiene. RN-E then handled the new dressing in the gloved hands and applied the dressing directly to the left heel wound followed by the dry dressing and wrap. Review of the undated facility policy 'Handwashing' revealed absence of direction about washing hands related to glove usage. Policy did reveal to wash hand before and after the staff's shift and after each resident. It was absent direction to wash hands before procedures or before contact with residents. Review of the CDC Guidelines revealed Healthcare Providers were to perform hand hygiene after glove removal and after contact with inanimate objects in the immediate vicinity of the patient. B. Observation on 03/04/19 at 12:08 PM revealed RN-E (Registered Nurse) performed a blood glucose check using the Assure Platinum test strips on Resident 88. After the procedure, RN-E wiped the glucometer machine with a Super-Sani Plus wipe for less than 15 seconds and did not perform a wet-set contact time on the machine to disinfect the machine. Inteview on 3-5-19 at 2:59 PM with LPN-J (Licensed Practical Nurse) revealed and demonstrated how to clean a glucose machine. LPN-J wiped the machine with a Super Sani Plus disinfectant wipe then discarded the wipe. LPN-J denied knowledge of the the manufacturer instructions of a wet-set contact time of 3 minutes and denied that was the facility practice to clean items. Review of the manufacturer instructions on the container of the Sani-Cloth Plus disinfectant wipes revealed to disinfect nonfood contact surfaces to use a wipe to remove heavy soil. Obtain a new clean wipe and thoroughly wet the surface to be disinfected, and the surface must remain visibly wet for a full three minutes. If needed use additional wipes to assure a continued 3 minute wet contact time, then let air dry. Review of the undated facility policy titled 'Blood Glucose' revealed to clean the glucose meter with a Super Sani cloth. The policy was absent about the manufacturer instructions of the wet contact time to actually disinfect the surface. C. Record Review of Resident 88's CCP dated 2/21/19 revealed that Resident 88 had a [DEVICE] (GT) ( Surgical creation of an opening in the abdominal wall for the purpose of introducing food into the stomach) in place for nutritional needs. Record review of Resident 88's Treatment Administration Record (TAR) dated (MONTH) 2019 revealed and order to wash Resident 88's [MEDICAL CONDITION] ( trach) ( a surgical incision to the neck, to provide open an airway) site one time per day. Observation on 2/27/19 at 9:30 AM revealed that Resident 88 was seated in a wheelchair in the activity lounge. Resident 88's feeding tube tubing was draped down and touched the wheel of the wheelchair. Observation on 02/28/19 at 1:10 PM revealed that Resident 88 was seated in a wheelchair in the residents room. The tube feeding tubing was dangling and intertwined in wheelchair wheel. Interview on 02/28/19 at 1:30 PM with DON confirmed that Resident 88's tube feeding tubing should not come in contact with the wheelchair wheel as this could be a potential for cross contamination. Observation 03/04/19 between 8:50 AM and 9:00 AM with RN E, during treatment to [MEDICAL CONDITION] and GT site, revealed that RN [NAME] did not perform hand hygiene upon entrance to Resident 88's room. Medication Aide ( MA) H entered Resident 88's room to assist RN [NAME] with residents repositioning. MA H did not perform hand hygiene upon entrance or exit to Resident 88's room. RN [NAME] applied gloves, opened the closet door; removed two trash bags from a box on the shelf. RN [NAME] removed the glove on the left hand and replaced it with a new glove. RN [NAME] did not remove or replace the glove on the right hand. Without reforming hand hygiene or changing glove on right hand, RN [NAME] removed the [MEDICAL CONDITION] and cleaned [MEDICAL CONDITION] with the same gloves on, prepared a q-tip with normal saline, wiped [MEDICAL CONDITION] inside to out with a q-tip. RN [NAME] removed the contaminated gloves. With no hand hygiene preformed, RN [NAME] applied new gloves and proceeded to apply a clean dressing to [MEDICAL CONDITION]. Without changing gloves or performing hand hygiene, RN [NAME] proceed to clean Resident 88's GT site with a wet soapy wash cloth. RN [NAME] removed gloves and applied new gloves. Without hand hygiene in between glove changes, RN [NAME] applied a clean dressing to the GT site. Interview on 03/05/19 at 10:51 AM with the DON confirmed the expectation that staff should perform hand washing or sanitizing ( hand hygiene) before and after patient care. The DON confirmed that gloves should be changed in between different site cares and glove changes. D. On 3/4/19 at 10:30 AM an observation during incontinence cares for resident #5 revealed, NA(Nursing Assistant) A and NA B performed peri care (Perineal care is usually called peri care. It means washing the genitals and anal area), during this care both the NAs changed gloves during the process without washing hands between each glove change. On 3/5/19 at 8:30 AM during dining observation NA B was observed to enter the dining room and put on gloves without washing or sanitizing hands prior to putting on gloves. Record review of facility glove removal policy revealed hands should be washed after removing gloves. Record review of World Health Organizations; Glove use and the need for hand hygiene revealed; When an indication for hand hygiene precedes a contact that also requires glove usage, hand rubbing or hand washing should be performed before donning gloves. When an indication for hand hygiene follows a contact that has required gloves, hand rubbing or hand washing should occur after removing gloves. E. An observation on 03/05/19 at 02:30 PM of the linen storage closet on 300 hall had a shelf that was 3.5 inches off the floor. It was noted that a blanket from the shelf hung off the shelf and touched the floor. An observation on 03/05/19 at 02:31 PM of the linen storage area on 100 hall of a shelf that was 3 inches from the floor. Linens were present on the shelf. An interview on 03/05/19 at 02:31 PM with the Administrator confirmed that the shelf on the 300 hall was 3.5 inches from the floor after it had been measured it with a tape measure, and the 100 hall was 3 inches from the floor after it had been measured by a tape measure.",2020-09-01
277,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2019-03-05,909,F,0,1,MX7V11,"LICENSURE REFERENCE NUMBER 174 NAC 12-006.18B3 Based on observation, record review, and interview, the facility failed to implement a process designed for routine preventative maintenance to inspect all bed frames, matresses, and bed rails as part of a regular maintenance program for possible areas of entrapment. This had the potential to affect all residents. Facility census was 35. Findings are: Observation on 02/27/19 at 3:30 PM revealed Resident 2's bed was up against the wall with a positioning bar on the outside edge of the bed. There was a large gap between the mattress and the bar. Observation on 02/28/19 at 2:55 PM with the DON (Director of Nursing) confirmed the head of the bed frame device to hold the mattress in place was absent from this bed. Interview on 02/28/19 at 2:18 PM with the (MS) Maintenance Supervisor revealed the beds in the facility had a mattress securing device on the head and foot of the beds. MS revealed the facility used positioning bars on some of the resident beds and had one resident who used siderails. MS confirmed the Maintenance Department did not contduct routine inspection of all bed frames, mattresses, and bedrails for preventative maintenance. MS revealed the beds were checked only when the nursing staff reported problems like a frayed cord on the controls or something broken. Interview on 02/28/19 at 2:49 PM with the ADM (Administrator) confirmed the facility did not perform regular inspection of all bed frames, mattresses, and bedrails to identify areas of entrapment.",2020-09-01
278,GOLD CREST RETIREMENT CENTER,285065,200 LEVI LANE,ADAMS,NE,68301,2016-10-13,225,D,0,1,MH0511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report fractures as potential instances of abuse/neglect for two residents (Residents 8 and 35). The facility census was 39. Findings are: Review of the facility's incident log from 10/5/15 through 10/11/16, revealed that Resident 35 was found on 10/22/15, to have a fractured ankle from a fall. Further review of the incident log revealed that Resident 8 suffered a [MEDICAL CONDITION] after a fall from a bath board on 5/24/16. On 10/11/16 at 2:30 PM, the Social Services Director (SSD) was interviewed about reporting requirements. The SSD stated that the facility had not been reporting fractures as potential instances of neglect to the state agency, which included Residents 8 and 35.",2020-09-01
279,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2018-07-31,583,F,0,1,NLZC11,"License Reference Number 175 NAC12-006.16C2 Based on observation and interview, the facility failed to ensure that electronic medical records were not visible to non staff members on the medication cart computers in the halls of the facility. This had the potential to affect all current and former residents in the facility. the facility census was 70. Findings On 07/24/18 at 5:00 PM observation revealed a medication cart on unit #2 with a computer on top, with the computer open and displaying resident information unattended. On 07/24/18 at 5:05 PM observation revealeed LPN(Licensed Practical Nurse) J exit a resident room and came to the cart. On 07/24/18 at 5:05 PM an interview with LPN J revealed the computer should not have been left open and unattended with resident information accessible. On 7/26/18 at 5:13 PM observation of a medication cart on Unit #3 revealed the computer on top open and displaying resident information unattended. On 7/26/18 at 5:16 PM LPN K exited a resident room and came to the cart. On 7/26/18 at 5:16 PM an interview with LPN K revealed, LPN K had forgotten to close the computer and confirmed it should not be left open and unattended. On 7/31/18 at 4:30 PM observation revealed a computer on the top of a medication cart on Unit #1 was open and unattended with resident information displayed and no staff member in the vicinity. On 7/26/18 at 11:00 AM an interview with the DON(Director of Nursing) revealed that the expectations of the facility were for staff to close the computers on the medication and treatment carts whenever staff left the cart. On 7/30/18 at 11:34 AM observation observed LPN L on station #5. LPN L left the computer open and unattended with resident information displayed. The Nurse Manager on the unit was observed closing the screen at 11:42 AM.",2020-09-01
280,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2018-07-31,761,E,0,1,NLZC11,"Licensure Reference Number 175 NAC 12.006.12E1 Based on observation, interview and record review; the facility failed to ensure medication and treatment carts were secured when unattended. This had the potential to affect 7 residents. (Residents 119, 167, 66, 123, 09, 45 and 56.) The facility census was 70. Findings: On 07/24/18 at 07:40 AM an observation of the treatment cart sitting outside of Unit #3 desk was unlocked and unattended. On 7/24/18 at 07:40 AM during an interview, RN(Registered Nurse) A acknowledged that the treatment cart was unlocked and unattended. An observation on 07/24/18 at 01:30 PM revealed the treatment cart parked outside of the Unit #3 desk was unlocked and unattended. On 7/24/18 at 1:40 PM, RN A returned to the Unit #3 desk, and acknowledged the treatment cart was unlocked and should be locked when not attended. An observation on 07/26/18 at 07:37 AM revealed the treatment cart by the desk on Unit #3 was unlocked and unattended. On 07/30/18 at 12:35 PM an observation revealed RN C prepaired an insulin injection, and walked away from the treatment cart leaving it unlocked and unattended. On 7/31/18 at 4:30 PM an observation revealed the medication cart on Unit #1 was unlocked and unattended with no staff in sight. On 7/31/18 at 4:31 PM observation revealed that MA H (Medication Aide) came out of a room two doors away from the medication cart and said I was only gone a minute. On 07/26/18 at 03:51 PM an interview with the DON (Director of Nurses), confirmed there was an issue with nurses leaving med carts and treatment carts unattended and unlocked. The expectation was for the carts to be locked when the nurse walks away from the cart. Record review of Storage of Medications policy dated 12/2016 revealed that compartments containing drugs shall be locked when not in use.",2020-09-01
281,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2018-07-31,805,D,0,1,NLZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-000.09 Based on observation, interview and record review, the facility failed to provide the physician ordered diet consistensy to Resident 15. The facility census was 70. Findings are: Interview with Resident 15 on 07/25/18 at 10:17 AM revealed that the food was dry. Observation on 07/25/18 at 01:41 PM revealed Resident 15 was assisted with Resident 15's meal. The meal consisted of a bowl of soup and a bowl of green beans. The ham and bean soup had 4 packages of crackers added to it per the Resident request. The green beans were whole and RN F (Registered Nurse) cut the green beans with the spoon into smaller pieces. Record review of Resident 15's [DIAGNOSES REDACTED]. Record review of orders revealed the following: -On 1/3/18 a Physician order [REDACTED]. -On 1/20/18 an order had been signed by the Physician for a 1 week trial for Dysphagia 2 (ground meats, soft solids) altered solids and continue nectar thick liquids. -On 1/31/18 an order had been signed by the Physician for Dysphagia 2 with no mixed constancies (cereal with milk, fruit that is not drained). -On 3/7/18 revealed, a Physician order [REDACTED]. -On 5/4/18 revealed, a Physician order [REDACTED]. -On 7/10/18 revealed, a Physician order [REDACTED]. Record review of nurses notes revealed on 06/13/2018 at 5:31PM the RT (Respiratory Therapist) heard patient coughing while aide was feeding the resident dinner. The resident coughed up a small cubed potato. The resident was advised to not eat anymore potatoes with the resident's dinner. Interview on 07/26/18 at 03:15 PM with Unit Manager G confirmed that there were no other evaluations from Speech therapy after (MONTH) of (YEAR). Record review revealed a signed Physician order [REDACTED]. Interview with Unit Manager G on 7/31/18 at 2:20 PM confirmed the order dated 3/7/18 had been missed and was not entered into the computer and the resident had been receiving the mechanical soft diet that was ordered on [DATE].",2020-09-01
282,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2018-07-31,812,F,0,1,NLZC11,"License Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to ensure that staff wore hair nets and beard covers while serving meals in the dinning room and failed to not store scoops in the flour and sugar bins when not in use. This had the potential to affect all residents eating in the facility. Facility census was 70. Findings are: On 07/24/18 at 12:13 PM observation of Dietary Aid I serving lunch in the main dinning room revealed, the facial cover was not covering all of the facial hair on the staffs face. On 07/24/18 at 12:32 PM MA (Medication Aid) H was observed going in and out of kitchen and serving lunch in the main dinning room with hair net covering only half of head/hair. Interview with Dietary Manager on 07/30/18 at 11:52 AM revealed kitchen staff's hair was to be completely covered. On 07/30/18 at 03:45 PM record review of Dietary Policy Staff Hygiene Practices dated 09/2015 revealed [NAME] Hair must be restrained and hairnets must be worn. I. Facial hair will be covered with beard guard. License Reference Number 175 NAC 12-006.11E B On 07/24/18 at 08:42 AM observation during initial tour revealed scoops left in the flour and sugar bins. On 7/30/18 at 11:34 AM observation revealed scoops left in the flour and sugar bins. Record review of the Dietary Manual dated 4/2017 provided by the facility revealed, unless specified elsewhere; dietary follows the regulations related to the Nebraska Food Code. On 07/30/18 at 11:52 AM an Interview with the Dietary Manager confirmed the scoops were in the flour and sugar storage bins and were not to be stored there.",2020-09-01
283,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,176,D,0,1,Q5KD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NAC 12-006.10A1 Based on observation, record reviews, and interviews; the facility failed to ensure 2 residents were safely self-administrating all of their medications. The errors affected 2 residents (Resident 114 and 15) out of 2 residents sampled. The facility census was 77. Findings are: [NAME] Observation on 08-30-17 at 4:26 PM of LPN-I revealed the administration of Tecfidera 240 mg BID (twice a day) to Resident 15 in the resident's room. LPN-I entered the resident's room and the resident was in the bathroom. The resident instructed LPN-I to leave the medication on the table. LPN-I placed the medication cup on the table and left the room. Interview on 08-30-17 at 4:26 PM with LPN-I revealed the resident had an order to self-administer the oral medications and the staff always leave the medications in the resident's room. The staff keep the medications in the medication cart and distribute to the resident, but the resident self-administered them. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident 15's Physician order [REDACTED]. The Physician order [REDACTED]. The Physician order [REDACTED]. Review of Resident 15's TAHS Medication Self Administration form dated 07-28-17 revealed Resident 15 was assessed to self-administer the medications: [REDACTED]. The medication Tecfidera was not listed. B. Observation on 08-31-17 at 7:53 AM of MA-D (Medication Aide) revealed the administration of the following medications to Resident 114 in the resident's room. -[MEDICATION NAME] 0.25 1/2 tablet (an antianxiety medication) -Vitamin D3 1000 IU (international units) 2 tablets -Flax seed 1000 mg 1 tablet -[MEDICATION NAME] 500/400 mg 3 tablets -Magnesium Oxide 250 mg 2 tablets -Multi-Vitamin with minerals 1 tablet -[MEDICATION NAME] 200 mcg 1 tablet -[MEDICATION NAME]-HCTZ 37.5/25 mg 1 tablet -Tumeric 500 mg 1 capsule -[MEDICATION NAME] 20 mg 1 capsule MA-D observed the resident swallow the [MEDICATION NAME] 20 1 capsule then placed the rest of the medications in the medication cup on the residents food tray then left the room. Interview on 08-31-17 at 7:53 AM with MA-D revealed the resident takes the [MEDICATION NAME] then wants to wait 15 minutes before taking the rest of the medications. MA-D revealed the resident has a Physician order [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident 114's TAHS Medication Self Administration form dated 06-19-17 revealed Resident 114 was assessed to self-administer eye drop medications only of Refresh (used to treat dry eyes), Refresh [MEDICATION NAME] (used to treat dry eyes), [MEDICATION NAME] Balance (used to treat dry eyes), [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) , [MEDICATION NAME] (used to treat [MEDICAL CONDITION]), and [MEDICATION NAME] (corticosteroid) eye drops. Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED]. Review of the Medication Self-Administration policy dated 8/2010 revealed the resident must have a Physician order [REDACTED].",2020-09-01
284,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,225,D,1,1,Q5KD11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record reviews and interviews, the facility failed to submit the written investigations within 5 working days on 1 out 3 sampled reports for Resident 112. The facility census was 77. Findings are: Interview on 08-28-17 at 11:03 AM with Resident 112 revealed when the staff moved the resident from one room to another, five $1 bills came up missing from the resident's coin purse. Resident 112 revealed the resident was sure a staff person took the money but just not sure which one. The resident revealed the staff searched the resident's room was unable to find it so the facility reimbursed the resident the $5 into the resident's account. Review of the PN (Progress Notes) dated 07-05-17 revealed the Social Services department staff visited with the resident and the spouse who reported five $1 dollar bills were missing out of the resident's leather coin purse. The resident revealed the resident noted it was missing on 06-14-17. The resident did not want the Police notified. The documentation revealed the Social Service staff notified APS (Adult Protective Services) on 07-05-17. Review of Resident 112's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 07-14-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 10 which indicated Resident 112 had moderate cognition impairment. Requested from the DON (Director of Nursing) the facility investigation report on Resident 112's misappropriation from (MONTH) (YEAR). The DON provided the form Missing or Damaged Item Report dated 07-05-17 revealed Resident 112 reported $5 was taken by a staff person but the resident was unsure of which staff person. The documentation revealed APS was called on 07-05-17 at 11:15 AM. Interview on 08-30-17 at 2:08 PM with SW-F (Social Worker) revealed the SW called the misappropriate report into APS but it was a miscommunication between the staff who was to complete the 5 day report and SW-F confirmed a 5 day report was never done.",2020-09-01
285,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,242,D,0,1,Q5KD11,"**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 honor one of 27 sampled resident's (Resident 120) preferences regarding awake time. The facility census was 77. Findings are: Review of Resident 120's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 8/21/17 revealed Resident 120 had no cognitive impairment, required assistance with mobility and hygiene tasks, had a [DIAGNOSES REDACTED]. Review of Resident 120's Undated [MEDICAL TREATMENT] Care Plan revealed Resident 120 went out to the [MEDICAL TREATMENT] center on Tuesday, Thursday and Saturday mornings at 5:20 AM. Review of Resident 120's Progress Record dated 7/28/17 revealed the night shift staff assessed Resident 120's weight on a daily basis before 5 AM. Review of Resident 120's Admission Observation Detail List Report for Resident Choices dated 8/15/17 revealed Resident 120's preference for Time to get up was 0430 for [MEDICAL TREATMENT] Days. There was no mention of choices on the remaining 4 days that [MEDICAL TREATMENT] did not occur. Interview with Resident 120 on 08/30/2017 at 2:40 PM revealed Resident 120 was upset about being woken as early as 4 am on the non [MEDICAL TREATMENT] days. Resident 120 further reported complaining to and asking the night shift staff why Resident 120 had to get up so early on the 4 remaining days that [MEDICAL TREATMENT] was not scheduled. Resident 120 reported not being able to get back to sleep after being weighed at that time and complained of feeling very worn out. Interview with Licensed Practical Nurse (LPN) J and RN B on 08/30/2017 at 2:45 PM revealed Resident 120 went to [MEDICAL TREATMENT] a little after 5 AM three days a week and had to get up early on those three days. LPN J and RN B further explained they got all resident's receiving [MEDICAL TREATMENT] up on the night shift to obtain their weights to maintain consistency. LPN J then inquired if Resident 120 was complaining about getting up early again. RN B promised to check into changing the times Resident 120 could be weighed on non [MEDICAL TREATMENT] days. A follow up interview with RN B on 8/31/17 at 3:00 PM revealed Resident 120 was able to sleep in on days [MEDICAL TREATMENT] did not occur and that the weight could still be obtained upon rising and before breakfast.",2020-09-01
286,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,329,D,0,1,Q5KD11,"**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 attempt non pharmacological interventions prior to administrating anti anxiety medications to two of 27 sampled residents (Resident 71 and 120). The facility's census was 77. Findings are: [NAME] Review of Resident 71's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 8/21/17 revealed Resident 71 had moderate cognitive impairment, had symptoms of depression, a [DIAGNOSES REDACTED]. Review of Resident 71's Care Plan dated 7/11/17 revealed, [MEDICAL CONDITION] drug use related to Anti-anxiety use due to [DIAGNOSES REDACTED]. Resident 71's Care Plan did not list interventions to be attempted prior to the administration of anti-anxiety medication in an effort to relieve Resident 71's symptoms of anxiety. Review of Resident 71's Medication Administration History (MAH) from (MONTH) 1st (YEAR) through (MONTH) (YEAR) revealed Resident 71 received a PRN (as needed) dose of [MEDICATION NAME] (an [MEDICAL CONDITION] medication given for anxiety) 21 times in (MONTH) and August. No documentation of interventions attempted prior to administering the [MEDICATION NAME] could be found. Interview with the Unit Manager RN (Registered Nurse) [NAME] on 8/31/17 at 1:00 PM revealed any non-pharmacological interventions attempted should be documented on the MAH when the medication was given. B. Review of Resident 120's MDS dated [DATE] revealed Resident 120 had intact cognition, symptoms of depression, and received Anti-anxiety medication 6 out of the prior 7 days. Review of Resident 120's initial Care Plan dated 7/12/17 and later developed care plans dated 8/8/17 revealed no planned approaches or interventions to implement during complaints of anxiety prior to the implementation of [MEDICAL CONDITION] medication. Review of Resident 120's (MONTH) (YEAR) MAH revealed Resident 71 was administered [MEDICATION NAME] (a [MEDICAL CONDITION] medication used for anxiety) on a PRN basis 26 times. There was no documentation of any non-pharmacological interventions attempted prior to the administration of the [MEDICATION NAME]. Interview with RN A on 08/31/2017 at 8:46 AM revealed there was not a place in the current electronic record system to document if non pharmacological interventions were attempted. Review of the facility's policy for [MEDICAL CONDITION] Medication Use dated 8/2017 revealed, [MEDICAL CONDITION] medication is any drug that affects the brain activities associated with mental process and behavior. This therapy shall only be used when it is necessary to treat a specific condition. PRN [MEDICAL CONDITION] medication use shall meet the following criteria: Non-pharmacological interventions must be attempted, unless contraindicated, and documented in the resident record.",2020-09-01
287,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,332,D,1,1,Q5KD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10E Based on observation, record reviews, and interviews; the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications administered revealed 11 errors resulted in an error rate of 44%. The errors affected 3 residents (Resident 15, 114, and 83). The facility census was 77. Findings are: [NAME] Observation on 08-30-17 at 4:10 PM of LPN-I (Licensed Practical Nurse) revealed the administration of [MEDICATION NAME] 800 mg (milligram) 1 tablet to Resident 83 in the resident's room and gave with water but without any food. Review of the label on the medication revealed [MEDICATION NAME] 800mg QID (four times a day) with meals and at HS (hour of sleep). Interview on 08-30-17 at 4:22 PM LPN-I revealed the nurse passed the supper pills then when the residents were in their rooms. LPN-I confirmed supper for the residents started at 5:30 PM. LPN-I confirmed the facility practice was to administer medications in the dining room as needed. Review of Resident 83's Physician orders revealed [MEDICATION NAME] 800 mg QID give with breakfast, lunch, supper, and at HS. Review of Resident 83's (MONTH) (YEAR) MAR (Medication Administration Record) revealed [MEDICATION NAME] 800 mg 1 tab QID give with breakfast, lunch, supper, and at HS. B. Observation on 08-30-17 at 4:26 PM of LPN-I revealed the administration of Tecfidera 240 mg BID (twice a day) to Resident 15 in the resident's room. LPN-I entered the resident's room and the resident was in the bathroom. The resident instructed LPN-I to leave the medication on the table. LPN-I placed the medication cup on the table and left the room. Interview on 08-30-17 at 4:26 PM with LPN-I revealed the resident had an order to self-administer the oral medications and the staff always leave the medications in the resident's room. The staff keep the medications in the medication cart and distribute to the resident, but the resident self-administered them. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident 15's Physician Order Report dated 08-08-17 revealed Tecfidera tablet 240mg give 1 tablet orally BID, do not crush. The Physician Order Report was absent of an order to self-administer oral medications. The Physician Order Report only had orders for the resident to self-administer the medications: [REDACTED]. Review of Resident 15's TAHS Medication Self Administration form dated 07-28-17 revealed Resident 15 was assessed to self-administer the medications: [REDACTED]. The medication Tecfidera was not listed. C. Observation on 08-31-17 at 7:53 AM of MA-D (Medication Aide) revealed the administration of the following medications to Resident 114 in the resident's room. -[MEDICATION NAME] 0.25 1/2 tablet -Vitamin D3 1000 IU (international units) 2 tablets -Flax seed 1000 mg 1 tablet -[MEDICATION NAME] 500/400 mg 3 tablets -Magnesium Oxide 250 mg 2 tablets -Multi-Vitamin with minerals 1 tablet -[MEDICATION NAME] 200 mcg 1 tablet -[MEDICATION NAME]-HCTZ 37.5/25 mg 1 tablet -Tumeric 500 mg 1 capsule -[MEDICATION NAME] 20 mg 1 capsule MA-D observed the resident swallow the [MEDICATION NAME] 20 1 capsule then placed the rest of the medications in the medication cup on the residents food tray then left the room. Interview on 08-31-17 at 7:53 AM with MA-D revealed the resident takes the [MEDICATION NAME] then wants to wait 15 minutes before taking the rest of the medications. MA-D revealed the resident has a Physician order to self-administer all of the resident's medications. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Physician Order Report dated and signed by the Physician on 08-17-17 revealed absence of an order to self-administer oral medications. Review of Resident 114's TAHS Medication Self Administration form dated 06-19-17 revealed Resident 114 was assessed to self-administer eye drop medications only of Refresh, Refresh [MEDICATION NAME] Balance, [MEDICATION NAME], and [MEDICATION NAME]. Review of the Medication Self-Administration policy dated 8/2010 revealed the resident must have a Physician order to self-administer medications. Review of the facility policy medications: [REDACTED].",2020-09-01
288,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,431,E,0,1,Q5KD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E4 Based on observation, record review, and interviews; the facility failed to ensure expired glucose test strips were not available for resident use which affected 5 residents (Resident 178, 120, 182, 70, and 132) out of 6 residents sampled. Findings are: A Observation on [DATE] at 1:19 PM of the Rehabilitation unit treatment cart revealed one Assure glucose test strip bottle (test strips used to monitor residents' blood sugar) was absent of a date when the bottle was opened. Interview on [DATE] at 1:19 PM with the RN-A (Registered Nurse) revealed the nurse was unsure of the facility policy regarding if the glucose test strip bottles were to be dated when opened. Interview on [DATE] at 1:20 PM with the Rehabilitation UM-B (Unit Manager) revealed the manager was unsure of the facility policy regarding if the glucose test strip bottles were to be dated when opened. Observation on [DATE] at 1:25 PM of the glucose bins for Resident 182, Resident 178, and 120 revealed their glucose test strip bottles were absent with a date when the bottles were opened. Interview on [DATE] at 1:25 PM with RN-A (Registered Nurse) revealed each Resident 182, 178, and 120's glucose test strip bottles had been opened and confirmed the bottles did not have a date when they were opened. RN-A revealed the residents who required glucose monitoring had their own individual bottle of glucose test strips. A single bottle was kept on the treatment cart to be used for any resident PRN (as needed). B Observation on [DATE] at 1:42 PM on Unit 2 treatment cart revealed one bottle of Assure glucose test strips without a date wrote on the bottle when it was opened. The bottle only had 3 test strips remaining in it. Interview on [DATE] at 1:42 PM with LPN-C (Licensed Practical Nurse) confirmed the directions on the bottle revealed the test strips outdated 90 days from when the bottle was opened. LPN-C confirmed the bottle of glucose test strips were not dated and had been opened. Observation on [DATE] at 1:46 PM on Unit 2 of the glucose bins for Resident 70 and Resident 132 revealed the glucose test strips bottles had been opened and were absent of a date wrote on the bottles when they were opened. Interview on [DATE] at 1:46 PM with MA-D (Medication Aide) confirmed the glucose test strip bottles for Resident 70 and Resident 132 had been opened and were without a date when opened. Review of the package insert of the Assure Blood Glucose Test strips revealed When you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle.",2020-09-01
289,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2017-08-31,441,D,1,1,Q5KD11,"> Licensure Reference Number 175 NAC 12-006.17B Based on observation and interview, the facility failed to ensure resident care items were stored in a manner which prevented the potential for cross contamination. This failure had the potential to effect 3 of 38 sampled residents (Residents 87, 95, and 127). The facility census was 77. Findings are An observation on 08/28/2017 at 9:44 AM revealed an open bag of briefs (incontinence products) on the floor next to toilet in Resident 95's bathroom (BR). Another open bag of briefs was noted to be stored on the back of toilet, resting against an uncovered urinal (a device used to contain urine) which was hanging on a grab bar. An observation on 08/28/2017 at 10:42 AM in the BR shared by Residents 110 and 127 revealed a bedpan and a graduate cylinder (device used to measure fluids) on the floor in the BR. Another graduate cylinder was noted to be sitting on the grab bar in the BR. Further observation revealed that none of the devices were marked with a Resident's name or the date issued, and the devices were not covered. Observations on 08/31/20 at 7:50 AM with the Director of Nursing (DON) and Corporate Consultant revealed: the open bags of briefs remained on the floor and grab bar in Resident 95's BR; and uncovered, unmarked graduated cylinders and bedpan stored on the floor of BR shared by Residents 87 and 127. An interview on 08/31/2017 at 7:52 AM with the DON revealed: graduate cylinders were to be changed out wkly, marked with resident name and date issued; graduate cylinders and bed pans were to be stored in a bag; open bags of briefs were supposed to be stored on shelves in resident BRs or in the resident's closet and not on the floor of the bathroom; and the urinal should have been bagged following cleaning, not left hanging on the rail in the BR.",2020-09-01
290,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2019-11-13,565,D,1,1,ZG8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.06B Based on record observation, interview and record review the facility failed to initiate a grievance for 1 resident (Resident 222) of 2 resident reviewed. The facility census was 74. Findings are: An observation of the facility on 11/13/19 unable to locate the grievance forms that are out and available for the resident to be able to file a grievance anonymously. An observation of the facility on 11/13/19 when asked for a grievance from the LPN (Licensed Practical Nurse) D, the nurse located the form in a file cabinet behind the nurse's desk. An interview on 11/13/19 at 10:55 AM The Administrator could not recall any grievance or complaints filed by the resident or family. An interview on 11/13/19 at 11:15AM with the DON (Director of Nursing) confirmed there was an intervention in the care plan Resident 222 had specified a preference for gender specific care givers, and the request had been met. The DON had conversations with Resident 222 in relation to a staff member and the differences they had. The DON could not recall any complaint about long call light times, but did recall that conversations about differences with staff members. The DON confirmed a grievance form had not been filled out in relation to the conversations about differences with staff. An interview on 11/13/19 12:40 PM with the Corporate Administrator confirmed the anonymous grievance forms were not posted and the facility had taken them down with the remodel, and the forms had to be adjusted to have current administration on the forms and were not out at this time. AN interview on 11/13/19 01:01 PM with the DON revealed; they had not been filling out grievances for Residents with complaints in relation to the staff. The DON confirmed there should be a grievance form filled out if a resident has a concern regarding a staff member. Record review of Progress Note dated 10/10/2018 11:47 Resident has had increased behaviors. Resident does not come out of room even when encouraged. Stays in room all day and night. Refused to do activities. Resident constantly complains, Resident does not redirect. Resident makes the complaint worse after each encounter. Tried one on one, redirection, distraction. Behaviors never become better. The Resident was focus on the issue (gender) complained about and nothing made it better. Resident sits in room and cries at times. Resident has been calling different people such as doctors and staff a lot lately, demanding different things. Resident has had decrease is wanting to do things without assistance. Resident also refused to get up at night to use the bathroom. Was largely incontinent at night. This was documented by LPN B Record review of Progress note Date/Time: 10/08/2018 12:09 revealed; Resident Has had many complaints today. Complains of shoulder hurting. Given aqua k heat pad, tens unit, stretched out extremity, offered to call the ER, given all available PRNs (as needed) which pertain to this. Resident stated (gender) was having trouble breathing. O2 94% on Room Air, Respitory Rate even and unlabored, restated that when (gender) sat down (gender) lost (genders) breath. B/P 128/69, 61, 98, 17. Resident called endocrinologist and stated that (gender) had high B/P and really low blood sugars as well as having to pee all the time, educated Resident on High and lows of BP (Blood Pressure) and blood sugars, and (genders) mediation regimen of diuretics. Resident states to this nurse (gender) doesn't want to go to the ER (emergency room ). Stated to Resident that maybe (gender) should try distracting self. Resident made excuses why this wouldn't work. Resident also is now asking for assistance walking to the bathroom. This nurse stayed in room and watched Resident walk from (genders) recliner to the bathroom No gait issues noted at this time. Resident stated pain was a 10/10, no non-verbal signs of pain noted. Did eat all of he(gender) breakfast with no issues. Record review of Progress note dated 08/29/2018 17:03 Discussed with resident that (genders) [NAME] was for feelings of [DIAGNOSES REDACTED] only as resident has been ringing bell excessively for none diabetic issues. Resident reported that they misunderstood what the bell was meant for. Resident reported a sore throat was gone & (gender) has had no further coughing at this time. Assisted with cleansing of C-pap( masked conected to a machine to push air into lungs during sleep to keep lungs expanding and breathing) mask at this time. Record review of the facility Grievance policy dated 06/19/19 revealed; Any resident, family member or appointed resident representative may file a grievance concerning the residents care treatment behavior of other residents, staff members, theft of property, or any other concerns regarding his/her stay at the facility. Grievances also may be voice or filed regarding his/her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.",2020-09-01
291,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2019-11-13,578,E,0,1,ZG8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Advanced Directives and Cardiopulmonary Resuscitation preferences were care planned for 5 residents (Resident 4, 42,43,55, and 62). The facility census was 74. Findings are: [NAME] Record review of Resident 4's Code Status dated [DATE] revealed; Resident 4 wanted no resuscitation in the event of a [MEDICAL CONDITION]. Record review of Resident 4's Medical Treatment Decisions dated [DATE] revealed; Resident 4 wanted to be hospitalized , IV Therapy for nutrition, hydration and blood [MEDICAL CONDITION]. Record review of Resident 4's care plan revealed; the care plan had not addressed the residents Advanced Directives and Cardiopulmonary Resuscitation preferences B. Record review of Code Status dated [DATE] revealed; Resident 42 wanted CPR in event of a Cardiopulmonary Arrest. Record review of the Medical Treatment Decisions record dated [DATE] revealed; Resident 42 wanted to be hospitalized , IV therapy for nutrition/hydrations/medications and blood [MEDICAL CONDITION]. Record review of Resident 42's care plan revealed; the care plan had not addressed the residents Advanced Directives and Cardiopulmonary Resuscitation preferences C. Advance Directives Record review of Advanced Directive Medical Treatment Decisions dated; [DATE] revealed; Resident 43 wished to be hospitalized , have IV therapy for nutrition and hydration, medication and blood transfusion. Record review of Cardiopulmonary Resuscitation dated 9 revealed; Resident 43 wished to have CPR. Record review of Resident 43's care plan revealed; the care plan had not addressed the residents Advanced Directives and Cardiopulmonary Resuscitation preferences D. Advance Directives Record review of Resident 55's Medical Treatment Decisions dated [DATE] revealed; the resident wanted to be hospitalized , have IV therapy for hydration/nutrition/blood [MEDICAL CONDITION]. Record review of Code Status dated [DATE] revealed; Resident 55 wished to have CPR in the event of cardiopulmonary arrest. Record review of Resident 55's care plan revealed; the care plan had not addressed the residents Advanced Directives and Cardiopulmonary Resuscitation preferences E. Advance Directives Record review for Medical Treatment Decisions for Resident 62 dated [DATE] revealed; the resident wanted to be hospitalized , IV therapy for nutrition/hydration and blood [MEDICAL CONDITION]. Record review for Code Status for Resident 62 dated [DATE] revealed; Resident 62 wanted CPR in the event of cardiopulmonary arrest. Record review of Resident 62's care plan revealed; the care plan had not addressed the residents Advanced Directives and Cardiopulmonary Resuscitation preferences An interview on [DATE] at 10:15 AM with the DON (Director of Nurses) confirmed; that the Advanced Directives and Cardiopulmonary Resuscitation preferences are not care planned.",2020-09-01
292,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2019-11-13,636,D,1,1,ZG8M11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09B1(2) Based on Record review and interview the facility failed to ensure an MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) did not reflect 1 resdients ( Resident 14) current [DIAGNOSES REDACTED]. The facility census was 74. Findings are: Record review of MDS dated [DATE] admission reports [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed [DIAGNOSES REDACTED]. An interview on 11/7/19 at 12:40PM with DON ( Dirctor of Nursing) revealed no documentation is available that states when the [DIAGNOSES REDACTED].,2020-09-01
293,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2019-11-13,760,D,1,1,ZG8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10D Based on observation, and interview; the facility failed to ensure 1 resident (Resident 1) of 1 resident reviewed, were free of significant medication errors. The facility census was 74. Findings are: FACILITY Medication Administration An observation with the Corporate Nurse on 11/12/19 at 4:43 PM of Medication Administration for Resident 1. LPN B completed glucometer check for Resident 1. LPN B performed Hand hygiene from 4:43:50 to 4:44:22. LPN (Licensed Practical Nurse) B placed the accu-check machine on a paper towel and the glucometer was kept in the room. LPN B asked the resident a finger preference and the thumb was chosen by the resident. The thumb was cleansed with an alcohol wipe, a lancet was used to prick the thumb, the first drop of blood was wiped with a cotton ball and then the blood was placed on the strip that was inserted in the glucometer. Accu check was 146. Gloves were removed, HH was performed from 4:53:26 to 4:53:01 [MEDICATION NAME] 6 units and sliding scale was ordered. Sliding scale was not needed related to Blood glucose less than 149. LPN B cleansed the Insulin pen with an alcohol wipe and the needle was placed. The order was checked and the Pen was dialed to 6 units HH was performed for 27 seconds. The insulin was given in the abdomen (left side) per resident request. An interview with the Corporate Nurse on 11/12/19 at 5:05 PM confirmed; that the pen had not been primed and should be primed prior to the dialed dose of insulin, this is a part of the training for staff. An interview on 11/13/19 with the DON (Director of Nurses) confirmed; that the insulin Administration policy did not address insulin pens and the priming prior to dialing the dose for administration. The only thing on the policy that would cover that would be the staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system prior to their use.",2020-09-01
294,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2019-11-13,761,E,0,1,ZG8M11,"Licensure Reference Number 175 NAC 12-006.12E1 Based on observation, interview, and record review; the facility failed to ensure only authorized personnel had access to medications. This had the potential to affect 33 residents who were self-mobile of 74 residents in the facility. Findings are: An observation with the Corporate Nurse on 11/12/19 at 4:15 PM of LPN I during medication administration had prepared a residents medication and took the mediation, left the cart and went into the resident room, the cart was not locked. An interview on 11/12/19 at 4:16PM LPN I confirmed; the cart was not locked, had forgotten to do so. Record review of the Medication Administration Policy dared 09/2019 revealed; Secure Medications, never leave the medication unattended. The cart must be locked anytime it is out of sight.",2020-09-01
295,THE AMBASSADOR LINCOLN,285066,4405 NORMAL BLVD,LINCOLN,NE,68506,2019-11-13,880,E,1,1,ZG8M11,"**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 prevent cross contamination during catheter care for 1 Resident (Resident 55) and insertion of new catheter for 1 Resident (Resident 66). The facility also failed to ensure that hand hygiene was performed for a minimum of 20 seconds per the facility policy to prevent cross contamination during wound care for 2 resident (Resident 66 and 62). The facility census was 74. Findings are: [NAME] Record review of Resident 66 Care Plan (a comprehensive interdisciplinary plan to ensure the provision of quality care for the resident) dated 08/01/2017 revealed resident requires and indwelling urinary catheter (a medical tube that is inserted into the bladder to drain urine) related to having [MEDICAL CONDITION] bladder (a condition in which the bladder cannot fully empty its self). An observation on 11/7/19 from 2:00 PM-3:08 PM revealed LPN (Licensed Practical Nurse) A preformed hand washing for 7 seconds; applied gloves (gloves were in LPN uniform pant pocket). Catheter kit was dumped onto clean white barrier. Syringe full of sterile water was squirted into white basin. 25 CC of fluid were removed from old catheter balloon (a balloon full of water in the bladder- that holds catheter in place). Catheter was removed from patient. A 5 second hand washing was completed by LPN [NAME] Gloves from nurse's pocket were applied. Catheter tub( in open plastic wrap) was dropped on floor and then proceed to continue to use same syringe used to removed old water from previous catheter to test new catheter balloon. Gloves were removed. No hand washing completed. Sterile gloves applied, lubricant was applied to glove packaging, iodine swaps used to clean penis. Wiped using iodine swaps starting at the outer most of the penis and then working upward. Lubricant applied to tip of catheter and inserted into residents penis. Catheter was treaded all the way up to the bifurcation with the port to insert water into balloon. Clear urine with one blood clot drained out of new catheter tubing into catheter bag. Record review of policy Titled Foley Insertion/ changing dated 01/2015 revealed section 7. Cleanse meatus with antiseptic solution using clean cotton ball for each stroke (in females- cleanse from above downward- cleanse labia firth then urinary meatus). An interview on 11/12/19 at 8:52AM with DON (Director of Nursing) confirmed staff should not be carrying and using gloves from uniform pockets. Perineal care should be down according to policy and wiping should be done in a downward motion working from dirty to clean. B. An observation on 11/7/19 from 2:00 PM-3:08 PM revealed LPN (Licensed Practical Nurse) A preformed hand hygiene by applying soap to hands, turned on faucet, wet hands with water and washed hands with friction for 4-7 seconds; this occurred 8 times during wound care, perineal care, flushing of catheter and changing of catheter. Record Review of policy titled Hand Washing dated 02/2016 revealed: Section Antiseptic Hand Wash Procedure- Step 3 turn on the faucet and adjust the water to a comfortable temperature for you. Step 4 completely wet your hand and the area about the wrist 2-3 inches under the running water. Keep your fingertips pointed downward. Step 5 Apply antimicrobial soap. Step 6 Hold your hands lower than your elbows while washing. Step 7 Work up a good lather. Spread it over the entire area of your hands and 2-3 inches above the wrist. Get soap under nails and between your fingers. Step 8 Clean under the nails by rubbing your nails across the palms of your hands. Step 9. Use a rotating and rubbing (frictional) motion for a minimum of 20 seconds. - Rub vigorously -Rub one hand against the other hand - Rub between your fingers by interlacing them - Rup up and down to reach all skin surfaces on your hands and between your fingers. -Rinse well -Dry thoroughly with a paper towel Turn off the faucet with a paper towel. Discard the paper towel into the waste basket. An interview on 11/12/19 at 8:52AM with DON (Director of Nursing) confirmed staff should be following hand washing policy and wash hands for minimum of 20 seconds using a rotating and rubbing ( frictional) motion. C. Resident #55 Urinary Catheter or UTI An observation on 11/12/19 of perineal care for Resident 55 by RN [NAME] and LPN F. RN [NAME] performed hand hygiene from 10:44:43 to10:44:53. Resident 55 lowered the bed to Trendelenburg position and told staff it would reported would be easier for staff to complete perineal care. At 10:47AM the oximeter was placed on the great toe of the left foot. RN F changed gloves and provided care to the pannus with wet Tena cloths with soap applied in a patting motion to the left side of the pannus, cloth was discarded and gloves were changed, Right side of pannus was cleansed with new cloth, cloth was discarded and gloves were changed, the Pannus was dried with a new cloth, cloth was discarded and gloves were changed. Left Perineal area was cleansed with a new cloth, the cloth was discarded and gloves were changed, Right Perineal area was cleansed with new cloth, the cloth was discarded and gloves were changed, perineal area was dried with an new cloth to the left the cloth was turned and the right was dried, the cloth was discarded and gloves were changed, right labia was washed with new cloth, cloth discarded, left labia was washed with new cloth, gloves were changed, Right labia was dried the cloth was turned and the left was dried, gloves changed, the center was cleansed x 2 with 2 different cloths, gloves changed, Center was cleansed and wound dressing was removed with the wiping, gloves changed the center was dried, gloves were changed, additional cloths were wet soap applied, Gloves were changed middle labia area was cleansed, gloves change and was dried with 2 cloths. Resident 55 was turned with 2 staff members to the right, RN [NAME] changed gloves. Right Buttock was cleansed with a cloth, the cloth was discarded and the left buttock was cleansed gloves were changed. The buttocks were dried with a clean cloth for each side, gloves were changed. Anal area cleansed and RN [NAME] changed gloves. RN [NAME] without hand hygiene performed the catheter tube cleansing by holding tube wipe away from urethra, gloves were changed, and dry cloth to catheter, and gloves were changed. RN [NAME] then cleansed the Pannus without hand hygiene, patted dry gloves were changed, dried Pannus, gloves were changed RN [NAME] completed hand hygiene from 11:17:17 to 11:17:39 (22 seconds) An interview with Corporate Nurse 11/12/19 at 02:08 PM confirmed that hand hygiene should be completed when going from back to front or dirty to clean. D. An observation of wound care with the DON present on 11/12/19 at 09:32:21 AM of surgical site of abdominal skin area for Resident 62, the wound was shallow and had pink wound bed. The LPN (Licensed Practical Nurse) G wet the 4x4 with water and ungloved hands. LPN G performed HH (hand hygiene) from 09:33:52 to 09:34:22 AM (30seconds) and donned gloves. LPN H completed HH from 09:35:02 am to 09:35:12AM (10 Seconds) after completing hand hygiene the paper towel was discarded in the trash in the bathroom, the container was small and when putting the towel in the bin the hand was place down into the trash can. Wound dressing removed from the LUQ, gloves removed, hand hygiene was completed by LPN G from 9:36:56 to 9:37:39 (43 seconds), gloves donned and aqua cell was applied with a 4x4 over the wound. An observation for Resident 62's Skin Flap repair treatment Prep was completed at 09:42:02AM one 4x4 with soap and water, one 4x4 with water only, with ungloved hands. LPN H completed HH from 09:43:20 to 09:43:34 (14 seconds) [NAME] performed HH for over 30 seconds LPN H lowered the HOB (head of the bed) to low position and completed HH from 09:46:11 to 09:46:23AM (13 seconds) hand was placed in the trash receptacle when discarding paper towels. Gloves donned, Resident 62 was repositioned, and small open area on the flap line was open and actively bleeding. Wound had calmospetine placed on it, wound was washed with soap and water, rinsed with new cloth, calmospetine was placed on the wound, no glove changing and no hand hygiene performed between cleansing the wound and the application of calmospetine. LPN H completed hand hygiene from 09:46:11 to 09:46:23 (12 seconds) LPN G completed HH for 30 seconds LPN H returned to the sink and completed HH from 09:49:36 to 09:49:42 (6 seconds), hand was placed in the trash receptacle when discarded paper towel. An interview with [NAME REDACTED] DON 11/12/19 10:40 AM confirmed that the wound on the abdomen was a dehisced site where a feeding tube had been removed. Record review of Hand Hygiene Policy dated 02/2016 revealed; Antiseptic Hand Wash Procedure was; 1. The equipment used for hand washing will be found at all times at every sink in the facility 2. If the paper town dispenser is a roll down type be sure to roll out your paper towel before you wet your hands. 3. Turn the faucet and adjust the water to a comfortable temperature for you 4. Completely wet your hands and the area above the wrist by 2-3 inches under the running water. Keep your fingertips down. 5. Apply antimicrobial soap 6. Hold your hands lower than your elbow while washing. 7. Work up a good lather. Spread it over the entire area of your hand and 2-3 inches above the wrist. Get soap under nails and between your fingers. 8. Clean under nails by rubbing your nails across the palm of your hand. 9. Use a rotating and rubbing (frictional motion for a minimum of 20 seconds. a. Rub vigorously b. rub one hand against the other hand c. rub between your fingers by interlacing them d. rub up and down to reach all skin surfaces on your hands and between your fingers e. rub the tips of your fingers against the palm to cleans with friction around nail beds. 10. Rinse well. 11. Dry thoroughly with a paper towel. 12. Turn off the faucet with a paper towel. Faucet. 13. Discard the paper towel into the waste basket. An interview on 11/12/19 02:00 PM with the DON confirmed that not all the hand hygiene that was performed while skin care was completed had met the 20 second vigorously scrubbing. The DON reported that she was singing the ABC's and had not completed the song on some of the hand washing.",2020-09-01
296,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2019-03-12,609,D,0,1,L6LR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility staff failed to report a fall with injury requiring medical treatment outside of the facility as a potential allegation of neglect to the state agency within the required time frame for Resident 77. This affected 1 of 4 resident investigations for accidents. The facility identified a census of 77 at the time of survey. Findings are: Review of Resident 77's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 77 was rarely/never understood. Staff assessment for mental status revealed short term and long term memory problem and moderately impaired cognitive skills for daily decision making. Resident 77 required extensive assistance of 2 staff members for bed mobility, transfer, walk in room, and toilet use. Resident 77 was dependent on staff for locomotion on and off the unit. Resident 77 had 2 or more falls with no injury and 2 or more falls with injury since the prior assessment. Bed alarm and chair alarm were used daily. Review of Resident 77's Progress Notes revealed the following: On 2/16/2019 at 6:15 AM staff heard Resident 77's bed alarm sounding. Resident 77 was observed on the floor on the mat beside the bed. A 15 cm (centimeter) skin tear to the right arm and a right ear laceration were observed. The areas were cleansed; the right arm was wrapped with [MEDICATION NAME] and kling (dressings), and a cotton ball was placed to the right ear as the areas were bleeding. Resident 77 was assisted up with 2 assist and a FBL (full body lift) to their wheel chair. Resident 77 was sent to the ER (emergency room ) for sutures. There was no documentation the state agency was notified that Resident 77 had a fall with injury that required outside medical treatment. Interview with the SSD (Social Services Director) on 03/12/19 at 10:08 AM revealed they did not report the fall with injury requiring outside medical treatment to the state agency. The SSD revealed Resident 77 also had a CAT (Computed Axial [NAME]ography-a type of specialized scan used to detect internal injuries) scan while at the hospital and it was negative. Review of Resident 77's Patient Visit Information with the Location: Emergency Services dated 2/16/2019 revealed Resident 77 was seen for a fall, skin tear, and laceration of the ear with laceration repair. Activity Restriction or Additional Instructions included to have sutures removed in 7-10 days, follow-up with (medical provider) in 2 days for close monitoring of the ear to make sure there is no hematoma or infection developing. Return sooner if you notice more pain, redness, drainage or fevers develop. Review of Resident 77's Doctor's Appointment Sheet dated 2/21/2019 revealed documentation that Resident 77 was to theER on [DATE] after a fall. CAT scan done was negative. Resident 77 had sutures to the right ear and steri-strips (a strip style adhesive bandage) to the right hand. Review of the facility policy Abuse and Neglect Prevention Protocol revised 1/10/2019 revealed the following: If abuse or neglect or alleged abuse or neglect occurs, the facility will take appropriate action to intervene, document incidents, investigate, take measures to prevent further occurrences and report it to the proper authorities. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Denial of essential services is described as the denial of essential services to the extent that there is imminent or potential danger of the person suffering physical injury, psychological harm, or exploitation. Such services may include but are not limited to: sufficient and appropriate food and clothing, temperate and sanitary shelter, treatment of [REDACTED]. Examples: (include but are not limited to) inadequate supervision of resident, failing to intervene in resident to resident abuse, staff ignoring residents needs, or staff not answering call lights. Nebraska law states that when any physician, psychologist, physician assistant, nurse, nursing assistant, other medical, developmental disability, or mental health professions, law enforcement personnel, care giver or employee of a caregiver, operator or employee of a sheltered workshop, owner, operator or employee of any facility licensed by the Department of Health and Human Services professional or paraprofessional has reasonable cause to believe that a vulnerable adult has been subjected to abuse or neglect, or observes such adult being subjected to conditions or circumstances which reasonably would result in abuse/neglect, he or she shall report the incident or cause a report to be made to the appropriate law enforcement agency or the Department of Health or Human Services. Covered individuals must report any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility to the state survey agency and at least one or more local law enforcement entities for the political subdivision in which the facility is located within a designated time frame by e-mail, fax, or telephone. Serious bodily injury-2 hour limit; if the events that cause the reasonable suspicion result in serious bodily injury to a resident, covered individuals shall report the suspicion immediately, but not later than 2 hours after forming suspicion. All other-within 24 hours-if the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, covered individuals shall report the suspicion not later than 24 hours after forming the suspicion. The facility will submit written report of the investigation within 5 working days to the health and Human Services. In a situation of self-abuse/self-neglect or resident to resident abuse/neglect the following will be considered when investigating: The severity of the alleged abuse/neglect. The frequencies or the history of the abuse/neglect. The interventions used.",2020-09-01
297,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2019-03-12,638,D,0,1,L6LR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility staff failed to complete a Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) at least every 3 months for Resident 1. This affected 1 of 20 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 77 at the time of survey. Findings are: Review of Resident 1's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Review of Resident 1's OBRA (Omnibus Reconciliation Act, a federal mandated law including MDS assessments) MDS assessments revealed the last MDS completed had an ARD (Assessment Reference Date) of 10/30/2018. Interview with the MDS Coordinator on 3/12/19 at 8:04 AM revealed Resident 1's quarterly MDS should have been completed (MONTH) 2019 and it got missed.",2020-09-01
298,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2019-03-12,641,D,0,1,L6LR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility staff failed to code falls on the MDS (Minimum Data Set-a comprehensive tool used to develop a resident's care plan) consistent with the number of falls that occurred during the specified time frame for Resident 1 and Resident 15. This affected 2 of 20 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 77 at the time of survey. Findings are: [NAME] Review of Resident 1's quarterly MDS dated [DATE] revealed an admission date of [DATE]. 1 fall with no injury since prior assessment was marked on the MDS. Review of Resident 1's MDS assessments revealed the prior MDS assessment ARD (Assessment Reference Date) was 7/31/2018. Review of Resident 1's Progress Notes revealed Resident 1 had falls documented on 9/27/2018 and 9/13/2018. Interview with MDS Coordinator on 3/12/19 at 8:04 AM revealed 2 falls should have been marked on the MDS. B. Review of Resident 15's quarterly MDS dated [DATE] revealed an admission date of [DATE]. 1 fall with no injury since prior assessment was marked on the MDS. Review of Resident 15's MDS assessments revealed the prior MDS assessment ARD was 9/4/2018. Review of Resident 15's Progress Notes revealed documentation that Resident 15 had falls on 10/4/2018 and 11/1/2018. Interview with the MDS Coordinator on 3/12/19 at 8:05 AM revealed 2 falls should have been marked on the MDS.",2020-09-01
299,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2019-03-12,657,D,0,1,L6LR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, interview and record review; the facility staff failed to update Resident 59's care plan with interventions for respiratory care, failed to include interventions regarding a medical condition impact on falls and pain and failed to include interventions on the care plan for fall related injuries for Resident 77. This affected 2 of 20 residents whose care plans were reviewed during the survey process. The facility identified a census of 77 at the time of survey. Findings are: [NAME] Observation of Resident 59 on 3/06/19 on 1:47 PM revealed Resident 59 was audibly wheezing (a high-pitched [MEDICATION NAME] sound made while breathing). Review of Resident 59's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/22/2019 revealed an admission date of [DATE]. Resident 59 had shortness of breath or trouble breathing while lying flat. Review of Resident 59's Physician order [REDACTED]. Review of Resident 59's physician Nursing Home Visit report dated 1/15/2019 revealed documentation that Resident 59 had audible wheezing and a mild cough. Problems included acute [MEDICAL CONDITION]. Resident 59 was treated with [MEDICATION NAME] and [MEDICATION NAME]. Review of Resident 59's Doctor's Appointment Sheet dated 1/15/2019 revealed Resident 59 had an audible wheeze. Resident 59 was diagnosed with [REDACTED]. Check oxygen saturations (level) twice a day for 4 days. [MEDICATION NAME] for 5 days. Interview with the MDS Coordinator on 3/12/19 at 11:12 AM revealed Resident 59 had wheezing as part of their medical condition and had been treated for [REDACTED]. Review of Resident 59's care plan dated 1/22/2019 revealed no documentation Resident 59 had a wheezing condition and had an as needed treatment for [REDACTED]. Interview with the MDS Coordinator on 3/12/19 at 1:45 PM confirmed there were no interventions on Resident 59's care plan regarding breathing issues including wheezing. B. Observation of Resident 77 on 3/7/2019 at 8:57 AM revealed their right hand was wrapped with a stretch type bandage. Observation of Resident 77 on 3/7/2019 at 3:32 PM revealed their right hand and left arm were wrapped with bandages. Review of Resident 77's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 77 was rarely/never understood. Staff assessment for mental status revealed short term and long term memory problem and moderately impaired cognitive skills for daily decision making. Resident 77 required extensive assistance of 2 staff members for bed mobility, transfer, walk in room, and toilet use. Resident 77 was dependent on staff for locomotion on and off the unit. Resident 77 had 2 or more falls with no injury and 2 or more falls with injury since the prior assessment. Bed alarm and chair alarm were used daily. Review of Resident 77's Progress Notes revealed the following: On 3/08/2019 at 6:45 AM Resident 77 was found on the floor. Resident 77 had a skin tear to the right forearm 3 by 1 cm (centimeters) V-shaped. The area was cleansed, skin approximated, steri-strips (strip style adhesive bandage) were applied, and it was covered with [MEDICATION NAME] (non-stick gauze type dressing) & gauze wrap. On 2/24/2019 at 7:22 PM Resident 77 fell to the floor, scraping their left forearm on the ledge of the built in dresser creating a very large skin tear measuring 17 cm by 8 cm medially (toward the middle of the body) and 15 cm by 5 cm laterally (toward the outside of the body). The skin tears ran into each other in the center. The skin tears were cleansed with sterile water. Skin prep (a type of material used to help the bandage adhere to the skin) and many steri-strips were applied. [MEDICATION NAME] and kling (gauze wrap) was applied. Resident 77 was educated to leave it alone and not to pick at it. On 2/16/2019 at 6:15 AM Resident 77 was observed on the floor on the mat beside their bed. A 15 cm skin tear to right arm and right ear laceration were observed. The areas were cleansed, right arm was wrapped with [MEDICATION NAME] and kling, and a cotton ball was placed to the right ear as the areas were bleeding. Resident 77 was sent to the ER (emergency room ) for sutures. Review of Resident 77's Progress Notes revealed documentation that Resident 77 had falls on 9/21/18, 11/25/18, 12/27/18, 1/10/9, 1/16/19, 2/12/19, 2/16/19, 2/22/19, 2/24/19, and 3/8/19. Review of Resident 77's Patient Visit Information with the Location: Emergency Services dated 2/16/2019 revealed Resident 77 was seen for a fall, skin tear, and laceration of ear with laceration repair. Activity Restriction or Additional Instructions included to have sutures removed in 7-10 days, follow-up with (medical provider) in 2 days for close monitoring of the ear to make sure there is no hematoma or infection developing. Return sooner if you notice more pain, redness, drainage or fevers develop. Review of Resident 77's Doctor's Appointment Sheet dated 2/21/2019 revealed documentation that Resident 77 was to theER on ,[DATE] after a fall. CAT (Computed Axial [NAME]ography-a specialized test used to detect internal injuries) scan done was negative. Resident 77 had sutures to the right ear and steri-strips to the right hand. Interview with the Don (Director of Nursing) on 3/12/19 at 10:56 AM revealed Resident 77 had injections for [DIAGNOSES REDACTED] (a chronic pain condition that affects the trigeminal nerve, which carries sensation from the face to the brain) which had helped with the pain which was a contributing factor for Resident 77 falling. Interview with Resident 77's family member on 3/12/19 at 11:30 AM revealed Resident 77 had [DIAGNOSES REDACTED] pain which caused Resident 77 to fall. Resident 77 was being treated with injections in which they injected [MEDICATION NAME] into Resident 77's nose which relieved the pain for about 6 weeks. The pain pills Resident 77 was taking were making them unsteady. Resident 77's family member revealed the signs that Resident 77 was having the [DIAGNOSES REDACTED] pain included Resident 77 wouldn't wear their teeth, Resident 77 would hold their head and wouldn't eat very well. Resident 77's family member revealed Resident 77 still had falls but it was worse when they were having that pain from the [DIAGNOSES REDACTED]. Review of Resident 77's care plan dated 2/5/2019 revealed no documentation of interventions implemented to monitor the skin tears and no documentation of interventions regarding the [DIAGNOSES REDACTED] and the impact it had on Resident 77's pain and fall risk. Interview with the MDS Coordinator on 3/12/19 at 1:43 PM revealed there was no documentation on Resident 77's care plan regarding the implications of the [DIAGNOSES REDACTED] on Resident 77's pain and fall risk. Interview with NA-A (Nurse Aide) on 3/07/19 at 3:35 PM revealed they got the information they needed to care for the residents from the care plan.",2020-09-01
300,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2017-12-05,641,D,0,1,4Y7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure that one resident's (Resident # 74) restorative therapy reflected the current status of the resident on the MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes). The facility census was 79. Findings are: Review of Resident 74's undated [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 7 which indicated Resident 74 had a severely impaired cognition. Resident 74 required total dependence of 2 staff with bed mobility and total dependence with 1 staff for transfers, dressing, eating, toileting, and personal hygiene. The resident had impairment to one side on the upper extremity and impairment to both lower extremities. The MDS also revealed the resident received for Restorative Nursing Program AROM (Active range of motion defined by the MDS as exercises performed by the resident, with cueing, supervision, or physical assist by staff) one day during the 7 day assessment. Review of the MDS dated [DATE] revealed Resident 74 received 2 days of AROM. Observation on 11-30-17 at 08:08 AM revealed Resident 74 had a contracture of the left elbow and the left hand. Interview on 12/04/17 at 11:03 AM with LPN-D (Licensed Practical Nurse) the Restorative Nurse revealed the resident received PROM (Passive range of motion defined as passive movements to maintain flexibility and useful motion in the joints of the body completed by the resident ) 2-3 times a week for the past several years. Interview on 12-04-17 at 02:36 PM with the MDS Coordinator confirmed the data entry of the AROM for Restorative Nurse Program was incorrect and should have been PROM for both the 11-8-17 and the 08-08-17 MDS.",2020-09-01
301,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2017-12-05,689,D,0,1,4Y7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E43-8-17 Based on observation, record review, and interviews; the facility failed to ensure hazardous/poisonous chemicals on the housekeeping cart were stored to prevent accidental ingestion, inhalation or consumption by one wandering resident (Resident 36) out of one wandering resident on the unit. The facility census was 79. Findings are: Observations on 12-5-17 at 7:50 AM revealed a housekeeping cart in the hall near room [ROOM NUMBER] but off to the side of the door approximately 5 feet. The top shelf had a rolltop compartment on it which was unlocked. Inside the compartment were the following chemicals: Sheila Shine Aerosol Polishing Agency, an agent according to the MSDS (Material Safety Data Sheet) was irritating if exposed to the skin and harmful if inhaled with anaesthesia like symptoms. HD23 Bowl Cleaner, a chemical with hazards listed on the MSDS of causing severe [MEDICAL CONDITION] eye dame, toxic if inhaled, and harmful if swallowed. Orange Glo [NAME] Polish Valu-Chem Spot Zyme Antimicrobial Foaming Bath & Surface Cleaner, per MSDS may be harmful if swallowed and causedistention of the esophagus and stomach. The housekeeping was not in sight and all the residents and staff were in the dining room for breakfast. At 7:53 AM Housekeeper A came out of a resident room and dropped off a cloth on the housekeeping cart then walked back into the same room. At 7:57 AM Housekeeper A came back into the hall and walked past the cart and down the hall into a linen room. The linen room door had an automatic closure and the door shut completly shut behind Housekeeper A causing the housekeeping cart to be out of the line of vision. At 7:59 AM Housekeeper A came back into the hall and walked by the cart and into room [ROOM NUMBER]. At 8:10 AM Housekeeper A came back out to the cart to obtain supplies. Interview on 12-05-17 at 8:10 AM with Housekeeper A revealed the Housekeeping cart did lock but thought it was okay since it was outside the room Housekeeper A was working in. Interview with ESS (Environmental Services Supervisor) on 12-05-17 at 2:17 confirmed the Housekeeping carts were to be locked at times when not in direct view of the housekeeping staff. Interview with SSD (Social Service Director) on 12-5-17 at 2:26 PM revealed the nuring unit had one resident who wandered, Resident 36 but this resident was not known to rummage through items.",2020-09-01
302,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2016-12-13,278,D,0,1,VTPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175NAC 12-006.09B1 Based on interview and record review, the facility failed to ensure that Resident 82's MDS (Minimum Data Set-a federally mandated comprehensive assessment tool utilized to develop a comprehensive care plan) was coded to reflect the resident's current stataus. This practice affected 1 out of 2 residents sampled. The facility census was 79. Findings are: Review of Resident 82's MDS (Minimum Data Set-a federally mandated comprehensive assessment tool utilized to develop a comprehensive care plan) revealed that the quarterly MDS dated [DATE] contained documentation that the resident had a [DIAGNOSES REDACTED]. Record review of the Resident 82's Diagnosis List, the urologist (a doctor who specializes in the function and disorders of the urinary system) operative report dated 03/23/2015 and the urologist history and physical progress note dated 3/11/2015 revealed no [DIAGNOSES REDACTED]. Interview with the MDS nurse on 12/12/2016 at 11:58 AM revealed that the MDS nurse was unable to find any documentation in Resident 82's medical record for the [DIAGNOSES REDACTED]. Further interview with the MDS Nurse on 12/13/2016 at 1:23 PM revealed that the MDS nurse had miscoded Resident 82's 11/08/2016 MDS with the [DIAGNOSES REDACTED].",2020-09-01
303,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2016-12-13,309,D,0,1,VTPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D2c Based on record review and interview, the facility failed to assess a resident between the time of an unresponsive episode to the time of the death. Sample size was 1 of 1 resident (Resident 104). The facility census was 79. Findings are: Review of Resident 104's face sheet revealed admission to the facility on [DATE] and the resident died on [DATE]. The face sheet revealed a [DIAGNOSES REDACTED]. Review of Resident 104's Progress Notes revealed on [DATE] at 3:17 PM the resident did not respond to verbal stimuli and did not grasp the hands of the care giver. The resident's extremities were limp and bilateral upper legs continued to show mottling, as well as the capillary refill was sluggish to all nail beds, fingers and toes. Continued review of Resident 104's Progress Notes found the next entry was on [DATE] at 5:24 AM. This entry revealed at 4:00 AM the staff performed auscultation for heart and lung sounds and none were noted. An assessment was not completed for over 10 hours. Interview with the DON (Director of Nurses) on [DATE] at 10:33 AM revealed the expectation was that staff complete and document an assessment from [DATE] at 3:17 PM when the resident was not responsive to the time of death on [DATE] at 4:00 AM. The DON revealed the facility did not have a policy on assessments.",2020-09-01
304,"HOLDREGE MEMORIAL HOMES, INC",285067,1320 11TH AVENUE,HOLDREGE,NE,68949,2016-12-13,441,D,0,1,VTPZ11,"Licensure Reference Number: 175 NAC 12-006.17B Based on observations, record reviews, and interviews; the facility failed to: 1) ensure hand hygiene was performed during cares of 1 resident (Resident 92) to prevent cross contamination ; 2) clean a sit to stand lift after lifting a resident affecting 2 residents (Residents 92 and 53); 3) keep resident personal items clean before use on a resident affecting 1 resident (Resident 92). This affected 2 of 2 residents. The facility census was 79 at the time of the survey. Findings are: [NAME] Observation of cares for Resident 92 on 12/12/2016 at 9:14 AM found MA-B (Medication Aide) explained to the resident the procedure, privacy was provided by closing the door to the room. The lift was in the resident's room. The sling was put behind the resident and hooked to the lift. The legs were secured with a strap. The resident grasp the lift with both hands. The resident was moved to the the bathroom. The clothes were lowered and the pad was wet. MA-B placed a clean pad on the lift with the side that was to touch the resident next to the lift, The resident was stood with the lift and MA-B performed the resident's personal cares. Gloves were removed and the pad was placed next to the resident then the clothes were adjusted. The resident was moved to the recliner, lowered and sling unstraped. The lift was moved to the bathroom to store and was not cleaned. Interview with the MA-B on 12/12/2016 at 9:27 AM revealed there was 4 residents that use the stand lift and it is just stored here until I need it in another room. Each resident had their own slings. B. Observation of cares for Resident 92 on 12/12/2016 at 11:09:25 AM revealed MA-B was working on the computer in the room behind the nurses desk. MA-B walked to the resident room and talked to the resident about going to the bathroom then out to eat. MA-B did not perform hand hygiene. The sling was put behind the resident back then hooked to the sling. The resident grabbed the lift with the hands. The resident was moved to the bathroom and clothes lowered. MA-B put the pad over the lift with the side that goes against the resident next to the lift. MA-B placed the pad next to the resident and the clothes adjusted. The resident was moved to the wheelchair The sling and lift was removed. The lift was stored in the bathroom and not cleaned. MA-B gathered the garbage and tied the bag. MA-B disposed of the garbage in the bathing room and moved the resident to the television room. MA-B did not perform hand hygiene. Interview with MA-B on 12/13/2016 at 10:51 AM revealed hand hygiene did not happen before cares on 12/12/16 at 11:09 AM. MA-B confirmed the lift was not cleaned between residents. The residents have own lift sling. MA-B did not remember the pad used for the resident was placed upside down on the unclean lift then next to the resident. Interview with the DON (Director of Nurses) on 12/13/2016 at 10:55 AM revealed the staff were expected to perform hand hygiene between residents and to clean the lifts between residents. The pad used for the resident should not be placed upside down on the unclean lift then next to the resident. Review of the facility form entitled Handwashing, no date of origin, revealed the facilty considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Employees must wash their hands for at least twenty (20) seconds using antimicrobial soap and water or alcohol based hand rub before and after assisting a resident with toileting. Also after handling soiled equipment or utensils. Source: Hand Hygiene in Healthcare Settings. https:www.cdc.gov (MONTH) (YEAR) Hand hygiene is defined by the CDC (Centers for Disease Control) as cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol based hand sanitizer including foam or gel), or surgical hand sepsis. The CDC directs health care workers when to perform hand hygiene which identified hand hygiene should be done: Before and after direct contact with a patient's skin . after contact with inanimate objects (including medical equipment) . after glove removal . C. Observation of NA-A transferring Resident 69 on 12/13/2016 at 10:21:52 AM revealed NA-A transferred Resident 69 with a sit to stand lift. Resident 69 was observed holding on the the lift handle with the right hand. After completion of the transfer, NA-A took the lift from Resident 69's room and pushed it into the bathroom belonging to Resident 53. NA-A did not clean the lift after using it for Resident 69 and placing it in Resident 53's bathroom.",2020-09-01
305,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,609,D,1,1,4LDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.02 (8) Based on record reviews and interview, the facility failed to complete and submit an investigation of an incident involving one sampled resident's (Resident 56) family member in which Law Enforcement was notified for assistance and APS was notified. Sample size included 24 current residents. Facility census was 93. Findings are: Record review of Resident 56's Admission Record printed on 2/27/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 56's Progress Notes revealed the following entries on 4/7/18: - at 7:45 p.m. the resident was observed by staff crawling on the floor looking for a pink plastic Easter egg. The staff attempted to show the resident there was nothing on the floor and the resident continued insisting. The staff then distracted the resident by asking if (Resident 56) would go to another unit to watch television and have snacks, the resident complied. - at 7:58 p.m. Resident 56's FM (Family Member) came to the facility and became belligerent cursing and screaming at RN (Registered Nurse)-J as to why the resident was on the other unit. When RN-? attempted to calm the FM the FM continued yelling and cursing. Staff moved an unidentified resident away from the FM due to being in proximity to hear the yelling and cursing. - At 8:05 p.m. RN-J notified the manager on call and described Resident 56's FM's behaviors. At this time an unidentified resident began wheeling in the hall and the FM yelled at staff to get this (unidentified resident) the (expletive) away from (Resident 56's) room. The FM continued yelling at the staff. RN-J requested the FM leave due to the behaviors. The FM refused. The staff notified the Director of Nursing and reported. - At 8:10 p.m. Resident 56's FM slammed the door so hard it reverberated and (Resident 56's) plaque flew off. The resident next door was scared and we had to calm (the FM) down. I (RN-J) attempted to open the door and (the FM) slammed it in my face and told me to get the (expletive) out. - At 8:16 p.m. RN-J contacted the DON (Director of Nursing) again and the Director stated the Administrator had been notified. - at 8:23 p.m. the Administrator called RN-J who reported about FM's behaviors described as: highly inappropriate, with foul language, yelling, and screaming. The Administrator told RN-J the police were called. - at 8:25 p.m. RN-J talked with the DON and was told to ensure Resident 56's door remain open and that the police were called and on the way. RN-J expressed concern for Resident 56's well-being because we can hear (the FM) yelling in Resident 56's room and I am at least 30' (30 feet) away from the door. - At 8:30 p.m. the Administrator called RN-J and reported being on the way with police. - At 8:30 p.m. RN-J knocked on (Resident 56's) door and told the FM the door needed to remain open and that the police were on the way. The FM cursed and said what are thy going to do? RN-J again asked the FM to leave and the FM refused, slamming the door in RN-J's face. - At 8:38 p.m. Police arrived along with other family members who attempted to convince the FM to calm down and leave peacefully. The FM denied yelling or cussing. Police removed the FM from the property. Record review of an APS (Adult Protective Services) intake report revealed the facility's Administrator reported the incident to APS on 4/7/18 at 10:58 p.m. Record review of facility investigation reports forwarded to the State Agency between (MONTH) of (YEAR) through (MONTH) of 2019 revealed there was no investigation completed by the facility and forwarded to the State Agency regarding the events on 4/7/18 involving Resident 56's FM resulting in Law Enforcement contact and intervention to resolve the incident. Record review of the facility's Abuse and Neglect Prevention Standard policies revised in (MONTH) of (YEAR) revealed Verbal abuse defined as: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms used with or to residents, their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include but are not limited to: threats of harm, saying things to frighten a resident, . further review of the policy revealed in the section entitled Reporting/Response revealed instructions that: After conducting an internal investigation, you must submit a report of all investigation results to the state within five working days. Interview with the DON on 2/27/19 at 2:16 p.m. verified Resident 56's FM's incident on 4/7/18 met the definitions of verbal abuse and confirmed the facility's prior Administrator had not completed or forwarded an investigation of the incident to the State Agency.",2020-09-01
306,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,638,D,0,1,4LDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B2 Based on record review and interview, the facility failed to complete a required quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment for one sampled resident (Resident 56). Sample size was 24 current residents. Facility census was 93. Findings are: Record review of Resident 56's Admission Record printed on 2/27/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 56's OBRA, (Omnibus Reconciliation Act, a federal mandated law including MDS assessments) MDS assessments for the previous 12 month period revealed the following assessments were completed by the facility for the resident. - A quarterly assessment was completed on 1/23/2018. - A quarterly assessment was completed on 4/25/2018. - An annual assessment was completed on 10/24/208. - A quarterly assessment was completed on 1/23/2018. There was no OBRA MDS assessment completed between (MONTH) 25th of (YEAR) and (MONTH) 24th of (YEAR). Source: The facility's Long-Term Care Facility Resident Assessment Instrument (an instructional manual with directions on how to accurately assess and code MDS items) 3.0 User's Manual Version 1.16. Revised (MONTH) (YEAR). The manual identified the following regarding mandated time frames for completing OBRA MDS assessments: The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. Interview with the facility's MDS Coordinators, RN (Registered Nurse)-A and LPN (Licensed Practical Nurse)-B on 2/27/19 at 2:50 p.m. confirmed Resident 56 received an OBRA MDS quarterly assessment on 4/25/2018 and did not receive another OBRA MDS assessment until the annual assessment completed on 10/24/2018.",2020-09-01
307,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,641,D,0,1,4LDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to ensure MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment items accurately reflected the resident's condition regarding: 1) identifying a fall with major injury for one sampled resident (Resident 73); 2) identifying the most recent PASRR (Pre Admission Screening and Resident Review, a pre-admission assessment identifying serious mental illness) review and use of an antipsychotic medication for one sampled resident (Resident 56); and 3) identifying an antipsychotic medication was not used for one sampled resident (61). Sample size was 24 current residents. Facility census was 93. Findings are: [NAME] Record review of Resident 73's Admission Record printed on 2/27/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 73's Progress notes printed on 2/27/19 revealed the resident reported to the staff of having fallen in the room while getting ready for bed. The notes revealed the resident continued complaining of pain and was seen by a Nurse Practitioner on 1/14/19 for an evaluation of left leg and hip pain. The Nurse Practitioner ordered an x-ray and the resident was sent for an x-ray that afternoon. at 3:55 p.m. on 1/14/19 the Nurse Practitioner contacted the facility and reported the resident experienced a left [MEDICAL CONDITION]. Record review of Resident 73's MDS tracking records and assessments revealed the following: - A quarterly review assessment was completed on 11/7/18. - A discharge to hospital tracking was done on 1/14/19. - A re-entry from the hospital tracking was done on 1/19/19. - A Significant Change in status assessment was completed on 1/26/19. Further review of the significant change assessment revealed in the section entitled Health Conditions that the facility failed to record the resident had experienced a fall or fall with major injury following hospitalization . Source: The facility's Long-Term Care Facility Resident Assessment Instrument (an instructional manual with directions on how to accurately assess and code MDS items) 3.0 User's Manual Version 1.16. Revised (MONTH) (YEAR). Instructions in the manual in section J1800 (section for recording resident falls) reveal that when recording falls in a Significant change of status assessment the review period is from the day after the ARD (Assessment Reference Date) of the last MDS assessment to the ARD of the current assessment. The Coding instructions direct the staff to code yes if the resident has fallen since the last assessment. Interviews with the facility's MDS Coordinators, RN (Registered Nurse)-A and LPN (Licensed Practical Nurse)-B on 2/27/19 at 2:50 p.m. verified Resident 73 had a quarterly assessment completed on 11/10/18 and had fallen on 1/10/19 resulting in the [DIAGNOSES REDACTED]. RN-A and LPN-B confirmed that a significant change MDS was done upon return from the hospital on [DATE] and the facility failed to capture the fall and fracture on the significant change MDS assessment items. B. Record review of Resident 56's Admission Record printed on 2/27/19 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 56's MDS assessments revealed on 10/24/2018 the facility completed an Annual MDS for the resident. Further review of this assessment revealed in the section entitled: Preadmission Screening and Resident Review the facility recorded that a level II PASRR had not been completed regarding the resident's status pertaining to serious mental illness and/or intellectual disability. Review of a Quarterly MDS assessment on 1/23/2019 revealed in the section entitled: Medications the facility recorded the resident had not received an Antipsychotic (tranquilizing medication used to treat hallucinations and delusions) medication in the previous 7 days of the assessment (1/17/19-1/23/19). Record review of Resident 56's electronic medical records revealed the following: - A PASRR level II evaluation was completed for the resident on 2/22/2018. The PASRR II evaluation identified the resident meets criteria of a [DIAGNOSES REDACTED]. - Record review of Resident 56's MAR (Medication Administration Record) for (MONTH) of 2019 revealed the resident received daily administration of [MEDICATION NAME] (classified as an antipsychotic medication primarily used to manage symptoms of [MEDICAL CONDITION] such as delusions, hallucinations, paranoia, or confused thoughts) at 8:00 a.m. and 5:00 p.m. every day in (MONTH) of 2019. Source: The facility's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.16. Revised (MONTH) (YEAR) revealed the following instructions: - for the section on Preadmssion Screening and Resident Review, the facility is directed to code yes if PASRR Level II screening determined that the resident has a serious mental illness . - for the section on coding medications, the manual instructs staff to review the resident medication administration records to determine if the resident received an antipsychotic medication during the reference period (7 days during the assessment reference period). Interviews with the facility's MDS Coordinators, RN (Registered Nurse)-A and LPN (Licensed Practical Nurse)-B on 2/27/19 at 2:50 p.m. verified Resident 56's annual MDS on 10/24/18 had not captured the resident's PASRR 2 evaluation completed on 2/22/18. In addition, RN-A and LPN-B verified Resident 56's quarterly MDS assessment on 1/23/19 failed to capture the use of an antipsychotic medication on 7 of 7 days during the reference period. C. Record review of Resident 61's MDS Admission assessment completed on 1/28/19 indicated that this resident had received antipsychotic medication one day during the 7-day look-back period. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1/16 revised in (MONTH) of (YEAR) revealed the following Coding Instructions for Section N0410A, Antipsychotic : Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period. Record review of Resident 61's Medication Administration Record [REDACTED]. An interview on 02/27/19 at 9:55 AM with RN-A and LPN-B who both had responsiblity for completing MDS assessments for the facility verified that the MDS Admission assessment completed on 1/28/19 for Resident 61 was coded to indicate that an antipsychotic medication was administered on one day during the 7-day look-back period which was an error because the resident did not receive any antipsychotic medications in January. RN-A and LPN-B also verified that the Medication Administration Record [REDACTED].",2020-09-01
308,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,645,D,0,1,4LDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure accurate information was recorded on the PASRR Level I (Pre-Admission Screening and Resident Review, a federally required pre-admission assessment tool to determine appropriate placement in nursing facilities) for 1 sampled resident. Census: 93 residents. Sample size: 19 residents. On 02/25/19 at 04:00 PM a review of the eMar (electronic medical record) for Resident #54 revealed the resident was admitted on [DATE]. The eMar also revealed a [DIAGNOSES REDACTED].#54. On 02/25/19 at 04:35 PM a review of the PASRR Level I with the report date of 07/18/18 for Resident #54 revealed under the Diagnoses; Dementia/Neurocognitive Disorders, the question, Does the individual have a [DIAGNOSES REDACTED]. On 02/25/19 at 04:35 PM a review of the PASRR Level 1 for Resident #54 revealed the report was reviewed on 7/18/18, the date of admission for Resident #54, by the receiving facility and attested that .all information contained herein . and .take responsibility for the completeness and accuracy of information reported throughout . the report. On 02/27/19 at 04:30 PM an interview with the Director of Nursing confirmed Resident#54 had a [DIAGNOSES REDACTED].#54 failed to capture the correct information. On 02/27/19 at 04:30 PM an interview with the Administrator confirmed Resident#54 had a [DIAGNOSES REDACTED].#54 failed to capture the correct information.",2020-09-01
309,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,755,D,0,1,4LDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12 Based on observation, interviews, and record review, the facility failed to ensure that medications were administered on time for one sampled resident (Resident 82) and one non-sampled resident (Resident 3). Sample size was 24 current residents. Facility census was 93. Findings are: On 2/25/19 at 12:23 PM, MA (Medication Aide)-C was observed giving medications to Resident 3 which included [MEDICATION NAME] 100 mcg (micrograms) by mouth. At the time of administration, the electronic MAR (Medication Adminstration Record) for that medication was highlighted in red, and the scheduled time of administration showed 11:00 AM. On 2/25/19 at 12:25 PM, MA-C was observed giving medications to Resident 82 which included [MEDICATION NAME] 50 mcg by mouth and [MEDICATION NAME] 20 mg (miligrams) by mouth. At the time of administration, the electronic MAR for those medications was highlighted in red, and the scheduled time of administration showed 11:00 AM. Immediately following the administration of these medications on 2/25/19 at 12:25 PM, an interview with MA-C revealed that when the electronic MAR indicated [REDACTED]. Record Review of the Medication Administration Record [REDACTED]. Record Review of the Medication Administration Record [REDACTED]. On 02/28/19 at 10:11 AM, an interview with the DON (Director of Nursing) regarding timing of medication administration verified that medications must be administered within 1 hour of the scheduled time on the Medication Administration Record.",2020-09-01
310,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,761,E,0,1,4LDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12.006.12E4 Based on observations and interviews, the facility failed to remove expired and discontinued medications from one medication cart for one sampled resident (Resident 26) and for three non-sampled residents (Residents 77, 14, and 18). The sample size was 24 current residents. The facility census was 93. Findings are: On 2/27/19 at 11:24 AM, observation of the 200 wing medication cart with MA (Medication Aide)-D revealed multiple expired medications in the top drawer including: Ceri-[MEDICATION NAME] syrup for Resident 26 which expired 1/19 per manufacturer's label, cassettes containing [MEDICATION NAME] 75 mg (milligram) tablets and Atorvastatin 40 mg tablets for Resident 77 dated 2/2/18, cassettes of Trazadone 50 mg tablets and [MEDICATION NAME] 2 mg tablets for Resident 14 dated 7/6/17, [MEDICATION NAME] eye drops for Resident 18 which expired 3/18 per manufacturer's label, and Zim's Max Freeze cream with the label mostly rubbed off except for a partial date with no month legible but the day and year showing as /24/16. On 2/27/19 during this observation, an interview with MA-D verified that all of these medications were expired and should not be stored in the medication cart. RN (Registered Nurse)-E the charge nurse for the unit on 2/27/19, arrived during the observation and stated cassettes are no longer in use by the facility as a change to a new pharmacy system had been made some time ago. RN-E also verified all of these medications were expired and should not be stored on the cart. RN-E also stated all of the expired medications had been discontinued for those residents. RN-F who served as the Clinical Coordinator for the 200 wing arrived during the observation and verified the medications were expired before removing them for destruction. On 02/27/19 at 4:22 PM, an interview with RN-F revealed no consistent system had been developed on the 200 wing to remove discontinued or expired medication from the medication cart since the change to a new pharmacy system. RN-F verified this could potentially lead to a medication error. On 02/28/19 at 10:10 AM, an interview with the DON (Director of Nursing) verified expired and discontinued medications should not be kept in medication carts.",2020-09-01
311,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,801,F,0,1,4LDU11,Licensure reference Number: 175 NAC 12-006.04D2a Based on record review and interviews the facility failed to ensure the Dietary Manager had the credentialing to meet the regulatory requirements for the position. This had the potential to affect all residents. Facility census was 93. Findings are: Record review of the Dietary Manager's employee records on 02/26/19 verified the Dietary Manager did not have the regulatory required training to meet the required credentials. Staff interview on 02/25/19 at 8:29 a.m. Dietary Manager verified not having the certification and education required for the Dietary Manager Position. Dietary Manager reported being enrolled in the required training course to meet the required credentials for the Dietary Manager Position. Staff interview on 02/27/19 at 8:35 a.m. Dietary Manager and Administrator vitrified the Dietary Manager did not have the required credentials for the Position of Dietary Manager. Administrator reported the Dietary Manager is enrolled in the food services management course and would be completed in the very near future.,2020-09-01
312,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,812,F,0,1,4LDU11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interviews the facility failed to: 1) Clean the little stainless steal refrigerator located in the large kitchen, and 2) Failed to keep a bag of rice and box of Crisco off the pantry floor. These failures had the potential to affect all residents. Facility census was 93. Findings are: [NAME] Observation on 02/26/19 at 7:04 a.m. small stainless steal fridge on the back side of the large kitchen was not cleaned and had debris all over the bottom of the fridge. Observation on 02/27/19 at 6:51 a.m. small stainless steal fridge on the back side of the large kitchen was not cleaned and had debris all over the bottom of the refrigerator. Staff interview on 02/27/19 at 8:35 a.m. Staff interview with Administrator and Dietary Manager verified the small stainless steel refrigerator had not been cleaned and had debris all over the bottom of it. Dietary Manager reported they would get this cleaned immediately. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Authoritive reference for the food service sanitation practices, revealed the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. B. Observation on 02/25/19 at 8:29 a.m. There was a bag of rice and a box of Crisco located on the pantry floor. Staff interview on 02/27/19 at 8:35 a.m. Administrator and Dietary Manager verified there was a bag of rice and a box of Crisco located on the floor of the pantry. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Authoritive reference for the food service sanitation practices, revealed the following: 305.11 (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under 4-204.122.",2020-09-01
313,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-02-28,880,D,0,1,4LDU11,"Licensure Reference Number: 175 NAC 12.006.17D Based on observations and interviews, the facility failed to require staff members to perform hand hygiene after direct contact with one sampled resident (Resident 8) before assisting a non-sampled resident (Resident 39) during meals. Sample size was 24 current residents. Facility census was 93. Findings are: On 2/25/19 at 12:44 PM, observation in the 300 wing dining room revealed MA (Medication Aide)-C sitting at the corner of a table between Resident 8 and Resident 39. MA-C had to move Resident 8's hands from time to time to prevent touching Resident 39's plate and other items on the table. MA-C also had to move Resident 8's hand away from mouth in order for a cup and utensils to reach the resident's mouth. No hand hygiene was performed by MA-C after contact with Resident 8 before assisting Resident 39 to eat. On 02/26/19 at 8:18 AM, observation in the 300 wing dining room revealed MA-G sitting at the corner of a table between Resident 8 and Resident 39 to assist them with breakfast. MA-G used both hands to reposition Resident 8's hand in order to get a cup to this resident's mouth. MA-G then picked up a spoon and began to feed Resident 39 with no hand hygiene performed after contact with Resident 8. This pattern was repeated several times during the meal. On 02/27/19 at 8:07 AM, MA-G was again observed assisting Resident 8 and Resident 39 in the 300 wing dining room. Resident 8 appeared tired and was leaning back in the wheelchair with eyes closed. MA-G rubbed Resident 8's shoulder gently using left hand to awaken the resident while holding Resident 8's fork and then cup with right hand to feed the resident. MA-G then used left hand to pick up another fork and feed Resident 39. No hand hygiene was performed after contact with Resident 8 before picking up the fork to feed Resident 39. On 2/27/19 at 8:23 AM, MA-G picked up tissues from a box on the table and used them to wipe Resident 8's nose which had been dripping. MA-G then picked up a fork and began feeding Resident 39 without performing hand hygiene. On 2/27/19 at 8:32 AM, an interview with RN(Registered Nurse)-H who was the charge nurse on the 300 wing that day verified there was potential for cross contamination between residents when feeding more than one resident and not performing hand hygiene after physical contact with a resident. RN-H reported the facility had no specific policy related to feeding more than one resident at a time but stated MA-G had now been instructed to wear gloves when wiping a resident's nose and to perform hand hygiene afterward. On 2/27/19 at 10:41 AM, an interview with the DON (Director of Nursing) regarding touching a resident and then feeding another resident without performing hand hygiene after contact verified this as a potential source of cross contamination. The DON also verified that the facility had no specific policy regarding feeding more than one resident at a time.",2020-09-01
314,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,565,E,0,1,LINZ11,"Licensure Reference Number 175 NAC 12-006.05(17) Based on observations, interviews and record reviews; the facility failed to address grievances and issues brought up by resident council members (Residents 61, 25, 35, 18, 15, 11, 70, 34, 8, 85, 31, 82, and 52). Facility census was 89. Findings are: On 3/20/2018 at 1:30 PM observation of the 500 dining room at lunchtime revealed the residents were in the dining room at 12:00 noon and were not served yet at 12:40 PM. On 03/21/18 at 02:04 PM observation of the dining room at lunch time revealed the residents were out in the Dining room at 11:55 AM and at 12:35PM the residents were not served. On 3/21/2018 at 3:00 PM, the resident council members (Residents 61, 25, 35, 18, 15, 11, 70, 34, 8, 85, 31, 82, and 52) revealed that the resident council voiced a concern about meals that were served late on a regular basis. Record review of Resident Council Minutes revealed that the resident council had concerns about meals being served late in January, February, and (MONTH) (YEAR). Record review of Resident Council Minutes from (MONTH) of (YEAR) revealed that the resident council had concerns with staff not knocking and small portions of food. (MONTH) (YEAR) Resident Council Minutes revealed that the facility failed to address these concerns by the resident council. On 03/26/18 at 09:50 AM interview with the administrator confirmed that the meals were served late in the 500 and 600 units and the residents had complained about it for the last few months. On 03/26/18 at 11:27 AM interview with the Activity Director and Administrator confirmed that the facility failed to follow up on the complaints from resident council on staff not knocking.",2020-09-01
315,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,658,D,0,1,LINZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10 Based on observations, record reviews, and interviews; the facility failed to ensure residents received medications in accordance with prevailing professional standards for 2 residents sampled (Resident #80). Census was 89 residents. Sample size was 20 residents. [NAME] 03/21/18 08:15 AM MA-B administered [MEDICATION NAME], a beta-blocker, to Resident #80. MA-B did not check the residents heart rate and there was no place in the eMar to record the heart rate. The order was [MEDICATION NAME] 25mg 1/4 tablet (6.25mg) by mouth twice a day; Hold for pulse less than 60. On 03/21/18 at 08:25 AM an interview with MA-B confirmed there was no place to enter a heart rate on the eMar when administering [MEDICATION NAME]. MA-B revealed that If there's a place to record it on the eMar, then we get it but if not, then we don't. We get it for some and we don't for others. On 3/26/18 at 09:43 AM an interview with the DON (Director of Nursing) and Administerator confirmed that a professional standard was not met by not monitoring the heart rate for [MEDICATION NAME] administration. Source: [NAME]'s Drug Guide for Nurses 15th Edition (YEAR). Regarding [MEDICATION NAME] the Nursing Implications direct nurses to monitor BP (blood pressure) and pulse frequently.",2020-09-01
316,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,689,D,0,1,LINZ11,"Licensure Reference Number 175 NAC 12-006.18B Based on observation, record review, and interviews; the facility failed to implement processes designed forpreventative maintenance of a bed cane as it was loose for one sampled Resident (Resident 57). Sample size was 20 current residents. Facility census was 89. Findings are: Observation of Resident 57 revealed the following: -On 3/20/18 at 11:00 a.m. Resident 57's bed cane attached to the bed was up on the bed and the bed cane was loose. -On 3/21/18 at 7:30 a.m. Resident 57's revealed the bed cane remained loose on the resident's bed. -On 3/21/18 at 2:26 p.m. in Resident 57's room the bed cane remained loose. -On 03/22/18 at 07:30 AM in Resident 57's room the bed cane remained loose. Interview with Resident 57 on 3/20/18 at 11:00 a.m. revealed the bed cane attached to the bed had been loose for some time. Interview with the Administrator and RN (Registered Nurse)-C on 3/22/18 at 7:32 p.m. verified Resident 57's bed cane was loose and not functioning properly and no preventative maintenance had been completed.",2020-09-01
317,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,755,E,0,1,LINZ11,"Licensure Reference Number 175 NAC 12-006.12E1b Based on record review and interview, the facility failed to ensure the shift count of all controlled subtances was completed by 2 persons with each initially the separate medication control sheet for each medication when the count was completed. Record review of the narcotic count books for units 200/300/400/500 revealed the narcotic count books were not signed by 2 staff for the 3/20/18 06:00 AM narcotic count. On 3/21/18 at 11:45 AM interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) confirmed that the narcotic books for units 200/300/400/500 were not being signed out at the time the narcotic shift count was completed.",2020-09-01
318,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,759,D,0,1,LINZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review, and interview; the facility failed to administer medication at the manufacturers recommended time and instructions to obtain maximum benefits for 2 sampled resident (Residents #47 and #80). The error resulted in an 8% medication error rate (2 errors in 25 opportunities). Census was 89 residents. Sample was 20 residents. [NAME] On 03/21/18 at 07:45 AM observation of MA-B (medication aide-B) preparing medications for Resident #47 revealed that MA-B administered Rabeprazole (a proton pump inhibitor used to treat [MEDICAL CONDITION] reflux disease and other diseases that cause increased stomach acid) to the resident with the residents morning meal. The order was for Rabeprazole 20 milligrams 1 tablet by mouth every day 30-60 minutes before meal. On 03/21/18 at 07:55 AM an interview with MA-A confirmed that the order for the Rabeprazole was that the medication was to be administered 30 to 60 minutes before the residents meal and confirmed that the medication was administered with the residents meal rather than 30-60 minutes prior to the meal. B. On 03/21/18 at 08:15 AM observation of MA-B preparing medications for Resident #80 revealed that MA-B administered the resident's medication with a small drink of water. The potassium order was for Potassium Chloride Micro 10 milliequivelants Extended Release 1 tablet by mouth every day - Do not crush-take with food and full glass of water. On 03/21/18 at 08:35 AM an interview with MA-B confirmed that MA-B was not aware of the full glass of water portion of the potassium order as it wasn't entered into the eMar and that the medication was administered with a sip of water. On 03/26/18 at 09:43 AM an interview with the DON (Director of Nursing) and Administrator confirmed that the medication error rate was 8% based on observations of medication administration/directions for medications given to Residents #47 and #80. Source: [NAME]'s Drug Guide for Nurses 15th Edition (YEAR). Regarding Rabeprazole's Implementation nurses are instructed to Administer doses before meals. Regarding Potassium Implementation nurses are instructed to administer tablets and capsules with a meal and full glass of water.",2020-09-01
319,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,812,F,0,1,LINZ11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interviews, the facility failed to cover, date and label individual dishes of green sherbet cream in plastic cups in the freezer, clean the dirt and lent on the hood over the dishwasher, pick up 5 boxes of chicken patties on the walk in freezer floor, and pick up a bag of cereal, a tray of bread and hot dog buns located on the floor of the pantry. All residents could be affected. Facility census was 89. Findings are: -On 03/20/18 at 7.40 a.m. Kitchen observation revealed a bag of cereal, a tray of hot dog buns and bread located on the floor of the pantry. -On 03/21/18 at 10:00 a.m. Kitchen observation revealed Green sherbet in individual cups were not covered or labeled in the small kitchen freezer. -On 03/21/18 at 10:00 a.m. Kitchen observation revealed a build up of lent and dirt in the hood of the dishwasher. -On 03/22/18 at 6:20 a.m. Kitchen observation revealed five boxes of chicken patties on the floor of the walk in freezer. -On 03/26/18 at 9:27 a.m. Kitchen observation revealed build up of lent and dirt in the hood of the dishwasher. On 03/26/18 at 09:45 AM interview with the Administrator, Dietary Manager and Dietary Coordinator confirmed that the cereal and bread had been located on the floor of the pantry, the Green sherbet ice cream had not been cover, or dated, the five boxes of chicken patties had been left on the floor of the freezer, and the hood over the dishwasher had not been cleaned as there was lent and dirt located on it. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 3-201.11(C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.17 and 3-202.18. 6-5-1.14(A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt and other materials. 3-305.11(B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling Equipment as specified under 4-204.122.",2020-09-01
320,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2018-03-26,923,E,0,1,LINZ11,"Licensure Reference Number: 175 NAC 12-007.04D Based on observations and interview, the facility bathroom ventilation system was non-functional for 10 rooms occupied by 6 sampled residents (Residents 61, 20, 138, 75, and 77) and 9 non-sampled residents (Residents 6, 52, 53, 65, 71, 78, 80, 81, and 87). Sample size was 20 current residents. Facility census was 89. Findings are: Observations on 3/20/18 between 10:48 a.m. and 3:50 p.m. revealed the bathroom ventilation systems in bathrooms for Residents 61, 20, 1, and 138 were not functioning and drawing air into the ventilation ducts. Observations on 3/21/18 between 9:17 a.m. and 12 noon revealed the bathroom ventilation systems in bathrooms for Residents 75 and 66 were not functioning and drawing air into the ventilation ducts. Observations on 3/22/18 at 12 noon revealed the bathroom ventilation systems in bathrooms for Residents 61, 20, 1, 138, 75 and 66 were not functioning and drawing air into the ventilation ducts Observation with the maintenance supervisor on 3/26/18 at 8:15 a.m. verified the ventilation duct for resident 61 was not functioning and drawing air into the ventilation ducts Interview with the maintenance supervisor on 3/26/18 at 8:15 a.m. confirmed none of the ventilation systems in the bathrooms on the 100 (Juniper-Rehab) unit were functioning as these systems are connected. Record review of a facility Census Form updated on 3/19/18 verified 15 current residents (Residents 61, 20, 138, 75, 77, 6, 52, 53, 65, 71, 78, 80, 81, and 87) resided on the Juniper-Rehab unit.",2020-09-01
321,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-04-09,609,D,1,0,E6EI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.02(8) Based on record reviews and interview, the facility failed to ensure that an investigation report was sent to the State Agency within the required timeframe for one current sampled resident (Resident 2). The facility census was 96 with six current sampled residents. Findings are: Review of the facility Investigation Report, dated 4/5/19, revealed that Adult Protective Services was notified of Resident 2's fractured knee on 3/29/19. Further review revealed that the fracture was reported to the facility on [DATE]. Interview with the Director of Nursing on 4/9/19 at 3:30 PM confirmed that the investigation report was not sent to the State Agency within the required five working days.",2020-09-01
322,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2019-04-09,657,D,1,0,E6EI11,"> Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to update the care plan with specific instructions for safe transfers for one current sampled resident (Resident 1). The facility census was 96 with six current sampled residents. Findings are: Review of Resident 1's care plan, goal date 5/9/19, revealed that the resident required assistance with activities of daily living and was at risk for falls due to weakness and decreased mobility. Further review revealed interventions including transfer with a sit to stand mechanical lift and one to two assist. Interview with the Director of Nursing on 4/9/19 at 3:45 PM confirmed that the care plan instructions for the use of the sit to stand mechanical lift should specifically state how many staff were needed to safely and consistently transfer the resident to reduce the risk for injuries during transfers.",2020-09-01
323,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2017-04-12,157,D,0,1,4OLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on interviews and record reviews, the facility failed to notify one sampled resident's (Resident 102) family representative prior to the administration of a medication. The failure resulted in the resident receiving medication the family representative had not wanted administered. Sample size included three family interviews for current residents. Facility census was 89. Findings are: Interview with Resident 102's FR (Family Representative) on 4/11/17 at 10:13 a.m. revealed Resident 102 was diagnosed with [REDACTED]. During the interview, the FR stated a few months prior, the facility experienced a flu outbreak and the facility administered [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) to all of the resident's on the Prairie Rose unit which Resident 102 resided. The FR stated the medication was ordered, received, and administered to the resident without notification of the FR or Resident 102's medical power of attorney. When asked if the family wished for the resident to receive the [MEDICATION NAME], had they been notified prior, the FR replied no the family did not want any aggressive treatments for the resident due to prior advance directives, and stated the family and power of attorney were in agreement and would have declined the administration of the medication. Record review of Resident 102's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed a quarterly review assessment of the resident was completed on 3/22/17. Review of the resident's Brief Interview for Mental Status (a cognitive test to assess memory) revealed a Summary Score of 7 (severe impairment). Record review of Resident 102''s Medical Durable Power of Attorney form revealed the resident had signed the document assigning a family member with the authorization of the family member to provide informed consent to or refusal of medical treatment if (Resident 102) is unable. Record review of Resident 102's physician telephone orders revealed an order on 2/3/17 for [MEDICATION NAME] 75 mg (milligrams) to be administered twice a day for five days for flu symptoms. Record review of Resident 102's Medication Administration Record [REDACTED]. Record review of Resident 102's Interdisciplinary Progress Notes revealed the following entries: - 2/3/17- Received order from facility medical director (name of doctor) for [MEDICATION NAME] 75mg PO (by mouth) BID (twice daily) x (times) 5 days for flu symptoms. - 2/4/17 at 9:45 a.m.- Notified FR of new order for [MEDICATION NAME]. (name of family representative) POA (power of attorney) and siblings do not want resident to take [MEDICATION NAME] . - 2/4/17 at 10:05 a.m. FR called back and states (family members) are in total agreement of no treatment . - 2/4/17 at 11:00 a.m. Received telephone order from (name of doctor) to d/c (discontinue) [MEDICATION NAME] per POA's request. FR notified. Interview with the DNS (Director of Nursing Services) on 4/11/17 at 4:00 p.m. confirmed the special care units had an outbreak of flu symptoms in (MONTH) of (YEAR). The DNS stated all residents on the units received orders from the facility's Medical Director to administer [MEDICATION NAME] to the residents. The staff proceeded to receive orders from the personal physician's and administered the medication to the residents. The DNS confirmed Resident 102's family representative nor the POA were not notified of the orders prior to the administration of the medication.",2020-09-01
324,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2017-04-12,323,E,0,1,4OLZ11,"Licensure Reference Number: 175 NAC 12-006.18E4 Based on observations, record reviews, and interviews, the facility failed to ensure laundry room doors remained secure preventing access to potentially harmful chemicals by confused, mobile residents residing in locked special care units. This could potentially affect 6 current residents (Residents 67, 130, 6, 18, 58, and 80) identified with cognitive impairments and the ability to self-mobilize. Sample size was 28 residents residing in the special care units. Facility census was 89. Findings are: Observations during the initial tour of the facility on 4/6/17 between 9:25 a.m. and 10:30 a.m. revealed the following. - On the Golden Rod unit, the West door to the laundry area was not latched and the door into the laundry room was accessible without using the keypad entry. When pulled tight, the door latched and locked. - On the Prairie Rose unit, the North door to the laundry area was not latched and accessible without using the keypad entry. When the door was pulled tight, the door continued to open and not lock. Observations on 4/10/17 at 9:30 a.m. revealed the following: - The West door to the laundry on the Golden Rod unit was not fully latched and the door into the laundry room was not latched and accessible without using the keypad entry. Inspection of an accessible unlocked cabinet inside the laundry area revealed a spray bottle of Ecolab Grease Lift on the shelf. When pulled tight, the laundry door latched and locked. - The North door to the laundry on the Prairie Rose unit was not latched and accessible without using the keypad entry. Inspection of an accessible unlocked cabinet inside the laundry area revealed a spray bottle of Ecolab Grease Lift and a spray bottle of Diversey Shine Up inside the cabinet on the shelf. When the laundry door was pulled tight, the door continued to open and not lock. Observations with the Administrator and Maintenance Supervisor on 4/10/17 at 9:30 a.m. revealed the laundry room doors on the Golden Rod and Prairie Rose units were not locking and latching. Interview with the Administrator and Maintenance Supervisor on 4/10/17 at 9:30 a.m. confirmed the laundry room doors on the Golden Rod and Prairie Rose units were not locking and latching and were accessible without using the keypad entry locks. The Administrator verified there were spray bottles of Ecolab Grease Lift and Diversey Shine Up in the laundry area on Golden Rod and the chemicals were accessible in an unlocked cabinet. The Administrator verified there was a spray bottle of Ecolab Grease Lift in the laundry area on Prairie Rose and the chemical was accessible in an unlocked cabinet. Record review of Material Safety Data Sheets (a required data sheet specifying chemical product hazards) revealed the following: - Ecolab Grease Lift identified Hazards of eye irritation if the product came into contact with the eyes. If in eyes: Rinse cautiously with water for several minutes . continue rinsing. If eye irritation persists, get medical advice/attention. - Diversey Shine-Up identified exposure to eye contact: may be mildly irritating to eyes and for skin contact: may be mildly irritating to skin. Symptoms may include redness and/or transient discomfort. Interview with LPN (Licensed Practical Nurse)-D on 4/12/17 at 11:30 a.m. revealed LPN-D is the licensed coordinator overseeing the Golden Rod unit of the facility. LPN-D confirmed the unit is composed of residents in the middle stages of dementia and identified Residents 67 and 130 as residents that experienced confusion and independently mobile with a potential to wander into unsecured areas of the unit. Interview with RN (Registered Nurse)-E on 4/12/17 at 11:45 a.m. revealed RN-E is the licensed coordinator overseeing the Prairie Rose unit of the facility. RN-E confirmed the unit is composed of residents in the early stages of dementia and identified Residents 6, 18, 58, and 80 as residents on the unit that experienced confusion and were independently mobile with a potential to wander into unsecured areas of the unit.",2020-09-01
325,HERITAGE ESTATES,285071,2325 LODGE DRIVE,GERING,NE,69341,2017-04-12,371,F,0,1,4OLZ11,"LICENSURE REFERENCE 175 NAC 12-006.11E Based on observations, record review and interviews, the facility failed to 1)provide hand washing during food preparation and the passing of ice water in a manner to prevent the potential for foodborne illness, 2) clean the juice compressor grate of grey debris, and 3) provide a backflow prevention system to prevent contamination. This had the potential to affect 89 residents that consumed food prepared in the facility kitchen. The facility census was 89 at the time of the survey. Findings are: [NAME] Observation on 04/10/2017 at 4:42 PM found MA-B (Medication Aide) serving ice water to 13 residents on the 600 hall. The procedure was to pick up a clean pitcher, take it to the resident's room, sit it down, take the used pitcher back to the cart, place it on the second shelf, pick up a new pitcher and go to the next room repeating the procedure. Hand washing or the use of sanitizing gel was not observed between water pitchers. Observation on 4/11/2017 at 4:00 PM found NA-C (Nurse Aide) on 4/11/2017 at 4:00 PM passing ice water to 13 residents on the 600 hall. The procedure was to pick up a clean pitcher, take it to the resident's room, sit it down, take the used pitcher back to the cart, place it on the second shelf, pick up a new pitcher and go to the next room repeating the procedure. Hand washing or the use of sanitizing gel was not observed between water pitchers. Interview with the Director of Nurses on 04/12/2017 at 9:44 AM revealed the expectation was for the staff to clean their hands between pitchers. B. Observation of the meal prep on 04/11/2017 at 8:02 AM by Cook-A revealed a lathered hand wash that lasted 10 seconds before the potatoes were prepared to cook. After the preparation of the potatoes to cook a lathered hand wash for 10 seconds. Cook-A performed a 5 second hand wash before putting on gloves to coat the chicken for cooking. At 8:20 AM Cook-A performed a lathered 5 second hand wash then opened a box of steaks and put on gloves to place the steaks on a pan to bake. At 8:30 AM Cook-A removed the gloves and performed a 5 second hand wash. Interview with the DM (Dietary Manager) on 4/12/2017 at 9:40 AM revealed the expectation was for the staff to perform a lathered hand wash for 15 seconds. The DM stated I saw the same handwashing you saw. The DM produced the hand washing competency form that was used to monitor handwashing. Review of the Handwashing Competency, revised date of 1/2010, revealed the lathering and rub hands together should last a full 15 seconds. C. Observation of the kitchen on the 600 hall on 4/11/2017 at 12:00 PM revealed a juice compressor grate was covered with a grey debris. Interview with the DM on 4.11.2017 at 12:00 PM acknowledged the grey debris on the juice compressor grate. The DM revealed the cleaning schedule was to happen every Sunday. Review of the cleaning schedule for the month of (MONTH) (YEAR) revealed no documentation of the juice machine chiller and compressor being cleaned on 4/2 and 4/9. D. Tour of the three kitchens located on the 100/200 hall, 300/400 hall and the 500/600 halls on 4/11/2017 at 12:15 PM revealed the water drain tip from the dish washer to the floor rested on the grate of the floor. Interview with the DM on 4/11/2017 at 12:15 PM revealed the tip of the water drain from the dish washer rested on the grate of the floor. Review of the 7/21/16 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -Statute: 5-402.11 Backflow Prevention. A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.",2020-09-01
326,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,550,D,0,1,89P111,"Licensure Reference Number 175NAC 12-006.05 (21) Based on observation, record review, and interview the facility failed to ensure that the resident mechanical lift sling (a fabric device with straps that is placed underneath a resident when a mechanical assistive device is used to transfer a resident with difficulty or inability to stand up on their own from a seated or lying position) left underneath the resident was tucked in to provide resident dignity for 2 residents (Residents 11 and 70) and failed to ensure that the gait belt (a belt device placed around a resident's abdominal area used to aid in the safe movement of a resident with mobility problems) was removed from the resident after use to provide resident dignity for 1 resident (Resident 51). The facility census was 78. Findings are: [NAME] Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 11 revealed that Resident 11 was totally dependent for transfers and that the resident transferred with a total body lift (a mechanical assistive device used to transfer a resident that is unable to stand up on their own) with a large mechanical lift sling. Record review of the facility policy titled Mobility Support and Positioning Mobility dated 8/19 revealed the section Guidelines: Lifts, Slings, and Harnesses subsection Slings Bullet 3: Mesh slings may be left under resident if determined by nurse that removing the sling would cause the resident pain, contribute to skin injury or the resident has mobility restrictions. Bullet 4: Leaving a sling under the resident must be care planned. Bullet 5: If sling is left in place, tuck straps to avoid tripping injuries and provide resident right to privacy and dignity. Observation on 1/23/20 at 9:24 AM revealed that Resident 11 was seated in a wheelchair in the lobby area. The mechanical lift sling was underneath the resident and was visible along the sides of the resident torso and over the back of the wheelchair. The mechanical lift sling straps were hanging over the back of the wheelchair. Observation on 1/23/20 at 11:32 AM revealed that Resident 11 was seated in a wheelchair in the lobby area. The mechanical lift sling was exposed hanging over the back of the wheelchair and the lift sling straps were hanging down the back of the wheelchair. An unknown visitor entered the facility and walked through the lobby area. Observation on 1/23/20 at 11:48 AM revealed that Resident 11 was seated in a wheelchair at the dining room table. The mechanical lift sling and sling straps were visible hanging over the back of the wheelchair. Observation on 1/27/20 at 8:24 AM revealed that Resident 11 was seated in a wheelchair in the dining room. The mechanical lift sling was visible hanging over the back of the wheelchair and along the sides of the resident's shoulders. Observation on 1/27/20 at 9:39 AM revealed that Resident 11 was seated in a wheelchair near the fireplace in the lobby area. The mechanical lift sling was hanging over the neck support on the back of the wheelchair and the lift sling straps were hanging over the back sides of the wheelchair. An unidentified vending company employee was in the lobby area. Observation on 1/28/20 at 8:15 AM revealed that Resident 11 was seated at the table in the dining room in a wheelchair. The mechanical lift sling was visible hanging over the back and sides of the wheelchair. Observation on 1/28/20 at 9:12 AM revealed that Resident 11 was seated in a wheelchair in the lobby area. The mechanical lift sling was visible hanging over the back of the wheelchair with the lift sling straps hanging down over the back of the chair. The bottom of the mechanical lift sling and lift sling straps were visible on top of the resident's legs. Interview on 1/28/20 at 10:13 AM with the facility Director of Nursing (DON) in the DON office confirmed that when lift slings were left underneath a resident after a transfer the lift sling and sling straps were to be tucked in so they were not visible to provide for the resident's right to privacy and dignity. B. Interview on 1/27/20 at 2:15 PM with Certified Nursing Assistant B (CNA-B) revealed that Resident 70 is a total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) to transfer out of bed. Record review of the facility policy titled Mobility Support and Positioning Mobility dated 8/19 revealed the section Guidelines: Lifts, Slings, and Harnesses subsection Slings Bullet 3: Mesh slings may be left under resident if determined by nurse that removing the sling would cause the resident pain, contribute to skin injury or the resident has mobility restrictions. Bullet 4: Leaving a sling under the resident must be care planned. Bullet 5: If sling is left in place, tuck straps to avoid tripping injuries and provide resident right to privacy and dignity. Observation on 1/23/20 at 9:10 AM revealed that Resident 70 was seated in a wheelchair at a dining room table. The mechanical lift sling was hanging out over the back of the wheelchair. Observation on 1/23/20 at 9:18 AM revealed that Resident 70 was propelling self in the wheelchair towards the dining room exit door. The mechanical lift sling was hanging over the wheelchair back and the bottom sling straps were visible on top of the resident's legs. Observation on 1/23/20 at 10:25 AM revealed that Resident 70 was seated in a recliner in the lobby area. The mechanical lift sling was visible hanging over the back of the recliner behind the resident's head and along the sides of the resident's shoulders. Observation on 1/23/20 at 11:32 AM revealed that Resident 70 was seated in a recliner in the lobby area with the resident's feet elevated. The mechanical lift sling was visible hanging behind the resident and the sling straps were hanging out from the sides of the resident's shoulders. Observation on 1/23/20 at 11:38 AM revealed that Certified Nursing Assistant A (CNA-A) and Certified Nursing Assistant B (CNA-B) transferred Resident 70 from the recliner to a wheelchair with the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own). CNA-B folded the mechanical lift sling over the back of the wheelchair leaving the lift sling and lift sling straps visible. The bottom sling straps were visible hanging down between the resident's legs. Observation on 1/23/20 at 1:26 PM revealed that Resident 70 was seated in a wheelchair in the lobby area with the mechanical lift sling visible hanging over the back of the wheelchair and the bottom sling straps hanging down to floor in front of resident. Observation on 1/27/20 at 8:24 AM revealed that Resident 70 was seated in a wheelchair in the dining room. The mechanical lift sling was visible hanging over the back of the wheelchair and along the sides of the resident's shoulders. An unidentified vending company employee was in the lobby area. Interview on 1/28/20 at 10:13 AM with the facility Director of Nursing (DON) in the DON office confirmed that when lift slings were left underneath a resident after a transfer the lift sling and sling straps were to be tucked in so they were not visible to provide for the resident's right to privacy and dignity. C. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 51 revealed that Resident 51 transferred with staff assistance. Interview on 1/28/20 at 9:16 AM with Certified Nursing Assistant B (CNA-B) confirmed that Resident 51 required staff assistance with a gait belt and walker for ambulation (walking). Interview on 1/28/20 at 9:56 AM with Certified Nursing Assistant A (CNA-A) confirmed that Resident 51 was assisted by staff using a gait belt with a walker for walking. Record review of the facility policy titled Mobility Support and Positioning Mobility dated 8/19 revealed the Section titled Assisting With Ambulation Bullet 1: Unless contraindicated, a gait belt should be used for all residents who require assistance with ambulation. Bullet 3: The purpose of the gait belt is to ensure that the caregiver assisting can control the resident's center of mass if he or she loses his balance. Observation on 1/23/20 at 9:10 AM revealed that Resident 51 was seated in a wheelchair in the dining room eating breakfast with a gait belt in place around the resident's lower abdomen. Observation on 1/23/20 at 9:18 AM revealed that Resident 51 propelled self in a wheelchair to exit the dining room. A gait belt was visible around the resident's lower abdomen. Observation on 1/23/20 at 10:19 AM revealed that Resident 51 was seated in a chair in the lobby area in front of the television with the eyes closed and head down. A gait belt was in place around the resident's abdomen. Observation on 1/23/20 at 11:32 AM revealed that Resident 51 was seated in a chair in the lobby area in front of the television. A gait belt was in place around the resident's abdomen. Observation on 1/27/20 at 9:37 AM revealed that Resident 51 was seated in a chair in the lobby area in front of the television with the eyes closed. A gait belt was in place around the resident's abdomen. Observation on 1/27/20 at 10:16 AM revealed that Resident 51 was seated in a chair with a gait belt visible around the resident's abdomen. An unknown visitor entered the facility into the lobby area and visited with Resident 51. Observation on 1/28/20 at 9:12 AM revealed that Resident 51 was seated in a chair in the lobby area. A gait belt was in place around the resident's abdomen. Resident 51 rested with the head down and eyes closed. Interview on 1/28/20 at 9:56 AM with CNA-A confirmed that Resident 51 had a gait belt left in place around the resident's abdomen at that time. Interview on 1/28/20 at 10:13 AM with the facility Director of Nursing (DON) in the DON office confirmed that a gait belt should be removed after use and not left on the resident to provide resident dignity.",2020-09-01
327,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,606,D,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility failed to ensure 2 of 5 personnel files contained documentation of NA (Nurse Aide) Registry checks (Employee H and Employee I). The facility identified a census of 78 at the time of survey. Findings are: Review of the personnel files for Employee-H with DOH (Date of Hire) of 11/6/2019 and Employee-I with a DOH of 10/16/2019 revealed no documentation NA registry checks were completed. Interview with the facility Administrator on 1/26/20 at 3:55 PM confirmed the personnel files for Employee-H and Employee-I did not contain documentation of the NA registry checks. Interview with the facility Administrator on 1/27/20 at 12:17 PM confirmed the Employee-H and Employee-I had been working in the facility since they were hired and they worked in resident care areas. Review of the facility policy Abuse and Neglect dated (MONTH) 2013 and revised 10/18 revealed a purpose: To ensure the location has in place an effective system that, regardless of the source, prevents mistreatment, neglect, exploitation and abuse of residents and misappropriation of their property. To ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals. Policy: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultant or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. The location will not knowingly employ or otherwise engage individuals who have been found guilty of abusing, neglect, exploiting, misappropriation property or mistreating residents by a court of law or have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment or residents or misappropriation of their property or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED].",2020-09-01
328,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,641,D,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review; the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) to reflect status regarding a planned weight loss for Resident 68 and failed to code Resident 81's Discharge MDS with the correct location. This affected 2 of 21 residents. The facility identified a census of 78 at the time of survey. Findings are: [NAME] Review of Resident 68's quarterly MDS dated [DATE] revealed Resident 68 had weight loss and was not on a physician prescribed weight loss regimen. Interview with RD (Registered Dietician) on 1/27/20 at 2:50 PM revealed Resident 68 had gained an excess amount of fluid weight and was treated with diuretics (medications used to reduce fluid retention) for [MEDICAL CONDITION] (swelling). They had coded the weight loss as unplanned and not on a prescribed weight loss regimen on Resident 68's MDS. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.16 (MONTH) (YEAR) revealed the following: PHYSICIAN-PRESCRIBED WEIGHT-LOSS REGIMEN: A weight reduction plan ordered by the resident's physician with the care plan goal of weight reduction. (MONTH) employ a calorie-restricted diet or other weight loss diets and exercise. Also includes planned diuresis. It is important that weight loss is intentional. Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order. In cases where a resident has a weight loss of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan or expected weight loss due to loss of fluid with physician orders for diuretics, K0300 can be coded as 1. Review of Resident 68's Progress Notes revealed the following: 12/27/2019 22:34 Care Plan Review Discipline: Nutrition Write a brief summary of how the resident responded to plans/interventions and any changes made: (Resident 68) is showing a significant weight loss from 30 days ago with diuresis (fluid loss). (Resident) denies need for any nutrition interventions at this time with beneficial weight changes and improved fluid balance. 12/19/2019 13:39 Nutritional Status Note Text: Nutrition Risk Committee Meeting Resident's CBW(Current Body Weight) is 139# with goal of 134#. (Resident) has had a significant weight loss of 7.6% at 30 days, 5% gain from 90 days ago, and 6% gain from 180 days ago. During the time of weight loss Resident had OT (Occupational Therapy) performing [MEDICAL CONDITION] treatment and the [MEDICATION NAME] (Diuretic) was increased. 12/18/2019 10:57 Nutritional Status Note Text: Note significant weight loss following a significant weight gain with impaired fluid balance. [MEDICATION NAME] was increased 11/20/19 and [MEDICAL CONDITION] treatment was provided by OT. Resident is up 5% at 90 days and 6% at 180 days. Goal weight was 134# with CBW 139#. Review of Resident 68's Order Summary Report revealed an order for [REDACTED]. Review of Resident 68's Clinic Referral Sheet dated 11/19/19 revealed an order to refer to PTSR (Therapy) for [MEDICAL CONDITION]. Review of Resident 68's Clinic Referral Sheet dated 11/20/19 revealed an order to increase the [MEDICATION NAME] to 40 mg PO (by mouth) QD. Review of PTSR (Therapy) referral dated 11/20/2019 revealed the following: Diagnosis: [REDACTED]. Interview with the RD on 1/27/20 at 2:54 PM revealed Resident 68's MDS was coded in error. B. Review of Resident 81's Discharge Tracking Record dated 11/27/2019 revealed a discharge status to acute hospital. Review of Resident 81's Progress Notes dated 11/27/2019 revealed Resident 81 was discharged to an assisted living facility with their belongings accompanied by their spouse. Interview with the DON (Director of Nursing) on 1/23/20 at 10:45 AM revealed Resident 81 was discharged to an assisted living facility. The DON confirmed Resident 81's Discharge Tracking Record was coded in error. Review of the facility policy Procedure MDS 3.0 RAI revised 4/19 revealed the following: Before signing section A of an MDS, verify that all fields have the correct information.",2020-09-01
329,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,655,E,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility failed to offer a written summary of the baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) to the resident or resident representative prior to the initial care conference for Residents 1, 17, 37, 67, 5, 9, 45, 70, and 80 and ensure they understood it. This affected 9 of 11 sampled residents. The facility identified a census of 78 at the time of survey. Findings are: [NAME] Review of Resident 1's Entry Tracking Record revealed an admission date of [DATE]. Review of Resident 1's Medical Record revealed no documentation a written summary of the baseline care plan was given to Resident 1 or their personal representative. B. Review of Resident 17's Entry Tracking Record revealed an admission date of [DATE]. Review of Resident 17's Medical Record revealed no documentation a written summary of the baseline care plan was given to Resident 17 or their personal representative. C. Review of Resident 37's Entry Tracking Record revealed an admission date of [DATE]. Review of Resident 37's Medical Record revealed no documentation a written summary of the baseline care plan was given to Resident 37 or their personal representative. D. Review of Resident 67's Entry Tracking Record revealed an admission date of [DATE]. Review of Resident 67's Medical Record revealed no documentation a written summary of the baseline care plan was given to Resident 67 or their personal representative. Interview with the DON (Director of Nursing) on 1/27/20 at 9:30 AM revealed they did not complete a separate baseline care plan for the residents. A comprehensive care plan was completed for the residents at the time of admission. The DON revealed the resident and/or resident representative was not given a written summary of the baseline care plan. Interview with the SSD (Social Services Director) on 1/27/20 at 9:31 AM revealed they did not give a written summary of the baseline care plan to the resident or the resident representative. They went over the care plan at the first care conference. They did not offer a written summary to the resident and/or resident representative. They would give them one only if they requested it. Interview with the DON on 1/27/20 at 10:07 AM revealed the facility policy for baseline care plan revealed they were to give a written summary to the resident and/or resident representative. Review of the facility policy Care Plan revised 12/19 revealed the following: Baseline care plan-includes instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Documentation of care plan offer will be included in a progress note. E. Review of the Care Plan for Resident 5 with an initiation date of 10/18/2019 revealed no signature sheet indicating the resident or resident representative were informed of the contents of the care plan. Review of the face sheet for Resident 5 revealed an admission date of [DATE]. Review of the Care Conference notes revealed no documentation of the baseline care plan or summary being given to Resident 5 or the resident representative. Review of the all progress notes for Resident 5 revealed no documentation that the resident or the resident representative was given a summary of the baseline care plan. F. Review of face sheet for Resident 9 revealed an admission date of [DATE]. Review of the Care Plan for Resident 9 with an initiation date of 4/24/2019 revealed no signature sheet indicating the resident or resident representative were informed of the contents of the care plan. Review of the Care Conference notes revealed no documentation of the baseline care plan or summary being given to Resident 9 or the resident representative. Review of the all progress notes for Resident 9 revealed no documentation that the resident or the resident representative was given a summary of the baseline care plan. [NAME] Review of face sheet for Resident 45 revealed an admission date of [DATE]. Review of the Care Plan for Resident 45 with an initiation date of 4/03/2019 revealed no signature sheet indicating the resident or resident representative were informed of the contents of the care plan. Review of the Care Conference notes revealed no documentation of the baseline care plan or summary being given to Resident 45 or the resident representative. Review of the Care Plan Policy with a revision date of 12/2019 revealed A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Documentation of care plan offer will be included in a progress note. Review of the all progress notes for Resident 45 revealed no documentation that the resident or the resident representative was given a summary of the baseline care plan. An interview 1/27/2020 at 3:55 PM with the DON (Director of Nursing) revealed that the residents or resident representatives were not given a written summary of the baseline care plan. H. Record review of the Admission Record for Resident 70 revealed that the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the electronic health record for Resident 70 revealed that no baseline care plan was present. Record review of the facility policy titled Care Plan dated 12/19 revealed the definition of Baseline care plan- Includes instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. The policy also revealed: A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Documentation of care plan offer will be included in a progress note. Interview on 1/27/20 at 2:07 PM with the facility Social Services Director (SSD) revealed that a copy of the baseline care plan was not provided to the resident or the resident representative. The SSD revealed that the baseline care plan is reviewed as it is completed but that no copy is given to the resident or family. I. Record review of the Admission Record for Resident 80 revealed that the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the electronic health record for Resident 80 revealed that no baseline care plan was present. Interview on 1/27/20 at 2:07 PM with the facility Social Services Director (SSD) revealed that a copy of the baseline care plan was not provided to the resident or the resident representative. The SSD revealed that the baseline care plan is reviewed as it is completed but that no copy is given to the resident or family.",2020-09-01
330,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,656,D,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.04C3a(5) Based on record review and interview the facility failed to care plan (develop a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) the resident [MEDICAL TREATMENT] treatment (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) for 1 resident (Resident 70) of 1 resident reviewed. The facility census was 78. Findings are: Record review of the Admission Record for Resident 70 revealed that the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the physician orders for Resident 70 revealed that the resident had an order for [REDACTED].>Interview on 1/27/20 at 11:00 AM with Licensed Practical Nurse C (LPN-C) revealed that Resident 70 received [MEDICAL TREATMENT] 3 times weekly. Record review of the admission Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 70 dated 1/2/2020 revealed in section O (Special Treatments, Procedures, and Programs) question O0100J that Resident 70 received [MEDICAL TREATMENT] while a resident of the facility. Record review of the facility policy titled Care Plan dated 12/19 revealed the definition for Comprehensive care plan- Includes measureable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Record review of the facility policy titled [MEDICAL TREATMENT] Services dated 1/18 revealed Procedure step 3. Care plan [MEDICAL TREATMENT] care specific to the resident. Record review of the care plan for Resident 70 on 1/22/2020 revealed that no care plan section for resident [MEDICAL TREATMENT] care was present in the care plan. Record review of the current care plan for Resident 70 on 1/27/2020 at 8:42 AM revealed that no care plan section for resident [MEDICAL TREATMENT] care was present in the care plan. A request for a copy of the resident care plan for Resident 70 was given to the facility Director of Nursing (DON) by this surveyor. On 1/28/20 a copy of the care plan for Resident 70 was provided to this surveyor by the DON. Record review of the care plan that was provided revealed that a care plan section specific for [MEDICAL TREATMENT] was added to the resident care plan. The care plan did not contain dates of when each section of the care plan was initiated. This surveyor requested that the DON provide a copy of the care plan for Resident 70 containing the dates that care plan sections were initiated and revised. The DON then provided this surveyor with a copy of the care plan for Resident 70 documenting that the section of the care plan for resident [MEDICAL TREATMENT] care was initiated on 1/27/20. Interview on 1/28/20 at 10:13 AM with the DON in the DON office confirmed that Resident 70 received [MEDICAL TREATMENT] and that the MDS dated [DATE] identified that the resident received [MEDICAL TREATMENT]. The DON confirmed that the facility procedure titled [MEDICAL TREATMENT] Services procedure directed that the care plan was to have a section specific for [MEDICAL TREATMENT]. The DON confirmed that the care plan for Resident 70 did not have a care plan section specific for [MEDICAL TREATMENT] until one was added on 1/27/20 after a copy of the resident care plan was requested by this surveyor.",2020-09-01
331,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,657,D,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review; the facility staff failed to revise Resident 17's care plan after a fall and failed to include interventions for impaired dentition on Resident 17's care plan. This affected 1 of 21 sampled residents. The facility identified a census of 78 at the time of survey. Findings are: Review of Resident 17's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan)dated 10/31/2019 revealed an admission date of [DATE]. Resident 17 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 17 was cognitively intact. Resident 17 required supervision to limited assistance from staff for bed mobility, transfer, toilet use, walking in room and corridor, locomotion on and off the unit, personal hygiene, dressing, and bathing. Resident 17 used a walker for mobility. Review of Resident 17's annual MDS dated [DATE] revealed Resident 17 had obvious or likely cavity or broken natural teeth. Resident 17 fell in the 30 days prior to admission/entry and fell in the last 2-6 months prior to admission/entry. Interview with Resident 17 on 1/22/20 at 9:55 AM revealed the they fell about a month ago and splintered a leg bone. Resident 17 revealed they had to wear a leg brace for about 3 weeks. Resident 17 also revealed they only had 6 teeth. Observation of Resident 17 on 1/22/20 at 9:55 AM revealed they had 6 teeth. The remainder of Resident 17's teeth were missing. Review of Resident 17's Slipped or fell report dated 12/6/2019 revealed Resident 17 fell and fractured their leg. Review of Resident 17's Care Plan dated 7/24/2019 revealed an intervention to prevent falls and further injury was added to Resident 17's Care Plan on 12/9/2019, 3 days after Resident 17 fell and there were no interventions for Resident 17's impaired dentition. Interview with the DON (Director of Nursing) on 01/28/20 at 11:51 AM confirmed Resident 17 fell on ,[DATE] and the care plan was not updated until 12/9. The DON revealed the nurses were supposed to put a new intervention on Resident 17's care plan immediately. A new problem for fall was was added to the care plan and there was an intervention dated 12/6/19 however, the date the fall problem and intervention was added to Resident 17's care plan was 12/9/19. Interview with the DON on 01/28/20 at 12:12 PM confirmed there was no documentation of a fall problem and interventions on Resident 17's Care Plan before 12/9/19. Interview with the DON on 1/28/20 at 12:43 PM confirmed there were no interventions for impaired dentition on Resident 17's care plan. Review of the facility policy Care Plan revised 12/19 revealed the following: The plan of care will be modified to reflect the care currently required/provided for the resident. Interview with NA-N (Nurse Aide) on 01/27/20 at 9:04 AM revealed they got the information they needed to care for the residents from the Kardex in the electronic health record that compiles all of the information they need from the resident's care plan.",2020-09-01
332,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,692,D,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09Da Based on observation, record review and interview, the facility staff failed to serve residents the portion size of protein specified in the menu. This had the potential to affect 2 residents (Resident 26 and Resident 45) of the 7 sampled residents. The facility census at the time of the survey was 78. Findings are: Resident 26 [NAME] Review of the MDS (Minimum Data Set -a federally mandated comprehensive assessment tool used for care planning) dated 11/2/2019 revealed for Section K-Swallowing/Nutritional Status, resident was a 5% weight loss and not on physician-prescribed weight loss regimen. An observation on 1/23/2020 at12:05 PM of Resident 26 revealed that Resident 26 had for lunch 1 chicken leg, potato wedges, green beans, bread, margarine and frosted cake. An interview on 1/23/2020 at 12:15 PM with the RD (Registered Dietician) revealed that the chicken served at the meal was 2 ounces which was the amount of protein that was to be given at the meal. Review of the dietary ticket from the noon meal on 1/23/2020 revealed that the Fried Chicken was to be 4 ounces. Review of the undated care plan for Resident 26 revealed interventions for poor appetite and potential for pressure ulcer development. An observation on 1/23/2020 at 1:45 PM of what Resident 26 had eaten included the chicken leg (the bone was on the plate), one piece of potato wedges was left and the green beans. Resident 45 B. An observation on 1/23/2020 at 12:05 PM of Resident 45 in the 200 dining room revealed that Resident 45 was served 1 chicken leg, potato wedges, green beans, bread, margarine and frosted cake. 01/23/20 12:45 PM Resident 45 was in the 200 dining room and it was noted that the resident had eaten the chicken leg and the bone was left. 1/2 of the potato wedges and all of the green beans were left. 01/23/20 02:40 PM Review of the dietary ticket from the noon meal on 1/23/20 revealed that the Fried Chicken was to be 4 ounces. 01/27/20 09:11 AM Observation of Resident 45 in the dining room at breakfast revealed Resident 45 ate 100% of the breakfast meal. Review of progress notes revealed that resident continues with Stage III pressure ulcer to top of Right 2nd toe, and an unstageable pressure injury to Right medial 4th toe. Areas are slightly larger this week. Also continues with arterial ulcers x2 to Right foot. Res remains on hospice and prognosis for wound healing is poor due to severe [MEDICAL CONDITION] (decreased blood flow). Review of the stages of a pressure ulcer for nursing assessments revealed: Stage I pressure ulcer has redness on the surface of the skin that does not disappear when pressure is relieved. Stage II ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds. As they heal there is no scar tissue formation and the tissues damaged will regenerate as healing takes place. This is one of the reasons it is so important for the healthcare team to correctly treat pressure ulcers to reduce the risk of them progressing to more involved wounds. Stages III and Stage IV are full thickness wounds, which are much worse. Stage III is injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon. Stage IV is an injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed. Full thickness pressure ulcers are deeper and heal by scar tissue formation. There is no regeneration of the underlying tissues. The development of these ulcers gets the most attention from attorneys and their experts. The damages are significant. An interview on 1/27/2020 at 12:55 PM with LPN-C (Licensed Practical Nurse) revealed that the pressure ulcer on Resident 45's medial right foot the bone visible in the wound. Review of the undated care plan revealed Resident 45 was at risk for nutritional problem and a need for increased nutritional needs related to impaired skin and gradual weight loss. Review of the Wound Data Collection Sheet dated 1/27/2020 at 2:36 PM revealed under the evaluation of the ulcer, venous wound, bone visible, wound bed was pink and some yellow sluff present. An interview on 1/23/2020 at 1:16 PM with the RD (Registered Dietician) revealed the 4 ounce portion should have been served to ensure the residents receive at least 3 ounces of meat. Review of the Chicken, Fried recipe revealed the portion was 4 ounces; Serve hot. Serve a 4 ounce portion as prepared for 3 ounces of protein. (1/2 breast, 1 thigh, 1 drumstick with a wing).",2020-09-01
333,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,803,E,0,1,89P111,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, interview, and record review; the facility staff failed to serve the portion size of chicken per menu. This affected 33 of the 62 residents who were served food in the 100 (Residents 21, 17, 16, 60, 31, 30, 58, 39, 14, 40, 26, 9, 22, 6) and 200 (45, 18, 7, 34, 20, 43, 48, 44, 59, 29, 50 , 41, 33, 23, 56, 69, 52, 74, and 19) dining rooms. The facility identified a census of 78 at the time of survey. Findings are: Observation of the 100 dining room on 01/23/20 at 12:13 PM revealed Cook-M serving fried chicken to the residents. Cook-M was serving the residents from individual menu cards. Cook-M served 1 breaded chicken leg to the following residents: Residents 21, 17, 16, 60, 31, 30, 58, 39, 14, 40, 26, 9, 22, and 6. There were 32 residents in the dining room. Observation of the 200 dining room on 1/23/20 at 12:50 PM revealed the following residents received 1 breaded chicken leg: Residents 45, 18, 7, 34, 20, 43, 48, 44, 59, 29, 50 , 41, 33, 23, 56, 69, 52, 74, and 19. There were 30 residents in the dining room. Observation on 1/23/20 at 12:45 PM revealed the RD (Registered Dietitian) removed the breading from the chicken leg, removed the meat from the bone and placed the meat on a scale. The chicken meat weighed 2 ounces. Review of the untitled menu cards the cooks served from read a 4 ounce portion of fried chicken was to be served to Residents 21, 17, 16, 60, 31, 30, 58, 39, 14, 40, 26, 9, 22, 6, 45, 18, 7, 34, 20, 43, 48, 44, 59, 29, 50 , 41, 33, 23, 56, 69, 52, 74, and 19. On 1/23/20 at 1:16 PM the RD provided the recipe for the fried chicken and reviewed the portion size on the menu card. The RD confirmed the fried chicken portion was supposed to be a 4 ounce breaded portion so the residents would receive at least 3 ounces of meat. Review of the undated Chicken, Fried recipe revealed the portion was 4 ounces; Serve hot. Serve a 4 ounce portion as prepared for 3 oz protein. (1/2 breast, 1 thigh, 1 drumstick with a wing). Review of the facility policy Portion Control revised 12/17 revealed the following: The portion sizes listed on the menu extensions or tray cards are followed.",2020-09-01
334,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,812,F,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure that the hair restraints fully covered all hair during service observation in the kitchen and dining areas to prevent the potential for food borne illness and failed to ensure that staff did not handle glasses of liquids with the bare hand over the top of the glass with the bare hand touching the drinking surface to prevent the potential for cross contamination for 6 residents (Residents 18, 23, 19, 69, 51, and 59). This had the potential to affect all of the facility residents who were served food served from the kitchen, and the central dining areas they were served from. The facility identified a census of 78 at the time of survey. Findings are: [NAME] 1/21/20 11:00 AM at Observation in the kitchen revealed DA-D's hair did not have hair contained in hair restraints. 01/22/20 at 12:02 PM Observation of the kitchen and dining room [ROOM NUMBER] revealed dietary staff DA-D did not have hair contained in a hair restraint. 1/23/20 at 12:00 PM DA-D and Cook-J observation that the hair restraints did not cover all the hair that is required, including hair on neck and sideburns. 01/27/20 12:54 PM Interview with RD (Registered Dietitian), FSS (Food Service Supervisor). Confirmed that dietary staff should have hair restraints covering all hair including the neck and sideburns, to prevent contamination of food. Review of the facility policy Food Preparation revised 7/18 revealed the following: Food preparation procedures that protect against foodborne illness and promote quality in taste and appearance are used. Review of the facility policy Food Handling revised 7/18 revealed the following: Food is handled in a manner that minimizes the risk of contamination. B. Record review of the facility policy titled Hand Hygiene and Handwashing dated 1/18 revealed that the guidance goals were to prevent the spread of infection between residents and to protect all residents from foodborne illness. Section titled During Service of Meals step 2b. Do not touch any food or eating surfaces with bare hands (i.e. fork tines, eating surface of plates drinking surfaces of glasses). Observation on 1/21/20 at 12:01 PM revealed that Dining Assistant D (DA-D) picked up a glass of liquid for Resident 23 holding the glass with the hand over the top of the glass and moved the glass in front of the resident. Observation on 1/21/20 at 12:04 PM revealed that DA-D picked up a water glass with the hand over the top of the glass and placed it in front of Resident 18. Observation on 1/21/20 at 12:11 PM revealed that DA-D poured a glass of lemonade and picked up the glass from over the top and placed it on a tray for Resident 19. Observation on 1/21/20 at 12:14 PM revealed that DA-D picked up a glass of milk with the hand over the top of the glass and then picked up a glass of dark liquid with the other hand over the top of the glass and sat the glasses on a tray for Resident 69. Observation on 1/22/20 at 12:06 PM revealed that DA-D carried a cup of unknown liquid with the hand over the top of the cup and sat the cup on the table in front of Resident 59. Observation on 1/22/20 at 12:08 PM revealed that DA-D carried a glass of lemonade with the hand over the top of the glass and sat the glass on the table in front of Resident 19. Observation on 1/22/20 at 12:17 PM revealed that DA-D carried a glass of chocolate milk from the dining room service area holding the glass with the hand over the top of the glass and sat it on the table for Resident 51. Interview with the facility Registered Dietitian (RD) on 1/28/20 at 9:30 AM confirmed that handling a glass over the top of the glass is touching the drinking surface and is an infection risk and should not be performed.",2020-09-01
335,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,880,E,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A2 Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during meal service, failed to ensure a Health History Screen was completed for 1 of 5 employees (Employee H); failed to ensure that staff wet both hands prior to applying soap and failed to ensure that staff scrubbed the hands for at least 20 seconds before rinsing the hands during hand washing; and the facility failed to ensure that staff disinfected mechanical lifts after use to prevent cross contamination for 3 residents (Residents 44, 57, and 11). This had the potential to affect all of the facility residents. The facility identified a census of 78 at the time of survey. Findings are: [NAME] Observation of the 400 dining room on 01/21/20 at 12:08 PM revealed the following: At 12:08 PM Cook-J started serving the meal. LPN-L (Licensed Practical Nurse) and HS (Housekeeping Supervisor) took plates of food to the residents individually after Cook-J plated the food and put the plate on a tray. Cook-J was wearing gloves and handling the trays and utensils. Cook-J touched the refrigerator door and then picked up cookies with the same gloved hands out of a clear square container and put them in small dishes and put them on the trays then LPN-L and HS took them to the residents. Cook-J did not change gloves after touching the trays, utensils, and refrigerator door before handling the cookies. All of these residents received a cookie after the cook handled them with soiled gloves without performing hand hygiene: Residents 134, 54, 77, 131, 132, 78, 135, 37, 136, 133, 71, and 3. At 12:25 PM Resident 67 received a cookie on a room tray Cook-J had handled with the same gloved hands. Interview with the RD (Registered Dietitian) on 1/27/20 at 12:54 PM revealed if the staff person was using the gloved hand as a utensil, they cannot touch anything else with it. The RD revealed the staff were to change their gloves, perform hand hygiene, and don clean gloves before handling prepared food. Review of the facility policy Food Preparation revised 7/18 revealed the following: Food preparation procedures that protect against food borne illness and promote quality in taste and appearance are used. Review of the facility procedure Hand Hygiene and Handwashing revised 1/18 revealed the following: The goal is to protect all residents from food borne illness by never touching their food with bare hands or contaminated gloves. Proper handwashing and appropriate use of gloves protects residents against food borne illness from improperly handled time/temperature control for safety foods. Review of the facility policy Food Handling revised 7/18 revealed the following: Food is handled in a manner that minimizes the risk of contamination. B. Review of the personnel file for Employee-H with a DOH (Date of Hire) of 11/6/2019 revealed no documentation a Health History Screen was completed. Interview with the facility Administrator on 1/23/20 at 3:53 PM confirmed there was no documentation a Health History Screen was completed for Employee-H. Interview with the Administrator on 1/27/20 at 11:17 AM revealed Employee-H worked in the facility in resident care areas. Review of the facility policy Health Questionnaire revised 2/19 revealed the following: The Medical History Questionnaire must be reviewed prior to the employee beginning work in his or her respective department and any concerns must be addressed immediately. Documentation relating to the Medical History Questionnaire must be treated as a confidential medical record. All medical records must be filed and maintained in the Confidential Employee Medical File. Supervisors and managers who must be advised of work restrictions and accommodations of the conditional employee are allowed access to the employee's medical file. The Medical History Questionnaire will be completed by the conditional employee prior to general orientation. After the conditional employee has completed the Medical History Questionnaire, the supervisor, manager, or human resources representative will review the responses with the conditional employee and note any details or special concerns at the bottom of the form under the heading Summary of Findings or Comments. The summary of findings must be completed by the supervisor, manager or human resources representative in the presence of the conditional employee. C. 1/20/2020 at 12:20 PM Observation in dining room [ROOM NUMBER] revealed unidentified nursing staff not using hand hygiene before, during or after contamination of hands with touching food, residents and tables. DA-Q did not sanitize hands at any time with this food pass to residents. 1/20/2020 at 12:54 PM Interview with the DON (Director of Nursing) confirmed that the expectation was to have all staff that hand washing should occur if hands were contaminated and that the time expectation would be at least 20 seconds each time for handwashing. Interview on 01/23/20 at 09:22 AM with the RD confirmed that the expectation of staff was to wash hands for 20 seconds. If the staff person was using the gloved hand as a utensil, they cannot touch anything else with it. Review of the facility policy Food Handling revised 7/18 revealed the following: Food is handled in a manner that minimizes the risk of contamination. Review of the facility Procedure Hand Hygiene and Handwashing revised 1/18 revealed the following: The goal is to protect all residents from foodborne illness by never touching their food with bare hands or contaminated gloves or hair. Proper handwashing and appropriate use of gloves and wearing hair restraints protects residents against foodborne illness from improperly handled time/temperature control for safety foods. D. Record review of the facility policy titled Hand Hygiene and Handwashing dated 1/18 the Section Handwashing Techniques Step 1. Wet hands with water. Step 2. Apply 3 to 5 milliliters of soap. Step 3. Rub hands together for at least 20 seconds. Step 4. Cover all surfaces of hands, fingers and areas around/under fingernails. Step 5. Rinse hands with water and dry thoroughly. Observation on 1/21/20 at 11:41 AM revealed that Dietary Cook [NAME] (DC-E) scrubbed the hands with soap for 13 seconds before rinsing the hands at the dining room sink. Observation on 1/21/20 at 11:50 AM revealed that the facility Registered Dietitian (RD) scrubbed the hands with soap for 15 seconds and then rinsed and dried the hands at the dining room sink. Observation on 1/21/20 at 12:26 PM revealed that Certified Nursing Assistant A (CNA-A) applied soap to a dry hand and scrubbed the hands together with soap for 1 second and then scrubbed the hands underneath running water for 11 seconds at the dining room sink. Observation on 1/21/20 at 12:35 PM revealed that the RD scrubbed the hands together with soap for 13 seconds at the dining room sink and then rinsed the hands. Observation on 1/21/20 at 12:41 PM revealed that Dietary Assistant D (DA-D) held the hands for 2 seconds underneath running water without using soap and then dried the hands at the dining room sink. Observation on 1/22/20 at 12:00 PM revealed that DA-D applied soap to the dry left hand and scrubbed the hands together for 1 second underneath running water at the dining room sink. DA-D grabbed a paper towel and dried the hands. Observation on 1/22/20 at 12:01 PM revealed that Certified Nursing Assistant F (CNA-F) turned on the water at the dining room sink and applied soap to the dry left hand and scrubbed the hands together with soap for 8 seconds and then rinsed the right hand underneath running water. CNA-F rinsed the left hand underneath running water and then dried the hands. Observation on 1/22/20 at 12:01 PM revealed that the RD applied soap to the dry hand and then scrubbed the hands together for 13 seconds before rinsing the hands at the dining room sink. Observation on 1/22/20 at 12:07 PM revealed that DA-D turned on the water at the dining room sink and wet the hands for less than 1 second. DA-D turned off the water with a bare hand and dried the hands on the front of the apron. Observation on 1/22/20 at 12:10 PM revealed that RD turned on the water at the dining room sink and applied soap to the dry right hand and scrubbed the hands together for 8 seconds and then continued to scrub the hands underneath running water for 4 seconds before drying the hands. Observation on 01/22/20 at 12:13 PM revealed that CNA-F turned on the water at the dining room sink and applied soap to dry right hand and scrubbed the hands together for 5 seconds. CNA-F rinsed the right hand underneath running water and then rinsed the left hand underneath running water. CNA-F dried the hands with paper towels and turned the water off. Observation on 1/22/20 12:16 PM revealed that Licensed Practical Nurse C (LPN-C) turned the water on at the dining room sink and applied soap to a dry hand and scrubbed the hands together for 19 seconds. LPN-C rinsed the hands underneath running water. Interview on 01/28/20 at 9:30 AM with the RD confirmed that the procedure for hand washing specified that both hands were to be wet prior to applying soap and that the hands are then scrubbed together for at least 20 seconds before rinsing to prevent cross contamination. Interview on 1/28/20 at 10:13 AM with the facility Director of Nursing (DON) confirmed that the procedure for handwashing included wetting both hands prior to applying soap and scrubbing the hands together for 20 seconds before rinsing. E. Record review of the facility policy titled Mobility Support and Positioning Mobility dated 8/19 revealed Section titled Procedure: Section titled Lifts: Stand Aid, Sit-to-Stand, Total Lift and Ceiling Lift Subsection Procedure: Surface to Surface with Sit-to-Stand (a mechanical assistive device used to transfer a resident with difficulty standing up on their own from a seated position) Step 28. Clean sit-to-stand after use. Subsection Procedure: Surface to Surface with Total Lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own or unable to stand up on their own) Step 29. Clean lift after use. Observation on 1/23/20 at 1:20 PM revealed that Certified Nursing Assistant A (CNA-A) moved the sit to stand lift from room [ROOM NUMBER] and pushed it into to room [ROOM NUMBER] without cleaning it. Observation on 1/23/20 at 1:25 PM revealed that CNA-A pushed the sit to stand lift from room [ROOM NUMBER] to room [ROOM NUMBER] and transferred Resident 44 from the wheelchair into the bed. CNA-A pushed the lift from room [ROOM NUMBER] into the cove by the west hall soiled room. CNA-A did not clean the lift. Observation on 1/23/20 at 2:06 PM revealed that Certified Nursing Assistant B (CNA-B) obtained the sit to stand lift from the area by the west hall soiled room and placed it in front of Resident 57. Resident 57 was seated in a wheelchair in the lobby area. Resident 57 held onto the grab handles on the sit to stand lift. CNA-B and Assistant Director of Nursing G (ADON-G) attempted to place the lift sling on the resident. Resident 57 resisted the staff placing the sling on the resident. ADON-G removed the sit to stand lift from in front of Resident 57 and pushed the lift into room [ROOM NUMBER] without cleaning it. Observation on 1/27/20 at 9:50 AM revealed that CNA-A transported Resident 11 from the lobby area into the resident's room in a wheelchair. CNA-B pushed a total body lift into the room of Resident 11. CNA-A and CNA-B transferred the resident out of the wheelchair with the total body lift. CNA-B removed the total body lift from the room of Resident 11 and placed the lift in room [ROOM NUMBER] without cleaning it. Interview on 1/28/20 at 10:13 AM with the facility DON confirmed that the expectation is for staff to clean the mechanical lifts after use according to the procedure to prevent cross contamination.",2020-09-01
336,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2020-01-28,923,E,0,1,89P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure that the ventilation system was operational and keep the vents free of fuzzy matter in 5 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 22 sampled rooms. The facility census at the time of the survey was 78. Findings are: Observation on 1/23/2020 at 11:22 AM revealed a strong odor of feces noted in the hallway from room [ROOM NUMBER] to room [ROOM NUMBER]. This was a direct path to the 100 and 200 dining rooms. Observation on 1/27/20 at 12:26 PM revealed a strong odor of feces noted in the hallway from room [ROOM NUMBER] to room [ROOM NUMBER]. This was a direct path to the 100 and 200 dining rooms. An observation on 1/22/2020 at 9:20 AM of room [ROOM NUMBER] revealed the vent in the resident's bathroom had fuzzy gray matter on the vent blades. An observation on 1/22/2020 at 9:38 AM of room [ROOM NUMBER] revealed the vent in the bathroom ceiling was not able to suck up a 1 ply piece of toilet paper. The vent had fuzzy gray debris on vent blades. An observation on 1/22/2020 at 10:37 AM of room [ROOM NUMBER] revealed the vent in the bathroom ceiling was not able to suck up a 1 ply piece of toilet paper. An observation on 1/22/2020 at 12:41 PM of room [ROOM NUMBER] revealed the vent in the bathroom ceiling was not able to suck up a 1 ply piece of toilet paper. An observation on 1/22/2020 at 12:05 PM of room [ROOM NUMBER] revealed the vent in the bathroom ceiling was covered with fuzzy gray debris. An interview on 1/28/2020 at 12:15 PM with the MS (Maintenance Supervisor) revealed that the ceiling vents in the bathrooms for room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were not operational. The vents in the facility were check last month in December. An interview on 1/28/2020 at 12:15 PM with the HS (Housekeeping Supervisor) revealed that the ceiling vents in the bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] had fuzzy gray debris on them. Review of the Checks on the Bathroom venting system for the whole facility revealed that the last check completed on the system was (MONTH) 4, 2019.",2020-09-01
337,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-04-24,602,E,1,0,RTCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (9) Based on observation, interview, and record review; the facility failed to protect resident belongings from potential misappropriation by failing to account for personal care equipment (hearing aids and dentures) and clothing. This affected 4 of 4 sampled residents (Residents 1, 2, 4, and 5). The facility identified a census of 89 at the time of survey. Findings are: [NAME] Review of Resident 1's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 2/14/2018 revealed an admission date of [DATE]. Resident 1 had no BIMS (Brief Interview for Mental Status) score as Resident 1 was rarely/never understood. Resident 1 required extensive assistance from staff for personal hygiene which included oral/dental care. Review of Resident 1's care plan dated 7/23/2015 revealed Resident 1 required assistance with oral care and Resident 1 had upper and lower dentures. Observation of Resident 1 on 4/24/2018 at 4:15 PM revealed Resident 1 was not wearing a lower denture. Interview with Resident 1's family member on 4/24/2018 at 1:28 PM revealed they had reported Resident 1's lower denture missing on 12/10/2017 and it had not been located or replaced. B. Review of Resident 2's Annual MDS dated [DATE] revealed Resident 2 was admitted to the facility on [DATE]. Resident 2 was indicated as having used a hearing aid. Review of Resident 2's care plan dated 2/12/2018 revealed staff were to ensure the hearing aids were in place and that Resident 2's hearing aids were missing. Review of Resident 2's Progress Notes dated 10/13/2017 revealed Resident 2 had reported their hearing aids stolen. Resident 2's family member reported one hearing aid had been missing for quite a while and the other one had been missing for a couple of months. There was no documentation the facility staff had accounted for Resident 2's hearing aids prior to Resident 2 reporting them stolen. C. Review of Resident 4's Significant Change in Status MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 had a BIMS score of 15 which indicated Resident 4 was cognitively intact. Hearing aid used was indicated. Review of Resident 4's care plan dated 4/16/2017 revealed Resident 4 had bilateral hearing aids and staff were to ensure the hearing aids were in place. Observation of Resident 4 on 4/24/2018 at 11:41 AM revealed they were not wearing hearing aids. Interview with Resident 4 on 4/24/2018 at 11:41 AM revealed Resident 4 did not have hearing aids and never had hearing aids. Resident 4 revealed they had several items of clothing missing including 3 sweaters and a pair of pants when Resident 4 was inquired if they had any missing items. Resident 4 revealed they had reported the missing items to 2 facility staff members. D. Review of Resident 5's Significant Change in Status MDS dated [DATE] revealed an admission date of [DATE]. Resident 5 required extensive assistance for personal hygiene and used a hearing aid. Review of Resident 5's care plan dated 6/28/2015 revealed Resident 5 wore a hearing aid in the left ear and the facility staff were to ensure the hearing aid was in place. Observation of Resident 5 on 4/24/2018 at 11:33 AM, 12:15 PM, 1:16 PM, and 4:02 PM revealed they were not wearing their hearing aid. Interview with Resident 5 on 4/24/2018 at 4:02 PM confirmed they were not wearing their hearing aid and Resident 5 revealed they thought their hearing aid had been stolen. Interview with the DON (Director of Nursing) on 4/24/2018 at 4:45 PM confirmed Resident 1's lower denture was missing and it had not been replaced. The DON confirmed there was no documentation to determine when Resident 1's denture went missing. Resident 4's missing clothing should have been reported to the supervisor. The DON confirmed Resident 4's hearing aids should have been clarified. The DON revealed an investigation would be initiated for Resident 5's hearing aid they had reported had been stolen. The DON confirmed the facility did not have a procedure in place to account for resident care items such as dentures and hearing aids and there was a concern about accounting for these items. Review of the facility policy Missing Items reviewed 4/2016 revealed the following: When an item is reported missing, this will be reported immediately to the supervisor. Review of the facility policy Abuse and Neglect revised 1/2018 revealed the resident has the right to be free from misappropriation of resident property.",2020-09-01
338,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2017-09-12,225,D,1,1,5YGQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.02(8) Based on record review and interview, the facility staff failed to report a fall with a significant injury to the required State Agency within the required timeframes for 1 (Resident 12) of 5 facility investigations reviewed. The facility census was 91. Findings are: Record review of the facility Policy and Procedures for Abuse and Neglect dated revised 11/16 revealed the following under Notification Procedures: a. If there is a allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, than it will be reported no later then 2 hours after the allegation is made to the administrator and to other officials (including the state survey agency and Adult Protective Services where state law provides for jurisdiction in long term care centers) in accordance with state law. The location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including the state survey and certification agency within 5 working days of the incident Record review of a facility investigation report dated 5/11/17 for Resident 12 revealed that Resident 12 had a fall that occurred on 4/4/17 at 2230 (10:30 PM). Resident 12 was sent to the emergency room for a laceration above the left eyebrow that required 5 sutures and a superficial Hematoma diagnosed with [REDACTED]. The injury to Resident 12 was not reported to Adult Protective Services (APS) until 5/9/17, a total of 36 days past the required report to APS within 2 hours. The facility investigation was not reported to the Department of Health and Human Services until 5/11/17, a total of 33 days past the required report within 5 working days. Interview on 09/12/2017 at 7:47:16 AM with the Director of Nursing confirmed that the investigation into Resident 12's significant injury was reported late to both APS and DHHS.",2020-09-01
339,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2017-09-12,332,D,1,1,5YGQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License reference Number 175 NAC 12-006.10b1 Based on observation, interview and record review; the facility failed to monitor the administration of medications for one of 15 sampled residents. On 09/07/2017 at 12:08 PM MA (Medication Aid) A was observed to hand the resident [MEDICATION NAME] 250 mg (an antibacterial drug), [MEDICATION NAME]/Apap 5/325 mg (a non-opioid pain reliever) and [MEDICATION NAME] 40 mg (a diuretic used to treat fluid retention) in a medication cup to Resident 59 in the dinning room. MA A then spoke with the resident and walked away leaving the medications at the table with the resident. MA A then returned to the resident to answer a question then left the table again leaving the medications with the resident at the table. On 09/07/2017 at 12:10 PM an interview with the MA confirmed the medications were left with the resident at the table and confirmed that the medications should not have been left alone with the resident. On 09/07/2017 at 2:21 PM an interview with the DON confirmed the staff administering medications should not leave a resident alone to take to take medications, the staff should observe the residents take the medications. Record review of medication administration policy last revised 5/16 revealed,do not leave medications at the bed side or at a table unless there is a physician order [REDACTED]. Record review revealed no documentation of evaluation by physician for self administration of medications, Record review revealed the Dr orders for the medications did not include leaving the medications with the resident.",2020-09-01
340,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2017-09-12,514,E,1,1,5YGQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 12-006.16B Based on observation, record review and interview; the facility staff failed to document the monitoring of safety devices to ensure the devices remained functional for 4 (Residents 12, 75, 185 and 195) of 4 residents reviewed that were identified as at risk for falls with the use of safety devices. The facility census was 91. Findings are: [NAME] Record review of the facility Policy and Procedures for Alarms: Bed,Chair and Door dated [DATE] included the following procedures: 1. Alarms are to be checked for proper operation and battery charges as followed: - Bracelets, bed, personal and motion alarms: Rehab and Nursing are to check daily to see if alarm is functional. 2. Each nursing shift will be responsible for visually checking placement of alarms. 3. All staff will be responsible for physically checking on the resident when the alarm goes off. 4. Bed and chair pads will be placed in use only the length of time indicated. 5. Review of the resident condition will determine if the resident will benefit from the use of the alarm. 6. The charge nurse will notify the family of the use of the alarm and ensure that staff are knowledgeable about the alarm system. 7. The use of alarms will be reviewed on a regular basis but no less then quarterly by the interdisciplinary team. B. Record review of Resident 12's Falls Tool (a fall risk assessment) dated 6/17/17 identified Resident 12 as at medium risk for falls. Record review of Resident 12's Comprehensive Care Plan (CCP) dated 8/7/16 identified that Resident 12 had an intervention of a bed and chair alarm used to alert staff to residents movement and to assist staff in monitoring movement. C. Record review of a facility investigation report dated 5/11/17 for Resident 12 revealed that Resident 12 had a fall that occurred on 4/4/17 at 2230 (10:30 PM). Resident 12 was sent to the emergency room for a laceration above the left eyebrow that required 5 sutures and a superficial Hematoma diagnosed with [REDACTED]. The facility investigation revealed that the batteries in Resident 12's safety device (chair alarm) were not functional at the time of the fall. D. Observation on 9/6/17 at 11:45 AM revealed Resident 12 seated in a wheelchair with a safety alarm device in place on the wheelchair. E. Interview on 09/11/17 at 10:48 AM with Licensed Practical Nurse (LPN) B confirmed that Resident 12 had a safety device in place. LPN B confirmed that the device is checked routinely to ensure that it was working but staff do not document the monitoring of the function of the safety device. F. Record review of Resident 75's Falls Tool dated 9/3/17 identified Resident 75 as at medium risk for falls. Record review of Resident 75's CCP dated 5/6/17 identified that Resident 75 had an intervention of a bed and chair sensor alarm used to alert staff to residents movement and to assist staff in monitoring movement. [NAME] Observation on 09/11/17 at 10:11 AM revealed Resident 75 in bed with a sensor safety device in place underneath the resident. H. Record review of Resident 185's Falls Tool dated 8/31/17 identified Resident 185 as at medium risk for falls. Record review of Resident 185's CCP dated 7/12/17 identified that Resident 75 had an intervention of a bed and chair sensor alarm used to alert staff to residents movement and to assist staff in monitoring movement. I. Observation on 09/12/17 at 10:20 AM revealed Resident 185 seated in a recliner in the lobby area with a pad sensor alarm present underneath the resident. [NAME] Record review of Resident 195's Falls Tool dated 9/9/17 identified Resident 195 at high risk for falls. Record review of Resident 195's CCP dated 8/26/17 identified that Resident 195 had an intervention of a bed and chair alarm used to alert staff to residents movement and to assist staff in monitoring movement. K. Observation on 09/11/2017 at 10:04 AM revealed Resident 195 in bed with a sensor safety device in place underneath the resident. L. Record review of Resident 12's, 75's, 185's and 195's Electronic Medical Record (EMR) revealed no documentation of the daily monitoring of the safety devices to ensure they were functional. M. Interview on 09/11/17 at 12:20 PM with the Director of Nursing confirmed that the facility staff did not document the functionality of the alarm safety devices when they were checked by the facility staff.",2020-09-01
341,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,583,D,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to maintain resident privacy in the dining room by discussing medical appointments and checking blood pressures in view of other residents. This affected 3 of 35 residents present in the dining room (Residents 3, 47, and 69). The facility identified a census of 86 at the time of survey. Findings are: [NAME] Observation of the dining room on 10/03/18 at 12:16 PM revealed the DON (Director of Nursing) entered the dining room and talked to Resident 3 about an appointment with the doctor they scheduled for Resident 3. There was another resident sitting at the table with Resident 3. The DON could be heard talking to Resident 3 about the appointment from the far side of the next table. B. Observation of the dining room on 10/03/18 at 9:13 AM revealed an unidentified staff person checked Resident 69's blood pressure in the dining room. There were other residents in the dining room and the screen on the blood pressure machine which had the blood pressure reading on it was visible to others. C. Observation of the dining room on 10/03/18 at 9:16 AM revealed MA-E (Medication Aide) checked Resident 47's blood pressure in the dining room with the blood pressure machine. The screen was up on a pole and the blood pressure reading was visible to others. There were other residents in the dining room. Interview with the DON (Director of Nursing) on 10/04/18 at 9:57 AM revealed the staff should not check resident blood pressures in the dining room since the screen was visible to everyone in the dining room. Review of the undated facility booklet Resident's Rights for Skilled Nursing Facilities included in the facility admission packet revealed the following: The resident has the right to personal privacy and confidentiality regarding his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communication, personal care, visits and meetings of family and residents groups.",2020-09-01
342,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,623,E,0,1,JW4S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (5) Based on interview and record review, the facility staff failed to notify the Ombudsman (a person appointed by the state who advocates for residents' rights) when Resident 15 and 37 were transferred to the hospital. This affected 2 of 4 sampled residents. The facility identified a census of 86 at the time of survey. Findings are: [NAME] Review of Resident 15's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) discharge and re-entry tracking revealed Resident 15 was transferred to the hospital on [DATE] for an unscheduled hospitalization and returned to the facility on [DATE]. Review of Resident 15's Medical Record revealed there was no documentation that the Ombudsman was notified Resident 15 was transferred to the hospital. B. Review of Resident 37's Progress Notes revealed Resident 37 was transferred to the hospital for an unscheduled hospitalization on [DATE] and returned to the facility on [DATE]. There was no documentation the Ombudsman was notified Resident 37 was transferred to the hospital. Interview with the DON (Director of Nursing) on 10/04/18 at 11:33 AM revealed the Ombudsman was not notified that Resident 15 and 37 were transferred to the hospital.",2020-09-01
343,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,641,D,0,1,JW4S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) to reflect cognitive status for Residents 27 and 33 and reflect PASRR (Preadmission Screening and Resident Review (PASRR: a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) status for Resident 3. This affected 3 of 25 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 86 at the time of survey. Findings are: [NAME] Review of Resident 3's annual MDS dated [DATE] revealed the following: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability? was marked no. Active [DIAGNOSES REDACTED]. Review of Resident 3's [DIAGNOSES REDACTED]. Borderline personality disorder with an onset date 12/7/2017 during stay; [MEDICAL CONDITION] disorder with an onset date 5/4/2017 during stay; major [MEDICAL CONDITION] with an onset date 4/3/2018 during stay; and anxiety disorder with an onset date 2/14/2014 during stay. Review of the Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: These [DIAGNOSES REDACTED]. Interview with the SSD (Social Services Director) on 10/04/18 at 11:34 AM revealed a PASRR was not completed to reflect Resident 3's serious mental illness; therefore the Level II PASRR [DIAGNOSES REDACTED]. B. Review of Resident 27's Annual MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes) dated 8/2/18 revealed the information under Section B, Resident 27 had clear speech, can sometimes understand, and can sometimes be understood. Section C stated that a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) was not conducted due to Resident 27 was rarely/never understood. Section D for the question, Should Resident Mood Interview be Conducted the answer was No Resident 27 was rarely/never understood. The information in Section B, Section C and Section D had conflicting information. Review of Resident 27's Quarterly MDS dated [DATE] revealed under Section B, Resident 27 had clear speech, can sometimes understand, and can sometimes be understood. Section C stated that a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) was not conducted due to Resident 27 was rarely/never understood. Section D for the question, Should Resident Mood Interview be Conducted the answer was No Resident 27 was rarely/never understood. The information in Section B, Section C and Section D had conflicting information. Review of Resident 27's Face Sheet revealed an admission date of [DATE]. C. Review of Resident 33's Quarterly MDS (Minimum Data Set, a federally mandated assessment used for care planning purposes) dated 8/7/18 revealed under Section B Resident 33 had clear speech, can usually understand, and can usually be understood. Sections C stated Resident 33 was rarely or never understood and was able to rarely or never understand. Section D - Resident Mood interview was not conducted Resident 33 was rarely/never understood. The information in Section B and C had conflicting information. Review of Resident 33's Annual MDS dated [DATE] revealed under Section B Resident 33 had clear speech, can usually understand, and can usually be understood. Section C was coded as BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) was not assessed. Section D for Mood was not assessed. The information in Section B, Section C, and Section D had conflicting information. Review of Resident 33's Face Sheet revealed an admission date of [DATE]. An interview on 10/04/18 at 4:10 PM with the DON (Director of Nursing) revealed and confirmed that the MDS's for the dates of 8/2/18 and 5/7/18, for Resident 27, did not match and had conflicting information for Sections B and C.",2020-09-01
344,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,644,D,0,1,JW4S11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review; the facility staff failed to ensure a Level II PASRR screen was completed after Resident 3 was diagnosed with [REDACTED]. This affected 1 of 1 sampled residents. The facility identified a census of 86 at the time of survey. Findings are: Review of Resident 3's Identification Screen dated 7/30/2004 revealed a no response to the question does the individual have a [DIAGNOSES REDACTED]. Review of Resident 3's Medical Record revealed no documentation a Level II PASRR screen had been completed. Review of Resident 3's [DIAGNOSES REDACTED]. Review of the Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: These [DIAGNOSES REDACTED]. Interview with the SSD (Social Services Director) on 10/04/18 at 11:34 AM revealed a PASRR was not completed to reflect Resident 3's serious mental illness Review of the facility policy PASARR (sic) revised 9/17 revealed the following: If the resident is diagnosed with [REDACTED].,2020-09-01
345,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,677,D,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observation, interview, and record review; the facility failed to provide ADL (Activities of Daily Living) assistance for Resident 13. This affected 1 of 24 sampled residents. (Resident 13). The facility identified a census of 86 at the time of survey. Findings are: Observation of Resident 13 on 10/01/18 at 4:26 PM revealed they were not clean shaven. Resident 13 had long stubble on their face. Observation of Resident 13 on 10/03/18 at 9:09 AM revealed they were not clean shaven. Observation of Resident 13 on 10/4/2018 at 12:41 PM revealed they were not clean shaven. Review of Resident 13's SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/17/2018 revealed Resident 13 had a BIMS (Brief Interview for Mental Status) score of 2 which indicated Resident 13 had severe cognitive impairment. Resident 13 required extensive assistance from 2 staff for personal hygiene. Interview with RN-G (Registered Nurse) on 10/4/2018 at 12:34 PM revealed Resident 13 was supposed to receive a shave every morning. Interview with RN-G on 10/04/18 at 12:41 PM confirmed that Resident 13 needed a shave.",2020-09-01
346,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,684,D,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, interview, and record review; the facility staff failed to identify and monitor bruising present on Resident 37's arms and hand. This affected 1 of 24 sampled residents. The facility identified a census of 37 at the time of survey. Findings are: Observation of Resident 37 on 10/02/18 at 9:53 AM revealed they had bruises on both arms and the left hand; the bruises were of significant size and visible. Interview with the DON on 10/04/18 at 8:48 AM revealed the facility did not have a process in place for the nurses to identify skin issues. During any cares like bathing, the NA (Nurse Aide) looked at the residents' skin while they were doing hands on bathing. If the NA saw a skin tear or red area they would go get the nurse. Review of Resident 37's Medical Record revealed no documentation of the bruises on their arms and hand. Interview with the DON (Director of Nursing) on 10/04/18 at 2:40 PM confirmed there was no documentation of the bruises on Resident 37's hand and arms. Review of the facility policy Skin Assessment, Pressure Ulcer Prevention, and Documentation Requirements revised 4/16 revealed the following: A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. If a bruise, contusion, abrasion or skin tear is observed on a resident, this should be reported to the nurse immediately. The bruise/contusion/skin tear/abrasion should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation UDA (User Defined Assessment) and on the resident's care plan.",2020-09-01
347,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,689,D,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observation, interview, and record review; the facility staff failed to ensure resident care equipment was maintained in a manner to prevent potential accidents. This affected 1 of 24 sampled residents (Resident 12). The facility identified a census of 86 at the time of survey. Findings are: Observation of Resident 12's bathroom on 10/03/18 at 12:50 PM revealed the toilet riser was not secured to the toilet. Interview with NA-F (Nurse Aide) on 10/3/2018 at 12:58 PM confirmed Resident 12 used the toilet in that bathroom. Interview with the MS (Maintenance Supervisor) on 10/3/2018 at 1:06 PM confirmed the toilet riser was not secured to the toilet and the toilet riser did not fit that toilet. Interview with the DON (Director of Nursing) on 10/3/2018 at 2:00 PM revealed the facility did not have a policy for monitoring the safety of the toilet risers.",2020-09-01
348,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,725,F,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observation, interview, and record review; the facility failed to maintain sufficient staff to provide care to the residents including answering call lights to the residents' satisfaction and monitoring residents for needs. This had the potential to affect all of the facility residents. The facility identified a census of 86 at the time of survey. Findings are: Interview with Resident 70 on 10/02/18 at 11:40 AM revealed call lights weren't getting answered like they should. They have waited 45 minutes for staff to respond to their call for assistance. Interview with Resident 184 10/02/18 at 10:11 AM revealed there was not enough staff and it was noticeable at meal times. Interview with Resident 69 on 10/02/18 at 1:52 PM revealed the facility did not have enough staff. It was more evident sometimes around the end of each shift. Resident 69 revealed they had to wait for help usually 15 minutes and occasionally up to half an hour. Interview with Resident 180 on 10/02/18 at 12:14 PM revealed they had to wait for help a long time when getting up in the morning and when they went to bed at night. Resident 180 also stated that around meal time before and after it took the staff along time to get to them. Interview with Resident 15 on 10/01/18 at 3:09 PM revealed the staff left them on the toilet for a long time because they don't have enough help. The times when there is less staff varies. Last night I called because my roommate was sick. Nobody responded so I had to go find the nurse. They sent them to the hospital this morning. Resident 15 reported they have had 2 bowel accidents while they were waiting for someone to come and help them to the bathroom. Interview with Resident 189 on 10/02/18 at 10:43 AM revealed the staff rush and it takes a long time to get help getting up in the morning, going to bed and at meal times. Interview with Resident 229's family member on 10/02/18 09:13 AM revealed Resident 299 was not getting meal trays on time. Resident 299's family member reported they came in during the evening meal to assist their family member and found their lunch tray sitting in the room. Interview with Resident 3 on 10/02/18 at 11:29 AM revealed the facility did not have enough staff to provide the care and assistance they needed without having to wait a long time. Resident 3 reported they have had to wait sometimes 30 minutes for help. Interview with Resident 15's family member on 10/03/18 at 10:40 AM revealed there was a serious staffing problem in the facility. The staff made Resident 15 go to bed by 8 PM because they need assistance from 2 people and that's when it works for the staff to assist Resident 15 to go to bed. They don't lay Resident 15 down between meals because they don't have time as it takes 2 people. Resident 15 had been left on the toilet so long that they are starting to get a purple spot on their bottom. The night shift staffing was nil. Review of the facility Activity & Response Time Analysis reports revealed the following call light activity for 9/4/18-10/4/18 with call response times over 15 minutes: Resident 35: 9/9 call placed 9:07 AM. Canceled 9:33 AM. 26 minute 26 second response time. 9/11 call placed 1:09 AM. Canceled 1:24 AM. 15 minutes 12 second response time. 9/20 call placed 7:31 PM. Canceled 7:47 PM. 16 minute 39 second response time. 9/24 call placed 5:36 AM. Canceled 5:53 AM. 16 minute 42 second response time. 9/28 call placed 2:41 PM. Canceled 2:57 PM. 15 minute 19 second response time. 9/29 call placed 10:51 AM. Canceled 11:14 AM. 23 minute 14 second response time. 10/2 call placed 9:07 PM. Canceled 9:42 PM. 35 minute 30 second response time. 10/3 call placed 6:16 PM. Canceled 6:40 PM. 23 minutes 54 second response time. Resident 13: 9/25 call placed 5:38 AM. Canceled 5:59 AM. 20 minute 40 second response time. 9/29 call placed 9:36 PM. Canceled 9:54 PM. 17 minute 38 second response time. 10/1 call placed 5:43 AM. Canceled 6:03 AM. 19 minute 26 second response time. Resident 131: 9/6 call placed 6:51 AM. Canceled 10:02 AM. 19 minutes 30 second response time. 9/10 call placed 7:19 PM. Canceled 7:36 PM. 16 minute 11 second response time. 10/2 call placed 9:26 PM. Canceled 9:43 PM. 17 minute 24 second response time. 10/4 call placed 8:55 AM. Canceled 9:12 AM. 17 minute 8 second response time. Resident 32: 9/23 call placed 12:45 PM. Canceled 1:01 PM. Response time 16 minutes 43 seconds. 9/8 call placed 6:16 PM. Canceled 7:03 PM. 46 minute 22 second response time. 9/9 call placed 9:11 AM. Canceled 9:33 AM. 21 minute 17 second response time. 9/9 call placed at 12:50 PM. Canceled and 1:27 PM. 36 minute 38 second response time. 9/10 call placed 10:49 AM. Canceled 11:08 AM. 18 minute 34 second response time. 9/11 call placed 5:44 AM. Canceled at 6:18 AM. 34 minute 7 second response time. 9/11 call placed 5:32 PM. Canceled 6:05 PM. 33 minute 1 second response time. 9/26 call placed 9:08 AM. Canceled at 9:24 AM. 16 minute 7 second response time. 9/29 call placed 1:48 PM. Canceled at 2:08 PM. 19 minute 59 second response time. 10/2 call placed 8:56 PM. Canceled at 9:44 PM. 47 minute 51 second response time. 10/4 call placed 6:12 AM. Canceled at 6:47 AM 35 minute 11 second response time. Resident 15 and Resident 49 Bathroom calls: 9/8 call placed 6:48 AM. Canceled 7:08 AM. 19 minute 31 second response time. 9/13 call placed 4:56 PM. Canceled 5:13 PM. 16 minute 45 second response time. 9/22 call placed 7:02 AM. Canceled 7:25 AM. 22 minutes 21 second response time. 10/1 call placed 7:17 AM. Canceled 7:37 AM. 19 minute 37 second response time. Resident 49 Room calls: 9/12 call placed 9:33 AM. Canceled 9:57 AM. 24 minute 39 second response time. 9/16 call placed 5:17 PM. Canceled 5:44 PM. 27 minute 30 second response time. 9/19 call placed 5:21 AM. Canceled 5:47 AM. 26 minute 44 second response time. 9/21 call placed 6:41 AM. Canceled 6:57 AM. 16 minute 48 second response time. 9/21 call placed 9:56 AM. Canceled 10:16 AM. 20 minute 4 second response time. 9/28 call placed 3:24 PM. Canceled 3:44 PM. 20 minute 13 second response time. 9/28 call placed 10:37 PM. Canceled 11:07 PM. 30 minute 9 second response time. Resident 15 Room calls: 9/4 call placed 9:06 PM. Canceled 9:36 PM. 30 minute 25 second response time. 9/6 call placed 8:49 PM. Canceled 9:10 PM. 20 minute 26 second response time. 9/9 call placed 11:30 AM. Canceled 11:52 AM. 21 minute 51 second response time. 9/9 call placed 4:59 PM. Canceled 5:28 PM. 29 minute 19 second response time. 9/12 call placed 8:21 PM. Canceled 8:37 PM. 16 minute 16 second response time. 9/12 call placed 9:26 PM. Canceled 9:47 PM. 21 minute 17 second response time. 9/13 call placed 10:12 AM. Canceled 10:29 AM. 17 minute 9 second response time. 9/16 call placed 10:49 AM. Canceled 11:07 AM. 17 minute 54 second response time. 9/23 call placed 5:07 PM. Canceled 5:23 PM. 16 minute 19 second response time. 9/23 call placed 9:20 PM. Canceled 9:40 PM. 20 minute 41 second response time. 9/25 call placed 5:02 AM. Canceled 5:19 AM. 17 minute 2 second response time. 9/28 call placed 3:46 PM. Canceled 4:09 PM. 23 minute 7 second response time. 9/30 call placed 7:39 PM. Canceled 8:00 PM. 20 minute 24 second response time. 10/2 call placed 9:37 PM. Canceled 9:59 PM. 22 minute 11 second response time. 10/3 call placed 11:04 AM. Canceled 11:22 AM. 17 minute 50 second response time. 10/4 call placed 5:11 PM. Canceled 5:33 PM. 21 minute 37 second response time. Resident 3 Bathroom calls: 9/12 call placed 8:33 PM. Canceled 8:54 PM. 21 minute 21 second response time. Room calls: 9/4 call placed 8:58 PM. Canceled 9:35 PM. 36 minute 49 second response time. 9/7 call placed 8:30 AM. Canceled 8:48 AM. 18 minute 9 second response time. 9/14 call placed 8:49 PM. Canceled 9:16 PM. 27 minute 13 second response time. 9/25 call placed 4:02 AM Canceled 4:19 AM. 17 minute 5 second response time. 10/3 call placed 9:36 PM. Canceled 9:54 PM. 18 minute 26 second response time. Resident 69 Bathroom calls: 9/4 call placed 7:45 PM. Canceled 8:04 PM. 18 minutes 59 second response time. 9/8 call placed 1:12 PM. Canceled 1:29 PM. 16 minute 52 second response time. 9/13 call placed 4:17 PM. Canceled 4:32 PM. 19 minute 5 second response time. 9/16 call placed 11:13 AM. Canceled 11:31 AM. 18 minute 12 second response time. 9/19 call placed 5:35 AM. Canceled 5:54 AM. 18 minute 36 second response time. 9/29 call placed 11:01 AM. Canceled 11:18 AM. 17 minute 14 second response time. 10/2 call placed 9:21 PM. Canceled 9:28 PM. 16 minute 46 second response time. Room calls: 9/6 call placed 9:18 AM. Canceled 9:36 AM. 18 minute 13 second response time. 9/6 call placed 7:28 PM. Canceled 7:55 PM. 27 minute 40 second response time. 9/7 call placed 5:39 AM. Canceled 6:01 AM. 22 minute 8 second response time. 9/8 call placed 5:16 AM. Canceled 5:54 AM. 38 minute 9 second response time. 9/9 call placed 6:46 AM. Canceled 7:14 AM. 27 minute 25 second response time. 9/9 call placed 9:12 AM. Canceled 9:30 AM. 18 minute 33 second response time. 9/9 call placed 11:14 AM. Canceled 11:38 AM. 24 minute 4 second response time. 9/12 call placed 9:22 PM. Canceled 9:40 PM. 17 minute 11 second response time. 9/13 call placed 6:56 PM. Canceled 7:24 PM. 27 minute 45 second response time. 9/16 call placed 10:54 AM. Canceled 11:0 AM. 15 minute 11 second response time. 9/17 call placed 5:50 AM. Canceled 6:07 AM. 16 minute 49 second response time. 9/18 call placed 4:35 AM. Canceled 4:53 AM. 17 minute 48 second response time. 9/18 call placed 4:50 PM. Canceled 5:07 PM. 16 minute 49 second response time. 9/18 call placed 11:55 PM. Canceled 12:10 AM. 15 minute 4 second response time. 9/22 call placed 7:06 AM. Canceled 7:24 AM. 17 minute 26 second response time. 9/23 call placed 9:06 AM. Canceled at 9:22 AM. 16 minute 28 second response time. 9/25 call placed 6:09 AM. Canceled 6:26 AM. 16 minute 13 second response time. 9/27 call placed 5:45 AM. Canceled 6:16 AM. 31 minute 16 second response time. 10/4 call placed 7:49 AM. Canceled 7:10 AM. 20 minute 24 second response time. Resident 70 Bathroom calls: 9/7 call placed 6:45 AM. Canceled 7:08 AM. 22 minute 59 second response time. 9/9 call placed 7:00 AM. Canceled 7:19 AM. 19 minute 41 second response time. 9/10 call placed 7:02 AM. Canceled 7:31 AM. 28 minute 42 second response time. 9/25 call placed 9:14 PM. Canceled 9:38 PM. 24 minute 22 second response time. 9/27 call placed 6:40 AM. Canceled 6:56 AM. 15 minute 22 second response time. 9/27 call placed 8:47 AM. Canceled 9:04 AM. 16 minute 59 second response time. 9/27 call placed 8:00 PM. Canceled 8:18 PM. 17 minute 15 second response time. 9/30 call placed 8:22 PM. Canceled 8:40 PM. 18 minute 4 second response time. Room calls: 9/5 call placed 7:49 PM. Canceled 8:04 PM. 15 minute 12 second response time. 9/9 call placed 7:17 PM. Canceled 1:37 PM. 19 minute 56 second response time. 9/13 call placed 7:50 PM. Canceled 8:28 PM. 38 minute 14 second response time. 9/18 call placed 8:08 PM. Canceled 8:26 PM. 18 minute 4 second response time. 9/19 call placed 7:48 PM. Canceled 8:08 PM. 20 minute 4 second response time. 9/21 call placed 4:05 PM. Canceled 4:24 PM. 19 minute 36 second response time 9/21 call placed 7:57 PM. Canceled 8:23 PM. 25 minute 25 second response time. 9/23 call placed 7:40 PM. Canceled 7:57 PM. 16 minute 56 second response time. 9/25 call placed 12:40 PM. Canceled 12:59 PM. 18 minute 19 second response time. 9/25 call placed 2:27 PM. Canceled 2:46 PM. 18 minute 24 second response time. 9/25 call placed 7:58 PM. Canceled 8:48 PM. 50 minute 2 second response time. 9/28 call placed 8:39 PM. Canceled at 9:00 PM. 20 minute 20 second response time. 9/29 call placed 8:02 PM. Canceled 8:19 PM. 16 minute 15 second response time. 10/1 call placed 7:50 PM. Canceled 8:30 PM. 39 minute 41 second response time. Resident 45: Bathroom calls: 9/4 call placed 12:50 PM. Canceled 1:14 PM. 23 minute 26 second response time. 9/5 call placed 11:48 PM. Canceled 12:13 AM. 24 minute 54 second response time. 9/7 call placed 5:46 AM. Canceled 6:13 AM. 26 minute 59 second response time. 9/7 call placed 6:32 AM. Canceled 7:06 AM. 33 minute 55 second response time. 9/9 call placed 6:54 AM. Canceled 7:13 AM. 18 minute 38 second response time. 9/9 call placed 7:24 AM. Canceled 7:40 AM. 15 minute 50 second response time. 9/9 call placed 2:37 PM. Canceled 3:03 PM. 25 minute 55 second response time. 9/10 call placed 9:17 AM. Canceled 9:35 AM. 17 minute 51 second response time. 9/11 call placed 6:56 PM. Canceled 7:12 PM. 15 minute 27 second response time. 9/19 call placed 6:17 AM. Canceled 6:48 AM. 30 minute 23 second response time. 9/20 call placed 6:51 PM. Canceled 7:13 PM. 21 minute 50 second response time. 9/22 call placed 7:24 AM. Canceled 7:41 AM. 16 minute 53 second response time. 9/25 call placed 1:45 PM. Canceled 2:03 PM. 18 minute 2 second response time. 10/1 call placed 6:49 AM. Canceled 7:15 AM. 26 minute 14 second response time. Room calls: 9/4 call placed 6:29 AM. Canceled 6:45 AM. 16 minute 55 second response time. 9/8 call placed 7:04 PM. Canceled 7:38 PM. 34 minute 30 second response time. 9/9 call placed 10:49 AM. Canceled 11:09 AM. 20 minute 4 second response time. 9/9 call placed 7:12 PM. Canceled 7:32 PM. 19 minute 25 second response time. 9/13 call placed 7:12 PM. Canceled 7:40 PM. 28 minute 35 second response time. 9/14 call placed 7:59 PM. Canceled 8:23 PM. 24 minute 18 second response time. 9/16 call placed 10:50 AM. Canceled 11:06 AM. 16 minute 13 second response time. 9/17 call placed 11:41 AM. Canceled 12:01 PM. 20 minute 33 second response time. 9/18 call placed 6:59 AM. Canceled 7:20 AM. 21 minute 24 second response time. 9/18 call placed 5:19 PM. Canceled 5:36 PM. 17 minute 25 second response time. 9/19 call placed 5:27 AM. Canceled 6:13 AM. 45 minute 21 second response time. 9/20 call placed 7:14 AM. Canceled 7:41 AM. 26 minute 14 second response time. 9/20 call placed 11:13 AM. Canceled 11:44 AM. 31 minute 28 second response time. 9/21 call placed 7:21 PM. Canceled 7:40 PM. 18 minute 46 second response time. 9/22 call placed 7:45 PM. Canceled 8:05 PM. 20 minute 3 second response time. 9/23 call placed 4:59 PM. Canceled 5:17 PM. 17 minute 29 second response time. 9/25 call placed 11:25 AM. Canceled 11:43 AM. 18 minute 2 second response time. 9/27 call placed 7:02 AM. Canceled 7:38 AM. 36 minute 14 second response time. 9/28 call placed 7:00 AM. Canceled 7:39 AM. 39 minute 19 second response time. 9/29 call placed 4:24 PM. Canceled 4:43 PM. 18 minute 39 second response time. 9/30 call placed 6:33 AM. Canceled 6:50 AM. 17 minute 2 second response time. 9/30 call placed 4:14 PM. Canceled 4:31 PM. 17 minute 16 second response time. 10/2 call placed 6:59 PM. Canceled 7:18 PM. 19 minute 6 second response time. 10/2 call placed 7:34 PM. Canceled 7:50 PM. 16 minute 16 second response time. Resident 58: 9/24 call placed 1:50 PM. Canceled 2:10 PM. 20 minute 3 second response time. 9/21 call placed 4:05 PM. Canceled 4:40 PM. 34 minute 32 second response time. 9/21 call placed 7:35 PM. Canceled 8:12 PM. 36 minute 53 second response time. 9/22 call placed 10:00 AM. Canceled 10:18 AM. 18 minute 40 second response time. 9/22 call placed 6:30 PM. Canceled 6:58 PM. 28 minute 39 second response time. 9/26 call placed 11:09 AM. Canceled 11:26 AM. 17 minute 25 second response time. 9/26 call placed 9:07 PM. Canceled 9:26 PM. 18 minute 40 second response time. 9/27 call placed 7:09 PM. Canceled 7:30 PM. 21 minute 41 second response time. Resident 12 and Resident 4 Bathroom calls: 9/9 call placed 7:25 AM. Canceled 7:43 AM. 18 minute 24 second response time. 9/21 call placed 3:09 PM. Canceled 3:30 PM. 21 minute 18 second response time. 9/27 call placed 7:14 PM. Canceled 7:34 PM. 20 minute 8 second response time. Resident 12 Room calls: 9/4 call placed 5:47 PM. Canceled 6:03 AM. 15 minute 36 second response time. 9/4 call placed 9:37 PM. Canceled 10:00 PM. 23 minute 11 second response time. 9/7 call placed 10:18 PM. Canceled 10:41 PM. 22 minute 29 second response time. 9/9 call placed 4:49 PM. Canceled 5:08 PM. 18 minute 50 second response time. 9/9 call placed 7:59 PM. Canceled 8:16 PM. 16 minute 19 second response time. 9/13 call placed 8:47 PM. Canceled 9:08 PM. 20 minute 44 second response time. 9/14 call placed 2:18 PM. Canceled 2:39 PM. 21 minute 36 second response time. 9/14 call placed 8:13 PM. Canceled 8:43 PM. 29 minute 24 second response time. 9/15 call placed 11:01 AM. Canceled 11:21 Am. 20 minute 16 second response time. 9/17 call placed 5:04 PM. Canceled 5:21 PM. 17 minute 20 second response time. 9/17 call placed 9:29 PM. Canceled 9:46 PM. 16 minute 13 second response time. 9/20 call placed 9:35 AM. Canceled 9:5 Am. 16 minute 25 second response time. 9/20 call placed 10:08 AM. Canceled 10:27 AM. 18 minute 59 second response time. 9/20 call placed 10:16 PM. Canceled 10:34 PM. 17 minute 45 second response time. 9/25 call placed 2:02 PM. Canceled 2:21 PM. 19 minute 12 second response time. 9/26 call placed 7:34 PM. Canceled 7:56 PM. 22 minute 33 second response time. 9/27 call placed 6:01 AM. Canceled 6:24 AM. 23 minute 37 second response time. 9/28 call placed 3:54 PM. Canceled 9:22 PM. 25 minute 32 second response time. 9/28 call placed 10:33 PM. Canceled 10:54 PM. 21 minute 17 second response time. 10/2 call placed 9:17 PM. Canceled 9:35 PM. 18 minute 29 second response time. 10/2 call placed 9:40 PM. Canceled 9:57 PM. 17 minute 11 second response time. 10/3 call placed 6:25 AM. Canceled 6:43 Am. 18 minute 3 second response time. 10/4 call placed 7:18 AM. Canceled 7:40 Am. 22 minute 22 second response time. Resident 4 Room calls: 9/4 call placed 7:42 AM. Canceled 7:58 AM. 16 minute 5 second response time. 9/4 call placed 8:46 PM. Canceled 9:19 PM. 33 minute 9 second response time. 9/7 call placed 6:31 Am. Canceled 6:53 AM. 22 minute 21 second response time. 9/8 call placed 5:43 AM. Canceled 6:00 AM. 17 minute 39 second response time. 9/9 call placed 7:56 PM. Canceled 8:16 PM. 20 minute 1 second response time. 9/10 call placed 11:25 AM. Canceled 11:41 AM. 16 minute 3 second response time. 9/12 call placed 9:22 AM. Canceled 9:47 AM. 25 minute 8 second response time. 9/12 call placed 8:41 PM. Canceled 9:10 PM. 29 minute 6 second response time. 9/13 call placed 6:51 AM. Canceled 7:13 AM. 22 minute 7 second response time. 9/14 call placed 2:18 PM. Canceled 2:39 PM. 20 minute 58 second response time. 9/14 call placed 8:19 PM. Canceled 8:43 PM. 23 minute 60 second response time. 9/15 call placed 11:02 AM. Canceled 11:22 AM. 20 minute 16 second response time. 9/15 call placed 1:15 PM. Canceled 1:48 PM. 32 minute 44 second response time. 9/16 call placed 6:53 AM. Canceled 7:19 AM. 26 minute 3 second response time. 9/16 call placed 7:53 PM. Canceled 8:10 PM. 16 minute 48 second response time. 9/16 call placed 8:33 PM. Canceled 8:58 PM. 24 minute 39 second response time. 9/20 call placed 8:59 PM. Canceled 9:31 PM. 31 minute 49 second response time. 9/23 call placed 7:14 AM. Canceled 7:37 AM. 23 minute 2 second response time. 9/23 call placed 1:29 PM. Canceled 1:48 PM. 19 minute 2 second response time. 9/25 call placed 9:59 AM. Canceled 10:22 AM. 22 minute 46 second response time. 9/25 call placed 2:57 PM. Canceled 3:14 PM. 16 minute 34 second response time. 9/27 call placed 4:46 PM. Canceled 5:14 PM. 28 minute 5 second response time. 9/27 call placed 7:53 PM. Canceled 8:18 PM. 24 minute 20 second response time. 9/29 call placed 1:14 PM. Canceled 1:34 PM. 19 minute 44 second response time. 10/1 call placed 7:13 PM. Canceled 7:30 PM. 16 minute 33 second response time. 10/2 call placed 9:03 PM. Canceled 9:25 PM. 21 minute 27 second response time. 10/3 call placed 6:55 AM. Canceled 7:34 AM. 39 minute 4 second response time. 10/3 call placed 7:45 PM. Canceled 8:10 PM. 25 minute 31 second response time. 10/4 call placed 3:17 PM. Canceled 3:35 PM. 18 minute 0 second response time . Review of the facility policy Call Light dated (MONTH) 2012 revealed the following: Respond to requests as soon as possible. Record review from the Resident Group meeting minutes of 5/9/18 at 1:30 PM revealed the following residents ( Resident 14, 44, 4,5, and 21) were at the meeting and identified concerns regarding that there was not enough staff to assist residents. Resident Counsel meeting was held 10/3/18 at 11:00 AM and revealed that the following residents (Resident 35, 5, 12, 14, 47, and 40) were in attendance. When asked, do you get the help and care you need without waiting a long time and does staff respond to your call light timely, 6 residents (Resident 5, 12, 14, 35, 40 and 47) no, the nursing home does not have enough staff to take care of us, and our call lights go on for a long time. Interview on 10/03/18 at 12:24 PM with Resident (47) revealed there are times in the evening that there is not enough staff and the residents are the ones that end up not getting the help they need when they need it. Resident (47) revealed this resident, sat on the toilet for over 40 minutes last evening with the bathroom call light on, the resident had cell phone in pocket, so took it out and called facility number, asked for the residents' nurse and explained the situation at which time, staff showed up and assisted off the toilet. This resident also revealed that if the resident isn't ready to be put to bed by 8:00 PM then the nursing staff will be there to put the resident into bed about 10:30 or 11:00 PM.",2020-09-01
349,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,804,E,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interview, and record review; the facility failed to provide food that was maintained at safe temperatures and palatable. This had the potential to affect the 35 residents who were served food from the 100 unit dining room. The facility identified a census of 86 at the time of survey. Findings are: [NAME] Interview with Resident 3 on 10/02/18 at 11:32 AM revealed the food was not palatable. B. Observation on 10/03/18 at 11:49 PM revealed the steam table being set up for serving of the 100 Unit Dining Room. Items were placed on the steam table in pans and then covered with lids. Observation on 10/03/18 at 12:08 PM the first plate was served in the 100 Unit Dining Room On 10/03/18 at 1:04 PM a test tray was obtained due to complaints from residents regarding the food not being appetizing. Temperature on the test tray was the following: -Steak temp was 122 degrees F (Fahrenheit); -Vegetable temp was 127.2 F; -Potatoes temp was 141.3 F. -Flavor of the meat was bland and cold. - The vegetables were bland and cold.",2020-09-01
350,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,812,F,0,1,JW4S11,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11C Based on observation and interview the facility failed to store and label food items of vegetables and meat in the walk in refrigerator. This had the potential to affect all 86 residents who eat from the kitchen. The facility census was 86. Finds are: Observation on 10/01/18 at 11:38 AM revealed in the walk in refrigerator a clear plastic bag that contained green peppers was not marked with the date the green peppers were opened. A clear plastic bag of shredded carrots was not marked with the date the carrots were opened. A package of ham, in a plastic bag that was opened and then covered with Saran Wrap was noted dated with the open date. These items not marked with the open date had the potential for foodborne illnesses. Interview on 10/01/18 at 1:07 PM with the FSS (Food Service Supervisor) revealed and confirmed that the bag of green peppers and the bag of carrots were not market and dated. The package of ham in a plastic bag that was opened and then covered with Saran Wrap was noted market or dated with the open date.",2020-09-01
351,GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE,285072,926 EAST E STREET,HASTINGS,NE,68901,2018-10-04,880,E,0,1,JW4S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, interview, and record review; the facility staff failed to handle laundry, clean lifts between residents, perform hand hygiene, and perform catheter care to prevent potential cross contamination. This had the potential to affected 3 residents (Resident 131, 13, and 15) and had the potential to affect the 35 residents who resided on the 100 unit and the 36 residents who resided on the 200 unit. The facility identified a census of 86 at the time of survey. Findings are: [NAME] Observation of LA-A (Laundry Assistant) on 10/03/18 at 10:46 AM revealed they were pushing a cart of linen down a wing on the 100 unit. The cart cover was on top of the cart and the laundry was exposed. LA-A retrieved a bunch of clothes off the cart and slung them over their shoulder and walked into Resident 131's room. The clothes were touching LA-A's T-shirt. B. Observation of NA-B (Nurse Aide) providing catheter care for Resident 13 on 10/03/18 at 10:13 AM revealed the following: NA-B had gloves on and used a wash cloth to wipe the perineum. NA-B wiped the perineum first then wiped the meatus at the catheter insertion site using the same washcloth without turning after washing the perineum. NA-B then placed the soiled cloth on the over the bed table where Resident 13's water pitcher was sitting. NA-B wiped Resident 13's back side with a different washcloth, then used the same gloved hands to pull up their brief and pants. NA-B then used the same gloved hand to open the drawer and put the peri wash away. NA-B then tossed the washcloths on the floor by the closet door uncontained. NA-B removed their gloves, donned new gloves and emptied the catheter bag into a graduate that they had set on the bare floor. NA-I removed their gloves then went out into the hall and got the lift. NA-B removed their gloves and ran the lift. Neither NA-I or NA-B performed hand hygiene after removing their gloves before touching the lift. At 10:23 AM NA-B pushed the lift out into the hall after they used it to transfer Resident 13 from the bed to the wheelchair. At 10:24 AM NA-B was observed taking the trash out. Both NA-B and NA-I left the room and did not wash the over the bed table where the soiled washcloths had been and they left the lift in the hall on the unit without cleaning it. They also left the soiled washcloths on the floor in Resident 13's room and left the unit. They both walked off the hall and did not clean the lift or the over the bed table. Resident 13's water pitcher was still sitting on the table. The soiled washcloths were still on the floor. C. On 10/03/18 at 10:38 AM observation of NA-F assisting Resident 15 with toileting revealed the following: NA-F used the sit to stand lift to assist Resident 15 onto the toilet. Resident 15 was observed holding on to the lift during the transfer. After the transfer with the lift, NA-F pushed the lift out into the hall and left it there without cleaning it. Interview with the ICC (Infection Control Coordinator) on 10/04/18 at 9:31 AM revealed the following: The ICC confirmed the lifts were used for multiple residents. The staff were supposed to wipe them off between residents using the antimicrobial wipes. It was the ICC expectation that during catheter care the nursing staff would wash from clean to dirty; not the opposite. The nursing staff were supposed to take a bag and put the dirty washcloths in it and not store them on the table and the floor. The ICC revealed hand hygiene was expected after hands and gloves were soiled. Interview with the DON (Director of Nursing) on 10/04/18 at 10:19 AM revealed clothing was to be covered during transport. Laundry staff were not to touch the resident personal clothing to their own clothing. Soiled laundry should not have been taken out of a resident's room and placed on the clean laundry cart. Review of the facility policy Laundering and Drying Clothes and Linens revised 1/18 revealed the following: Following appropriate laundry procedures promotes the useful life of the materials and machines used in the process; helps to protect the health and well-being of residents. Review of the facility policy Perineal Care revised 10/2017 revealed the following: Perform hand hygiene and put on gloves. If additional supplies are needed during perineal care, remember to remove soiled gloves. Wash hands or use hand sanitizer before touching objects in environment. Begin at meatus and wash in a circular motion toward the (body). With a new washcloth, remake mitt and rinse area just washed. Place used washcloths in the hamper or plastic bag. Review of the facility policy Mobility Support and Positioning: Mobility revised 10/2017 revealed the following: Clean the lift after use. Review of the facility policy Catheter Care revised 10/2017 revealed the following: Cleanse around meatus toward (body) with one stroke. Then cleanse for four inches down the catheter. D. An observation of the laundry staff on 10/3/18 at 10:22 AM revealed the laundry staff holding personal laundry next to their body and had clean clothing over their shoulder, on hangers, prior to putting them in the resident's closet. Interview with ICC (INFECTION CONTROL COORDINATOR) on 10/04/18 at 10:28 AM revealed that the laundry personnel have all been trained and continued to be trained yearly not to put personal laundry, against the laundry staff clothing, and should not place over shoulder to go in and put it in the residents' closet. E. Observation on 10/2/18 at 10:34 AM on the 200 hallway, revealed LA-A (Laundry Assistant) delivering clean laundry on hangers with no plastic or draping over the clothing into a room with the clothing draped over the staff person's shoulder. Clothing was also being delivered to another room with the laundry coming into contact of the staff persons clothing. F. Observation on 10/03/18 at 11:15 AM of LA-A on the 100 hallway, revealed the protective cover was up on the linen cart with LA-A going from room to room. Observation was made of the LA-A taking a blanket from another staff person who came from a room with the blanket and stated that the resident in that room wanted it washed. LA-A then placed the blanket on the bottom of the clean linen cart instead of placing the blanket in the dirty linen. This caused a potential for cross contamination during the handling of linen. LA-A continued to deliver clean laundry to the residents without washing hands with soap and water or using hand sanitizer. Clothing was then taken to rooms and being carried in the LA-A's hands.",2020-09-01
352,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,609,E,0,1,U2PS11,"Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to send completed investigations to the required State Agency within 5 working days for 6 (Residents 9, 29, 17, 11, 83 and 84) of 7 sampled residents. The facility census was 30. Findings are: [NAME] Review of the Facility Abuse/Neglect Policy (undated) revealed the following: -identification of abuse occurred when there was as a reason to suspect or believe abuse had occurred, an allegation of abuse had been made or conditions were present that could result in abuse or neglect; -steps were to be taken to protect individuals; -the Administrator was to be notified; -an internal investigation was to be initiated; -Adult Protective Services (APS) to be called within 2 hours if an injury or within 24 hours if no injury; and -the completed investigation was to be submitted to the State Agency within 5 working days. B. Review of a Nursing Progress Note dated 6/26/19 revealed at 11:30 PM Resident 11's fall alarm was heard sounding and the resident was found lying on the floor on the resident's right side, next to the resident's bed. The resident voiced a complaint of right shoulder pain with range of motion. In addition, the resident was identified as having a 1.5 centimeter (cm) raised hematoma which measured 5 cm by 5 cm to the resident's right upper temple; Review of Resident 11's Nursing Progress Notes dated 6/27/19 revealed the following: -4:37 AM the resident continued to complain of pain to the right shoulder and stated, It hurts to move; and -5:08 AM the resident indicated the resident's right shoulder hurt really bad. Review of a Nursing Progress Note dated 6/28/19 at 5:17 PM revealed the resident was seen by the practitioner and an x-ray was completed. Review of an x-ray report dated 6/28/19 revealed a distal clavicle (collarbone) fracture as well as fractures to the right 7th and 8th ribs. Review of the facility investigations of potential abuse/neglect from 11/19/18 to 6/30/19 revealed no report had been filed to the State Agency regarding a potential allegation of abuse/neglect related to a fall with a significant injury for Resident 11. C. Review of a Facility Investigation Report dated 10/31/19 revealed the following: -on 10/20/19 at 9:15 AM, Resident 83 had told Resident 9 to get out of the way and then kicked Resident 9; -the residents were immediately separated and Resident 83 was redirected to the resident's room; and -APS were called on 10/21/19. Further review of the Facility Investigation Report revealed a Facsimile (Fax) Cover Sheet was attached to the investigation and which identified the report had been sent to the State Agency on 11/6/2019 (15 days later) at 11:38 AM. D. During an interview on 1/27/20 at 1:59 PM, the Administrator verified Resident 11's fall with significant injury had not been reported to the State Agency and the resident to resident altercation between Resident 9 and 83 had not been sent to the State Agency within the required time frame. E. Review of Resident 84's Progress Note dated 4/11/19 at 7:07 PM revealed Resident 29 hit Resident 84 on the hand for no apparent reason. Resident 29 moved away, and then returned and hit Resident 84's hand two more times. Resident 84 reported the incident to a Nurse Aide. The Nurse Aide reported the altercation to the Charge Nurse. The Charge Nurse assessed Resident 84 for injury and no injury was identified. An intervention was implemented to separate Resident 29 and Resident 84 by at least 5 feet for 24 hours and monitor for any additional problems. F. Review of Resident 29's Progress Note dated 4/11/19 at 7:07 PM revealed Resident 29 hit Resident 84 on the hand for no apparent reason. Resident 29 moved away, and then returned and hit Resident 84's hand two more times. Resident 84 reported the incident to a Nurse Aide. The Nurse Aid reported the altercation to the Charge Nurse. The Charge Nurse assessed Resident 84 for injury and no injury was identified. An intervention was implemented to separate Resident 29 and Resident 84 by at least 5 feet for 24 hours and monitor for any additional problems. Review of the facility investigations of potential abuse/neglect from 4/11/19 to 1/28/20 revealed no completed report had been filed to the State Agency within 5 working days as required. Interview with the facility Administrator on 1/28/20 at 9:26 AM confirmed the facility failed to submit a completed report of Resident 29 and Resident 84's altercation to the State Agency within 5 working days. [NAME] Review of a Nursing Progress Note dated 9/20/19 revealed at 2:45 AM, Resident 17 was heard yelling out for help and the resident was found sitting on the floor, with blood on the resident's pajamas, the corner of the bed and on the floor. The resident had a 4 cm x 4 cm x 1 cm gash to the forehead and an abrasion to the left shoulder. The resident reported striking head and felt dizzy. Additionally, the resident was identified as being confused after the fall. The practitioner was notified and gave an order to transfer the resident to the hospital. Review of a Nursing Progress Note dated 9/20/19 at 3:05 AM revealed the Administrator was notified of Resident 17's fall and transfer to the hospital. Review of a Nursing Progress Note dated 9/20/19 at 5:38 AM revealed the resident returned to the facility with sutures (stitches) and a dressing (a covering over a wound) to the forehead. Review of a Facility Investigation Report dated 9/20/19 revealed no evidence APS had been notified and no report was sent to the State Agency regarding a potential allegation of abuse/neglect related to a fall with a significant injury for Resident 17. During an interview on 01/27/20 at 11:19 AM, the Administrator confirmed Resident 17's fall with significant injury had not been reported to the State Agency.",2020-09-01
353,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,610,E,0,1,U2PS11,"**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 complete an investigation related to a fall with significant injuries for Resident 11 and for a resident to resident altercation for Resident's 29 and 84. The sample size was 7 and the facility census was 30. Findings are: [NAME] Review of the Facility Abuse/Neglect Policy (undated) revealed the following: -identification of abuse occurred when there was as a reason to suspect or believe abuse had occurred, an allegation of abuse had been made or conditions were present that could result in abuse or neglect; -steps were to be taken to protect individuals; -the Administrator was to be notified; and -an internal investigation was to be initiated. B. Review of Resident 11's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/1/19 revealed the following related to Resident 1: -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene; -always incontinent of urine and frequently involuntary of bowel and -had 1 fall with no injury and 2 or more falls with injury (except major) since the previous assessment. Review of a Nursing Progress Note dated 6/26/19 revealed at 11:30 PM Resident 11's fall alarm was heard sounding and the resident was found lying on the floor on the resident's right side, next to the resident's bed. The resident voiced a complaint of right shoulder pain with range of motion. In addition, the resident was identified as having a 1.5 centimeter (cm) raised hematoma which measured 5 cm by 5 cm to the resident's right upper temple; Review of Resident 11's Nursing Progress Notes dated 6/27/19 revealed the following: -4:37 AM the resident continued to complain of pain to the right shoulder and stated, It hurts to move; and -5:08 AM the resident indicated the resident's right shoulder hurt really bad. Review of a Nursing Progress Note dated 6/28/19 at 5:17 PM revealed the resident was seen by the practitioner for continued complaints of right shoulder pain and x-rays were completed. Review of an x-ray report dated 6/28/19 revealed a distal clavicle (collarbone) fracture as well as fractures to the right 7th and 8th ribs. Review of the facility investigations of potential abuse/neglect from 11/19/18 to 6/30/19 revealed no investigation was completed regarding Resident 11's fall with a significant injury. During an interview on 1/27/20 at 1:59 PM, the facility Administrator verified Resident 11's fall with significant injury was not investigated as a potential allegation of abuse/neglect and had not been reported to the State Agency. C. Review of Resident 84's MDS dated [DATE] revealed Resident 84 had -no cognitive impairment, -no documented behaviors, and -[DIAGNOSES REDACTED]. Review of Resident 84's Progress Note dated 4/11/19 at 7:07 PM revealed Resident 29 hit Resident 84 on the hand for no apparent reason, Resident 29 moved away, and then returned and hit Resident 84's hand two more times. Resident 84 reported the incident to a Nurse Aide. The Nurse Aide reported the altercation to the Charge Nurse. The Charge Nurse assessed Resident 84 for injury and no injury was identified. An intervention was implemented to separate Resident 29 and Resident 84 by at least 5 feet for 24 hours and monitor for any additional problems. D. Review of Resident 29's MDS dated [DATE] revealed Resident 29 had -severe cognitive impairment, -no documented behaviors, -and [DIAGNOSES REDACTED]. Review of Resident 29's Progress Note dated 4/11/19 at 7:07 PM revealed Resident 29 hit Resident 84 on the hand for no apparent reason, Resident 29 moved away, and then returned and hit Resident 84's hand two more times. Resident 84 reported the incident a Nurse Aide. The Nurse Aide reported the altercation to the Charge Nurse. The Charge nurse assessed Resident 84 for injury and no injury was identified. An intervention was implemented to separate Resident 29 and Resident 84 by at least 5 feet for 24 hours and monitor for any additional problems. Review of the facility investigations of potential abuse/neglect from 4/11/19 to 1/28/20 revealed that no internal investigation had been conducted or completed. Interview with the facility Administrator on 1/28/20 at 9:26 AM confirmed the facility failed to conduct or complete the investigation.",2020-09-01
354,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,684,D,0,1,U2PS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D2 Based on observation, interview, and record review; the facility failed to provide ongoing monitoring and to develop and/or implement interventions to prevent ongoing skin breakdown for Resident 20. The sample size was 2 and the facility census was 30. Findings are: Review of Resident 20's current undated Care Plan revealed the resident was at risk for skin breakdown related to impaired mobility, urinary incontinence, and chronic [MEDICAL CONDITION]. Interventions included: - Apply skin barrier as needed for redness or possible breakdown and inform the nurse if any redness/breakdown was observed. - Monitor [MEDICAL CONDITION] to bilateral lower extremities and inform the physician as needed if [MEDICAL CONDITION] worsened. - Pressure relieving mattress to bed. - Skin was to be assessed daily with cares and weekly by professional nursing staff. Notify the physician as needed for any new skin issues. - The resident transferred with extensive assist of 1-2 with either a pivot transfer or use of a mechanical lift. - The resident wore glasses. Provide 1 assist with glasses as needed and ensure they are clean and in good repair. - Monitor the open area to the back of the right ear until healed and then discontinue. (There was no evidence to indicate any preventative interventions were identified to prevent recurrence) Review of Resident 20's Progress Note dated 10/31/19 revealed the resident had three new skin issues to the backside of the resident's right ear. The biggest area was a superficial open area that measured 0.9 centimeters (cm) by 0.6 cm. This area was pink/red in color. The two other areas were scabbed areas that measured 0.3 cm by 0.3 cm and 0.4 cm by 0.3 cm. These were all in areas that could have been irritated by the resident's glasses if the resident's ear was pressed against the ear piece of the glasses. The resident stated that the right ear was sore. Review of Resident 20's Treatment Administration Record dated 11/2019 and Skin Observation Tools dated 10/2/19 to 1/2/20 revealed no evidence to indicate Resident 20's wounds from 10/31/19 had ongoing monitoring. Review of Resident 20's Progress Note dated 1/2/20 revealed the resident had obtained a 2.4 cm by 1.1 cm open area to the back of the right ear. The area appeared it have been from the bow on the resident's glasses. The area had some serosanguinous drainage (discharge that contained both blood and a clear yellow liquid). Observation of Resident 20 on 1/28/20 at 8:05 AM revealed the resident still had a scabbed area to the back of the right ear with redness/irritation around it. The resident's glasses were currently on. Interview with Registered Nurse (RN) -A on 1/27/20 at 9:21 AM confirmed the resident continued to have scabbed areas to the back of the right ear. RN-A confirmed no changes had been made since the skin breakdown to prevent potential recurrence. Interview with RN-H on 1/27/20 at 9:43 AM confirmed the resident had trouble with open areas behind the right ear from the resident's glasses. RN-H stated the resident did at times sleep with the glasses on and felt the areas may have been caused by shearing when the glasses were removed after having slept on them. Interview on 1/27/20 at 10:11 AM with the Director of Nursing (DON) confirmed any information related to a new skin issue would be in either the Skin Observation Tools or in a Progress Note. The DON confirmed there was no evidence that the facility had taken any action to prevent recurrent skin breakdown for Resident 20 related to the resident's glasses.",2020-09-01
355,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,686,D,0,1,U2PS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and interviews; the facility failed to provide the necessary care and monitoring to promote healing of pressure ulcers for Resident 28. The total sample size was 1 and the facility census was 30. Findings are: [NAME] Review of the facility policy Pressure Ulcers/Skin Breakdown (revised 4/18) revealed the nursing staff were to assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the following was to be documented: -full assessment including location, stage, length, width, depth and the presence of drainage or necrotic (dead) tissue; -active diagnoses; -pain assessment; -mobility status; and -current treatments. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/30/20 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene; and the resident had two Stage I (Staging system is a method of summarizing characteristics of pressure ulcers, including the extent of tissue damage. Stage I refers to intact skin with non-blanchable redness (redness does not fade when skin is pressed) of a localized area usually over a bony prominence) pressure ulcers and one Stage II (partial skin loss that presents as an abrasion, blister or shallow crater) pressure ulcer. Review of a Nurses' Admission assessment dated [DATE] at 12:15 PM revealed the resident was admitted from the hospital with the following areas of skin breakdown: -redness to the right shoulder blade (no assessment/documentation regarding the length or the width of the area); -purple/red discoloration to the coccyx (no assessment/documentation regarding the length or the width of the area); and -1 centimeter (cm) by 1 cm open area to the left buttock. Review of a Skin Observation Tool dated 12/27/19 at 5:56 AM revealed the following areas of skin breakdown: -coccyx with pressure area (no assessment was documented regarding the stage, length, width, depth or presence of drainage of the ulcer); -left buttock with a 1 cm by 1 cm skin tear; and -area to the resident's right shoulder is now identified as a rash. Review of a Physician Communication Form facsimile (fax) dated 12/30/19 at 10:30 AM revealed the resident's physician was notified the resident had 3 open areas to the resident's left buttock. The skin surrounding the open areas was identified as a blanchable redness which measured 5 cm by 3 cm. The 3 open areas measured 1 cm by 0.5 cm, 0.1 cm by 0.2 cm and 0.6 cm by 0.4 cm. The note indicated the staff were covering these areas with a [MEDICATION NAME] dressing (absorbs drainage and maintains a moist wound-healing environment). In addition, the resident had a 4.5 cm by 2.5 cm blanchable redness to the right buttock. A new order was identified for [MEDICATION NAME] cream (moisture barrier) to the areas. Review of a Weekly Skin Assessment Progress Note dated 1/3/20 at 10:33 AM revealed a 5 cm by 3 cm pink area to the left buttock with 4 open areas. The upper/inner left buttock had smaller areas which appeared to have joined together to form a 2 by 2.2 cm area. In addition, the upper/outer left buttock open area measured .5 cm by .5 cm, the middle/outer left buttock open area measured .4 cm by .3 cm and the lower/outer left buttock area measured .4 cm by .6 cm. The large red area to the right buttock was now pink. The skin was dry and now had a .6 cm slit. Review of a Nutrition/Dietary Note dated 1/6/20 (11 days after the resident's pressure ulcers were first identified) at 3:08 PM revealed a recommendation for [MEDICATION NAME] (nutritional supplement with increased vitamins and proteins for wound healing) 240 cubic centimeters (cc) daily to help with wounds. Review of the resident's current Care Plan with revision date 1/7/20 revealed the resident had actual impaired skin integrity with two Stage II and one Stage I pressure ulcers to the resident's left buttock. The following interventions were identified: -administer [MEDICATION NAME] per physician's order to promote healing; -apply [MEDICATION NAME] to right buttock as ordered; -apply [MEDICATION NAME] dressing to left buttock twice a week and as needed until areas resolved; -weekly documentation to include measurements of each area of skin breakdown with width, length, depth, type of tissue and exudate; -pressure relieving mattress to bed; and -pressure relieving cushion to recliner. Review of a Skin Observation Tool dated 1/16/20 (10 days since the previous assessment) at 10:15 AM revealed the following regarding the resident's areas of skin breakdown: -right buttock redness which measured 4.5 cm by 2.5 cm; -left buttock redness which measured 6 cm by 2.5 cm; -left buttock Stage II pressure ulcer which measured 0.8 cm by 0.5 cm; -left buttock Stage II pressure ulcer which measured 1.5 cm by 1 cm; and -left buttock Stage II pressure ulcer which measured 1 cm by 0.9 cm. Review of a Skin Observation Tool dated 1/23/20 at 12:42 PM revealed the following regarding the resident's skin breakdown: -right buttock pink area which measured 5 cm by 2.5 cm; -left buttock redness which measured 5.5 cm by 3 cm; -left buttock Stage II pressure ulcer which measured 0.7 cm by 0.3 cm with a depth of 0.1 cm; and -left buttock Stage II pressure ulcer which measured 1.2 cm by 1 cm with a depth of 0.1 cm During an observation of a treatment on 1/27/20 from 10:15 AM until 10:25 AM, Registered Nurse (RN)-A assisted the resident to stand from the bath chair. Resident 28 was observed to have three Stage II pressure ulcers to the resident's left buttock. RN-A indicated 2 of the areas had now merged into one larger area. RN-A used a 2 cm by 2 cm square of gauze and patted the areas with normal saline and then applied a [MEDICATION NAME] dressing which covered all of the areas. The skin to the resident's coccyx and bilateral buttocks had a purple/reddish discoloration which was non-blanchable and was scaly and dry in appearance. The resident identified the areas were painful especially when seated in the dining room or when using exercise equipment. During an interview on 1/27/20 at 10:30 AM, RN-A confirmed the following: -the pressure ulcers to the resident's buttock/coccyx area were not present on admission and have been identified as facility acquired; -staff should complete a weekly assessment of the resident's skin breakdown and the areas should be Staged and measured so that the staff can determine if the areas are healing; -the Registered Dietician should have been notified when the pressure ulcers were first identified so that a nutritional intervention could be initiated; and -the resident's physician should have been notified whenever there was a change or a decline in the resident's skin breakdown to assure interventions were in place for healing.",2020-09-01
356,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,689,D,0,1,U2PS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to assess causal factors and to develop or revise interventions for the prevention of falls for 1 resident (Resident 11). The sample size was 2 and the facility census was 30. Findings are: [NAME] Review of a policy titled Falls and Fall Risk Managing (revised 3/2018) revealed based on previous evaluations and current data, the staff were to develop interventions related to the resident's specific risks to try and prevent the resident from falling and to minimize complications from falling. The following approaches were identified: -the staff were to implement a resident-centered fall prevention plan to reduce specific risk factors of falls; -if falling recurred despite initial interventions, the staff were to implement additional or different interventions; -staff were to monitor the resident's response to interventions; and -if the resident continued to fall, staff were to re-evaluate the situation and determine if interventions remained appropriate or if current interventions needed to be changed. B. Review of Resident 11's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/1/19 revealed the following regarding the resident: -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene; -always incontinent of urine and frequently involuntary of bowel; and -had 1 fall with no injury and 2 or more falls with injury (except major) since the previous assessment. Review of Resident 11's Nursing Progress Notes dated 6/26/19 at 11:30 PM revealed the resident's fall alarm was heard sounding and the resident was found lying on the floor on the resident's right side, next to the resident's bed. The resident voiced a complaint of right shoulder pain with range of motion. In addition, the resident was identified as having a raised hematoma which measured 5 centimeter (cm) by 5 cm to the resident's right upper temple. Review of an Incident Audit Report dated 6/27/19 at 3:07 AM revealed the resident had a mat on the floor next to the resident's bed, as a safety precaution for rolling out of bed. No causal factors were identified regarding the resident's fall. Review of a Nursing Progress Note dated 7/1/19 at 8:00 PM revealed the resident had been restless and had requested to lie down in bed. The resident remained restless and staff witnessed the resident sit down on the floor mat next to the resident's bed. Three staff assisted the resident up and back into the bed. review of the resident's medical record revealed [REDACTED]. Review of Resident 11's current Care Plan (revision date 8/19/19) revealed the resident was at high risk for falls related to [DIAGNOSES REDACTED]. Interventions included the following: -3/27/17 Physical Therapy to evaluate and treat as needed; -1/22/18 ensure resident wearing appropriate footwear (shoes, bedroom slippers or non-skid socks); -4/16/19 assure call light is within reach at all times with frequent room checks to ensure the resident's safety; -4/16/19 pressure bed alarm in place and to assure functioning. Staff to provide prompt response with alarm activation; -5/21/19 anticipate and meet the resident's needs; and -5/21/19 bed to be at safe transfer height with fall mats to both sides when resident in it. Review of an Incident Report dated 8/20/19 revealed at 5:00 PM the resident was witnessed standing beside the Nurse's Station. The resident turned around, lost balance and fell on to the resident's right side. No injuries were identified. The report indicated the resident was pleasantly confused with impaired memory, the environment was crowded and the resident had been ambulating without assistance. Further review of the report revealed current interventions were not revised and no new fall interventions were developed. Review of an Incident Report dated 8/26/19 at 6:45 PM revealed the resident's fall alarm was heard sounding. The resident was found on the floor of the resident's room next to the bed and on the floor mat. The resident's bed was all the way to the floor. The resident was identified as having a 3.5 cm by 2.7 cm bruise to the resident's left knee. The report identified the resident was confused and had been incontinent of urine. The report further identified the resident's bed was to be at a safe transfer height instead of all the way to the floor. Review of an Incident Report dated 9/4/19 at 11:35 AM revealed the resident was found sitting on the floor in the resident's room. The resident complained of pain to the left hip and had a bruise above the left eye. The report indicated the resident was confused, incontinent and was ambulating without assistance. No new fall prevention interventions were identified. Review of an Incident Report dated 11/26/19 at 6:15 AM revealed the resident's fall alarm was heard sounding and the resident was found on the floor mat next to the resident's bed. No injuries were noted. The resident's bed had been placed in the lowest position and the report indicated the resident's bed was to be at a safe transfer height. The resident was incontinent of urine. Further review of the report revealed current interventions were not revised and no additional fall interventions were developed to prevent ongoing falls. Interview with the Director of Nurses on 12/3/20 at 2:14 PM confirmed staff were to assess each resident fall to determine causal factors. Current interventions were to be revised or new interventions developed to prevent further falls and the potential for injury.",2020-09-01
357,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,761,E,0,1,U2PS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to ensure medications were labeled correctly for 4 Residents (Residents 9, 20, 10, 11) and multi-dose (medications that are dispensed more than once from a single container to one or more persons) containers were dated when opened to prevent potential medication errors. This had the potential to affect all Residents. The total sample size was 26 and the facility census was 30. Findings are: [NAME] Review of the facility policy on Storage of Medications (Revised (MONTH) 2007) confirmed drug containers that had missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. B. Review of the facility policy on Administering Medications (Revised (MONTH) 2012) confirmed: -the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication; -medications must be administered in accordance with the orders, including any required time frame; and -when opening a multi-dose container, the date opened should be recorded on the container. C. Review of Resident 9's Electronic Medication Administration Record [REDACTED]. During observations of the medication administration on 1/23/20 from 11:20 AM to 11:35 AM, RN-A prepared Resident 9's Insulin ([MEDICATION NAME]). The label on the bottle said give 6 Units 2 times a day with specified times printed as (7a.m., 11.am. & 6 p.m.) which indicated 3 times a day. D. Review of Resident 11's Emar dated 1/2020 revealed Resident 11 had a physician's order for [MEDICATION NAME] (a medication used to treat psychotic symptoms) 12.5 milligrams (mg) 2 times a day at 12:00 PM and 6:00 PM. Medication Administration was observed on 1/23/20 at 12:00 PM with Medication Aide (MA)-B. MA-B administered [MEDICATION NAME] 12.5mg to Resident 11. The medication label indicated the medication was to be administered at 2:00 PM and 6:00 PM. The [MEDICATION NAME] medication container was dark green (which indicated it was to be given at a different time as 12:00 PM containers were yellow). E. Review of Resident 20's Physician's Order Summary Report dated 12/19/19 revealed Resident 20 had an order for [REDACTED]. Medication Administration was observed on 1/23/20 from 11:30 AM to 11:35 AM with MA-B. MA-B administered Refresh (a brand of lubricating eye drops) 1 drop in the right eye of Resident 20. The label on the bottle of Resident 20's Refresh eye drops said give 1 drop OU BID (OU is a medical abbreviation indicating both eyes, BID indicates to give twice a day). F. Review of Resident 10's Physician's Order Summary Report dated 11/25/19 revealed Resident 10 had an order for [REDACTED]. Medication Administration was observed on 1/23/20 at 11:55 AM with MA-B. MA-B administered Tums 2 tablets to Resident 10. The label on Resident 10's Tums bottle indicated give 1 tablet 3 times a day. [NAME] During observations of Medication Storage on 1/23/20 from 10:20 AM to 10:45 AM with Registered Nurse (RN)-A, the following was observed in the refrigerator located in the central Medication Room: -1 undated opened multi-dose bottle of influenza (a vaccine used for prevention of influenza); -1 undated opened multi-dose bottle of PPD (a vaccine used for screening [MEDICAL CONDITION] infection); and -8 undated opened multi-dose bottles of laxatives (medication used for relief of constipation). H. During interviews with RN-A on 1/23/20 from 10:20 AM to 11:20 AM, RN-A verified the opened bottles of the Influenza vaccine, PPD vaccine and laxatives were not dated. RN-A verified Resident 9's Emar for Insulin ([MEDICATION NAME]) 6 Units was to be given 2 times a day. RN-A stated the pharmacy would be contacted to correct the label. During interviews with MA-B on 1/23/20 from 11:30 AM to 12:10 PM, MA-B verified Resident 20's Emar for Refresh eye drops was scheduled to be given 4 times a day, and would notify an RN to have the label corrected. MA-B verified Resident 11's Emar for [MEDICATION NAME] 12.5mg 2 times a day was scheduled for 12:00 PM and 6:00 PM. MA-B also confirmed the green colored container indicated medications were to be given at 2:00 PM and confirmed the pharmacy was supposed to correct the label and the medication should have been in a yellow colored container. During an interview on 1/23/20 at 2:03 PM the Director of Nursing confirmed the facility has had a problem with the pharmacy updating labels on medications in a timely manner and had been working with them to correct this.",2020-09-01
358,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2020-01-28,865,F,0,1,U2PS11,"Licensure Reference Number 175 NAC 12-006.07C Based on observations, record reviews and interviews; the facility failed to ensure that the QA (Quality Assurance) and QAPI (Quality Assurance and Performance Improvement) Committees identified and corrected quality of care issues. This had the potential to affect all residents in the facility. The total sample size was 26 and the facility census was 30. Findings are: Results of the facility's previous recertification survey on 11/19/18 included the following citations: -F 600 failed to put interventions in place to protect residents from verbal and physical abuse; -F 609 failed to report allegations of verbal and physical abuse; and -F 684 failed to assess, monitor and provide care for the healing of skin break down. Review of the findings during the annual recertification survey, dated 1/28/20, revealed the following deficient areas were identified: - F 609 failed to submit investigations within the required times frames; - F 610 failed to complete investigations related to a fall with significant injuries and a resident to resident altercation; - F 684 failed to provide ongoing monitoring and to develop and/or implement interventions to prevent skin breakdown; - F 686 failed to provide treatment and monitoring to ensure healing of pressure ulcers; - F 689 failed to evaluate causal factors and to revise or develop interventions to prevent ongoing falls: - F 761 failed to ensure medication labels matched current medication orders [REDACTED] Interview with the Administrator on 1/28/20 at 9:31 AM revealed the facility did not have a QAPI plan in place with the necessary policies and procedures. The Administrator confirmed that the QAPI Committee was not effective in identifying or developing a plan to address quality of care issues in the facility.",2020-09-01
359,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2019-03-18,689,D,1,0,RKTO11,"> Licensure Reference Number 175 NAC 12-006.09D7a Based on interview and record review, the facility failed to assess causal factors and develop/implement interventions to prevent potential injuries related to falls for Resident 1. The sample size was 3 and the facility census was 30. Findings are: [NAME] Review of Resident 1's current undated Care Plan revealed the resident had limited physical mobility related to impaired vision and a mild balance deficit. The resident used a cane with ambulation and had some forgetfulness related to short term memory. Further review revealed the resident as at high risk for falls. Interventions included anticipating the resident's needs, remind the resident to walk with the cane, ensure the resident's call light was in reach, and therapy as ordered/as needed. Review of Resident 1's Incident/Accident Report dated 2/28/19 revealed the resident slipped in the shower room while taking a shower. The details of the fall were reported by the resident. Review of a Progress Note dated 3/1/19 revealed Resident 1 returned from the emergency room with a right humerus fracture. During an interview with the Director of Nursing (DON) on 3/18/19 at 12:35 PM, the DON revealed when Resident 1 fell in the shower room the resident was showering alone, per the resident's request. Prior to that day, the staff had always helped the resident when showering. The DON was unsure which of the 3 staff working at the time knew the resident was in the shower alone. During interviews with the Administrator on 3/18/19 at 1:50 PM and 2:10 PM, the Administrator confirmed Nursing Assistant-C knew Resident 1 went into the shower alone on 2/28/19. Further interview confirmed there was no evidence to indicate staff were interviewed during the investigation to determine all the causal factors, and therefore there had been no staff education completed to prevent potentially recurrence.",2020-09-01
360,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,221,D,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12- (8) Based on record review and interview, the facility failed to evaluate the use of a geri-chair (a chair that fully reclines and does not allow the resident to stand) as a potential physical restraint for Resident 43 who had a history of [REDACTED]. Findings are: [NAME] Review of the facility policy titled Use of Restraints dated 4/2017 included the following: -Physical Restraints were defined as any method, device, material or equipment that restrict freedom of movement or normal access to one's body; -examples of devices that could be considered physical restraints included geri-chairs; -practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including placing a resident in a chair that prevents the resident from rising; -prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints; -restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative; -the opportunity for motion and exercise is provided for a period of not less than 10 minutes during each 2 hours in which restraints are used; -restrained residents must be repositioned at least every 2 hours on all shifts; -care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms; and -care plans shall include the measures taken to systematically reduce or eliminate the need for restraint use. B. Review of Resident 43's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/21/16 indicated [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderately impaired cognition, required extensive assistance with transfers and mobility, and had a history of [REDACTED]. Review of Resident 43's Care Plan dated 8/17/16 revealed the resident had an ADL (activities of daily living) self-care performance deficit. Nursing interventions included extensive assistance by 2 staff for transfers if agitated or anxious, by ambulation with limited to extensive assist, or with use of a sit-to-stand mechanical lift. The Care Plan further indicated Resident 43 was at high risk for falls due to an unsteady gait, and impulsiveness with impaired safety awareness. Review of Nursing Progress Notes revealed the following related to Resident 43: -11/5/16 at 3:57 PM - Resistive with cares today, keeps scooting to the edge of the wheelchair, hits at staff as they attempt repositioning. 1:1 (one-to-one supervision) provided without success. Wheelchair changed to the geri-chair for safety. Message left for (spouse) to call the facility for notification; and -11/6/16 at 3:52 PM - Spouse arrived at the facility, indicated dislike for the geri-chair and demanded the resident be placed in the old chair. The spouse was instructed that the reason for the geri-chair was for safety and that we are unable to provide constant 1:1's to assure the resident wouldn't scoot out of the chair. There was no evidence in the medical record of the following related to use of the geri-chair for Resident 43: -an assessment and review to determine the need for physical restraint; -a written order from the physician and prior consent from the resident and/or representative; -documentation that the opportunity for motion and exercise was provided, and that the resident was repositioned every 2 hours during the time the geri-chair was used; and -that the Care Plan addressed the use of the geri-chair. During interviews the following was revealed related to Resident 43: -9/27/17 at 11:30 AM - The Administrator verified the geri-chair was considered a physical restraint and was unaware that it was used; and -9/28/17 at 7:50 AM - The Director of Nursing (DON) verified the geri-chair was used for this resident.",2020-09-01
361,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,279,E,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record review and interview, the facility failed to develop Care Plan interventions 1) for the use of a geri-chair (a chair that fully reclines and does not allow the resident to stand) as a potential physical restraint for Resident 43, 2) for Resident 11 to spend time outside the facility without staff supervision, and 3) to assure a safe smoking plan for Resident 26. The total sample size was 25 and the facility census was 27. Findings are: [NAME] Review of Resident 43's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/21/16 indicated [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderately impaired cognition, required extensive assistance with transfers and mobility, and had a history of [REDACTED]. Review of Resident 43's Care Plan dated 8/17/16 revealed the resident had an ADL (activities of daily living) self-care performance deficit. Nursing interventions included extensive assistance by 2 staff for transfers if agitated or anxious, by ambulation with limited to extensive assist, or with use of a sit-to-stand mechanical lift. The Care Plan further indicated Resident 43 was at high risk for falls due to an unsteady gait, and impulsiveness with impaired safety awareness. Review of Nursing Progress Notes revealed the following related to Resident 43: -11/5/16 at 3:57 PM - Resistive with cares today, keeps scooting to the edge of the wheelchair, hits at staff as they attempt repositioning. 1:1 (one-to-one supervision) provided without success. Wheelchair changed to the geri-chair for safety. -11/6/16 at 3:52 PM - Spouse agreed to use of the geri-chair but asked that the wheelchair be used during (the spouse's) visits as the resident was supervised during that time. There was no evidence Resident 43's Care Plan addressed the use of the geri-chair as a potential physical restraint. During interview on 9/28/17 at 7:50 AM, the Director of Nursing (DON) verified Resident 43's Care Plan should have addressed the use of the geri-chair. B. Review of Resident 26's Minimum Data Set (MDS) dated [DATE] indicated the resident had [DIAGNOSES REDACTED]. The assessment further indicated Resident 26's cognition was moderately impaired and the resident had trouble breathing when at rest, lying flat or with exertion. Observation of Resident 26 on 9/25/17 at 10:03 AM revealed the resident was lying in bed in the resident's room. The resident had a small zippered bag which was opened and lying on the resident's chest. A pack of cigarettes and a lighter were visible from the open bag. Observations of Resident 26 on 9/26/17 from 9:18 AM until 9:45 AM, revealed the resident was taken outside by the facility staff and was then left unsupervised. The resident removed a cigarette and a lighter from a zippered bag, proceeded to the light the cigarette and then to smoke. Review of the residents current Care Plan dated 11/1/16 revealed the resident had an altered respiratory status and difficulty breathing related to [MEDICAL CONDITION]. An intervention to encourage a smoking cessation program was identified. There was no evidence Resident 26's Care Plan addressed the resident's smoking, any interventions to assure the resident's safety when smoking and for the storage of the resident's smoking supplies. During interview on 9/27/17 the MDS Coordinator verified Resident 26's current Care Plan did not address the resident's smoking. C. Review of Resident 11's MDS dated [DATE] revealed the resident had hallucinations and delusions. Review of Resident 11's current undated Care Plan revealed the resident required a wheelchair with assistance of 1 for mobility. Review of a Progress Note dated 9/2/17 revealed Resident 11 went outside after supper in the resident's wheelchair with possible assistance from a visitor. Another resident (Resident 23) reported to staff that Resident 11 went down the hill in the resident's wheelchair. Resident 11 put a foot down and stopped from rolling all the way to the street. Resident 23 felt Resident 11 was unsafe and was concerned that Resident 11 could have tipped out of the wheelchair while trying to stop. Interviews with the Administrator on 9/26/17 at 9:36 AM and on 9/27/17 at 11:50 AM, revealed Resident 11 liked to sit outside and often sat outside with Resident 23, without staff supervision. The Administrator stated on 9/2/17 Resident 11 was going to sit outside with Resident 23 and was able to get outside with the help of an unidentified visitor. The brakes were not locked on the wheelchair and the resident started to roll towards the parking lot but was able to get stopped. Further interview confirmed an assessment had not been completed to ensure Resident 11 was safe to sit outside without staff supervision; and no interventions had been put in place to prevent Resident 11 from going outside without staff supervision, since the incident on 9/2/17. During an interview with the DON on 9/28/17 at 9:14 AM, the DON confirmed Resident 11's ability to go outside without staff supervision had not been addressed on the resident's Care Plan.",2020-09-01
362,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,280,D,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to review and revise Care Plans for Resident 43 related to fall interventions, and for Resident 13 regarding significant weight loss. The total sample size was 25 and the facility census was 27. Findings are: [NAME] Review of Resident 43's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/13/16 indicated [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderately impaired cognition, required extensive assistance with transfers and mobility, and had a history of [REDACTED]. Review of Resident 43's Care Plan dated 5/10/16 revealed Resident 43 was at high risk for falls due to an unsteady gait, and impulsiveness with impaired safety awareness. Nursing interventions included the following: -assure call light is within reach and encourage resident to use it for assistance as needed; -prompt response to all requests for assistance; -bed in low position at night and personal items within reach; -tabs alarm (a device attached to the resident that alarms and alerts staff when the resident attempts to get up) in wheelchair and bed; assure the device is in place and working properly; -Physical Therapy (PT) to evaluate and treat as ordered; and -provide diversional activities such as watching television, going for walks in the facility, and participating in large group activities if willing. Review of an Incident/Accident Report and Investigation Follow-up dated 5/16/16 at 6:00 AM revealed Resident 43 was found seated on the floor mat beside the bed. Documentation indicated recommendations to prevent further falls included a tabs alarm on at all times and a pressure alarm (a pressure sensitive pad placed beneath the resident that alarms and alerts staff when the resident gets up from the bed/chair) on while in bed. There was no evidence the Care Plan was reviewed and revised to include implementation of a pressure alarm when in bed. Review of a Progress Note dated 5/21/16 at 6:39 PM revealed Resident 43 stood up from the wheelchair with the brakes unlocked. The tabs alarm was sounding, and the resident lost balance and fell to the floor. Recommendations made to prevent further falls included 1:1 (one-to-one supervision), a pressure alarm, and a seat belt alarm (a belt with a velcro closure placed around the resident's waist in the wheelchair, that alarms and alerts staff when the resident attempts to get up from the chair). Documentation further indicated the resident's spouse suggested to give a snack at 4:00 PM as the resident may be hungry. There was no evidence the resident's Care Plan was reviewed and revised to include implementation of 1:1, a pressure alarm in the wheelchair, a seat belt alarm, and/or a snack at 4:00 PM in an attempt to prevent further falls. Review of Progress Notes revealed the following related to Resident 43: -11/5/16 at 3:57 PM - Resistive with cares today, keeps scooting to the edge of the wheelchair, hits at staff as they attempt repositioning. 1:1 provided without success. Wheelchair changed to the geri-chair (a chair that fully reclines and does not allow the resident to stand) for safety; and -11/6/16 at 3:52 PM - Spouse agreed to use of the geri-chair but asked that the wheelchair be used during (the spouse's) visits as the resident was supervised during that time. There was no evidence the resident's Care Plan was reviewed and revised to include implementation of a geri-chair as an intervention to prevent further falls. During interview on 9/28/17 at 7:50 AM, the Director of Nursing (DON) verified Resident 43's Care Plan should have been reviewed and revised to include new interventions implemented related to fall prevention. B. Review of Resident 13's Minimum Data Set ((MDS) dated [DATE] revealed [DIAGNOSES REDACTED]. The resident's weight was 143 lbs. (pounds) and the resident was not on a prescribed weight loss regime. Review of Resident 13's current Care Plan revised on 5/30/17 revealed the resident had the potential for nutritional problems related to pain and loss of appetite. The following interventions were identified: -Offer snacks as requested by the resident. -Provide and serve diet as ordered. -Registered Dietician (RD) to evaluate and make recommendations as needed. Review of Resident 13's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed the following regarding the resident's weight: -7/24/17 the resident's weight was 143 lbs. -8/21/17 the resident's weight was 134 lbs. (down 9 lbs. or a 6.3 % (percent) loss in 1 month) Review of a Nutrition Progress Note by the RD dated 8/22/17 at 1:06 PM, revealed the resident's current body weight was 133.5 lbs. with a significant weight loss of 6.8 % in 30 days. The resident was on a regular diet and had poor intakes averaging 25 to 100% at meals. The RD made a recommendation for the resident to receive Ensure (drink with added calories) 240 cubic centimeters (cc) twice a day to deter further weight loss. There was no evidence the Care Plan was revised to address the resident's significant weight loss or that additional weight loss interventions were developed. During interview on 9/28/17 at 8:50 AM, the MDS Coordinator verified Resident 13's Care Plan should have been reviewed and revised to include the resident's significant weight loss and additional nutritional interventions developed to stabilize the resident's weight.",2020-09-01
363,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,323,E,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Numbers 175 NAC 12-006.18E4 and 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to: 1.) transfer Resident 13 in a safe manner, 2.) assure Resident 26's safety related to smoking, 3.) assess causal factors and develop fall prevention interventions for Resident 43, 4.) assure hazardous chemicals were secured from Residents 17, 18, 33 and 36 who had been assessed at risk for wandering, and 5.) assess Resident 11 to assure safety to be outside without staff supervision. The facility census was 27 and the sample size was 25. Findings are: [NAME] Review of facility Smoking Policy dated 10/24/16 revealed no smoking was allowed as the facility was smoke free. However, smokers were not denied admittance to the facility nor were they not allowed to smoke. The following procedure was identified: -Cigarettes, lighters or matches were not to be permitted in the resident's rooms nor in their possession. All cigarettes were to be kept at the Nurse's Station. -When a resident desired to smoke, the resident was to ask for a cigarette and then staff were to light the cigarette once outside the facility. -If the resident was assessed and found to be unsafe, then the resident was not to be allowed to smoke without staff supervision. B. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/24/17 indicated the resident had [DIAGNOSES REDACTED]. The assessment further indicated Resident 26's cognition was moderately impaired and the resident had trouble breathing when at rest, lying flat or with exertion. Review of the residents current Care Plan dated 11/1/16 revealed the resident had an altered respiratory status and difficulty breathing related to COPD. The following interventions were identified: -Administer medications as ordered. -Assist in learning signs of respiratory compromise. -Elevate the head of the resident's bed. -Oxygen at 2 liters per nasal cannula. -Monitor for signs of respiratory distress. -Encourage a smoking cessation program Observation of Resident 26 on 9/25/17 at 10:03 AM revealed the resident was lying in bed in the resident's room. The resident had a small zippered bag which was opened and lying on the resident's chest. A pack of cigarettes and a lighter were visible from the open bag. Observations of Resident 26 on 9/26/17 revealed the following: 9:18 AM- the resident was seated in a wheelchair by the facility front entrance door. Nurse Aide (NA)-C assisted the resident with donning a [NAME]et, propelled the resident's wheelchair out the door and positioned the wheelchair next to a cigarette ash receptacle. 9:20 AM- NA-C locked the wheelchair brakes and then reentered the facility leaving Resident 26 unsupervised. Resident 26 removed a cigarette and lighter from a small zippered bag on the resident's lap, lit the cigarette and proceeded to smoke. 9:28 AM- the resident placed the remainder of the cigarette into the receptacle and then knocked on the front door. 9:35 AM- NA-C walked by the door and Resident 26 waved at NA-C. NA-C opened the door and assisted the resident back into the facility. 9:45 AM- Resident 26 placed the pack of cigarettes and the lighter back into the zippered bag and returned to the resident's room with the bag on the resident's lap. Review of Resident 26's medical record revealed no evidence that a Safe Smoking Assessment had been completed to determine if the resident was safe to smoke without direct staff supervision. During an interview on 9/26/17 at 11:00 AM, the Director of Nursing (DON) confirmed the following: -Any residents who smoked were to be assessed to determine the resident's need for supervision when smoking and need for any additional interventions to assure the resident's safety. -A Safe Smoking Assessment had not been completed for Resident 26. -Residents were not to keep cigarettes, lighters or matches on their person or stored in their room. The items were to be kept at the Nurse's Station and staff were to provide assist and supervision with smoking as needed. C. Review of the manufacturer's safe operation instructions (revised 3/11/09) for the EZ Way Stand Lift (assistive device that allows residents to be transferred between a bed and a chair using hydraulic power) revealed a patient should be able to bear some weight, have upper body strength (be able to sit on the side of the bed unattended) and be able to follow simple commands to use the lift effectively and safely. If a patient does not meet each of these 3 criteria, the lift should not be used. D. Review of Resident 13's MDS dated [DATE] revealed the resident was cognitively intact, was unsteady with surface to surface transfers (transfer between bed and chair or wheelchair) and required extensive staff assistance with transfers. In addition, the resident had a functional limitation in range of motion to the lower extremities (hip, knee, ankle and foot). Review of Resident 13's current Care Plan dated 6/6/17 revealed the resident had a self-care performance deficit related to hip, back and left leg pain. The resident required assistance of 2 staff with transfers and use of a mechanical stand lift at times. Observations of Resident 13 on 9/28/17 from 8:09 AM to 8:24 AM, revealed the following: -NA-C and NA-H entered the resident's room and indicated it was time for the resident to get out of bed for breakfast. The resident identified the presence of pain to the resident's back and left leg. NA-H removed the bed linens and assisted the resident to donn a pair of anklet socks. No shoes, gripper socks or slippers were placed on the resident. -NA-C positioned the lift next to the resident's bed and proceeded to remove the foot plate from the lift. -NA-C and NA-H assisted the resident to a seated position on the side of the bed. Resident 13 moaned and again indicated pain to the resident's back. NA-H remained next to the resident as the resident was leaning to the left and was unable to maintain balance independently while seated on the side of the bed. -NA-H positioned a sling around the resident's upper torso and then secured the sling to the lift. Resident 13's lower legs were not secured to the lift. - NA-C and NA-H stood on either side of the resident and the resident was lifted from the side of the bed. into a standing position. The resident's feet were directly on the floor and began to slide. Staff balanced the resident and provided weight bearing assistance until the resident was able to maintain a standing position. Once the resident was stabilized, staff cued the resident to step forward and towards a bedside commode chair. -The resident took several small steps forward and staff attempted to pivot the resident and the lift so the resident was positioned in front of the commode. -Staff lowered the resident onto the commode. During an interview on 9/28/17 from 8:35 AM until 8:45 AM, the DON indicated Resident 13 had a recent decline in functional status and the staff had been transferring the resident 13 manually until the last few days. The DON confirmed the following: -Resident 13 was unable to maintain balance while seated unattended on the side of the bed. -The resident's upper and lower extremity strength had declined and the resident was having difficulty with bearing own weight. -The resident had not been assessed to determine the safest mode to transfer the resident and the resident did not meet all the criteria to assure safety with use of the stand lift. -Staff should have placed gripper socks, shoes or slippers on the resident to assure the resident's safety when transferring. E. During the Initial Tour of the facility on 9/25/17 from 7:50 AM to 7:40 AM, the following were observed: -the 100 corridor had a door which read Soiled Utility, -the door was unlocked, and -a padlock was hanging from a cabinet with a sign which indicated the cabinet was to remain locked at all times. The padlock was not secured and the cabinet contained a bottle of Bleach, -a covered linen cart was positioned in the middle of the corridor and contained a spray bottle which was labeled Zeph Air Mountain Mist Air/Fabric Refresher, an aerosol can labeled Spar San Q Deodorant Spray and a container of Super-Sani Germicidal disposable wipes, -the 200 corridor had a door which read Soiled Utility. -the door was unlocked, and -a padlock was hanging from a cabinet with a sign which indicated the cabinet was to be locked at all times. The padlock was unsecured and a container of Sani-cloth Bleach disposable wipes and a spray bottle labeled Oasis 146 Sanitizer were stored in the cabinet, and -in the middle of the 200 corridor was a covered 2 compartment garbage disposal unit. The unit a pouch hanging from the center. The pouch contained an aerosol can labeled Spar San Q Disinfectant spray. During observations on 9/26/17 at 7:00 AM the following was noted: -the 100 corridor had a covered linen cart positioned in the center of the corridor which contained a spray bottle which was labeled Zeph Air Mountain Mist Air/Fabric Refresher, an aerosol can labeled Spar San Q Deodorant Spray and a container of Super-Sani Germicidal disposable wipes, and -in the 200 corridor was a covered 2 compartment garbage disposal unit which had a pouch hanging from the center. The pouch contained an aerosol can of Spar San Q Disinfectant spray. During an interview on 9/27/17 at 1:53 PM, the Administrator identified 4 residents (Residents 7, 33, 36 and 18) had been assessed at risk for wandering and frequently wandered in the hallways. The Administrator further identified all chemicals should be stored in a secured area and inaccessible to any of the residents. During observations on 9/28/17 at 7:00 AM the following was identified: -the 100 corridor had a covered linen cart positioned in the center of the corridor which contained a spray bottle which was labeled Zeph Air Mountain Mist Air/Fabric Refresher, an aerosol can labeled Spar San Q Deodorant Spray and a container of Super-Sani Germicidal disposable wipes, and -the 200 corridor had a covered linen cart positioned in the center of the corridor which contained a spray bottle which was labeled Zeph Air Mountain Mist Air/Fabric Refresher, an aerosol can labeled Spar San Q Deodorant Spray and a container of Super-Sani Germicidal disposable wipes. F. Review of the Material Safety Data Sheet (MSDS) for Sani-Cloth Bleach Wipe dated 1/24/06 revealed the following: -Hazards Identification: (MONTH) cause eye and skin irritation and irritation to the respiratory tract. [NAME] Review of the MSDS for Zeph Air Mountain Mist dated 7/1/13 revealed the following: -Hazards Identification: (MONTH) cause serious eye damage/eye irritation. H. Review of the MSDS for Super Sani Germicidal Wipes dated 8/1/13 revealed the following: -Hazards Identification: (MONTH) cause eye and skin irritation. I. Review of the MSDS for Surfine Bleach (undated) revealed the following regarding hazards identification: -Inhalation of vapors will irritate breathing passages and may cause breathing difficulty. -Will cause severe irritation to eyes and skin. -Ingestion will cause burning sensation in the mouth, throat and stomach. [NAME] Review of the MSDS for Spar San Q Disinfectant Deodorant dated 8/14/15 revealed the following hazards identification: -May be harmful if swallowed. -May cause eye irritation. -May cause skin irritation -Inhalation of vapors or mist can cause respiratory irritation. K. Review of the MSDS for Zeph Air Mountain Mist dated 7/1/13 revealed the following: -Hazards Identification: (MONTH) cause serious eye damage/eye irritation. L. Review of the MSDS for Oasis 146 Sanitizer (undated) revealed the following hazards identification: -Corrosive to eyes. -Corrosive to skin. -Corrosive to respiratory system. -Causes burns to mouth, stomach and throat if swallowed. . M. Review of Resident 43's MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderately impaired cognition, required extensive assistance with transfers and mobility, and had a history of [REDACTED]. Review of Resident 43's Care Plan dated 5/10/16 revealed the resident had an ADL (activities of daily living) self-care performance deficit. Nursing interventions included extensive assistance by 2 staff for transfers if agitated or anxious, by ambulation with limited to extensive assist, or with use of a sit-to-stand mechanical lift. The Care Plan further indicated Resident 43 was at high risk for falls due to an unsteady gait, and impulsiveness with impaired safety awareness. Nursing interventions included the following: -assure call light is within reach and encourage resident to use it for assistance as needed; -prompt response to all requests for assistance; -bed in low position at night and personal items within reach; -tabs alarm (a device attached to the resident that alarms and alerts staff when the resident attempts to get up) in wheelchair and bed; assure the device is in place and working properly; -Physical Therapy (PT) to evaluate and treat as ordered; and -provide diversional activities such as watching television, going for walks in the facility, and participating in large group activities if willing. Review of an Incident/Accident Report and Investigation Follow-up dated 5/12/16 at 12:20 PM indicated Resident 43 was lowered to the floor in the bathroom by NA-[NAME] The resident would not stay sitting on toilet and was not standing or ambulating well. Documentation indicated NA-A had to seek assistance from a second staff member to transfer the resident to the recliner. Resident 43 was not transferred in accordance with the Care Plan which indicated transfers were to be performed with 2 staff by ambulation or mechanical lift, and there were no new interventions put in place to prevent further falls. Review of an Incident/Accident Report and Investigation Follow-up dated 5/16/16 at 6:00 AM revealed Resident 43 was found seated on the floor mat beside the bed. Documentation indicated recommendations to prevent further falls included a tabs alarm on at all times (this was already a current intervention) and pressure alarm (a pressure sensitive pad placed beneath the resident that alarms and alerts staff when the resident gets up from the bed/chair) on while in bed. Review of Care Plan interventions dated 5/17/16 revealed the following: -bed in low position and wheels locked; -floor mats in place beside bed; and -no evidence the pressure alarm in bed was implemented. Review of a Progress Note dated 5/21/16 at 6:39 PM revealed Resident 43 stood up from the wheelchair with the brakes unlocked. The tabs alarm was sounding, and the resident lost balance and fell to the floor. Recommendations made to prevent further falls included 1:1 (one-to-one supervision), a pressure alarm, and a seat belt alarm (a belt with a velcro closure placed around the resident's waist in the wheelchair, that alarms and alerts staff when the resident attempts to get up from the chair). Documentation further indicated the resident's spouse suggested to give a snack at 4:00 PM as the resident may be hungry. There was no evidence in the resident's Care Plan to indicate 1:1, a pressure alarm in the wheelchair, a seat belt alarm, and/or a snack at 4:00 PM were implemented in an attempt to prevent further falls. Review of an Incident/Accident Report and Investigation Follow-up dated 7/17/16 at 5:30 PM indicated Resident 43 was observed in the hallway and sitting on the floor with the wheelchair pedals underneath the buttocks. Recommendations made to prevent further falls included no foot pedals and a pressure alarm in the wheelchair (a recommendation made following the fall on 5/21/16). Review of an Incident/Accident Report and Investigation Follow-up dated 7/18/16 at 5:30 AM revealed Resident 43 was found sitting on the floor mat beside the bed. Recommendations made to prevent further falls included a pressure alarm and tabs alarm on the bed (both interventions were recommended following the fall on 5/16/16). Review of a Progress Note dated 9/7/16 at 4:52 PM revealed Resident 43 was sitting in wheelchair in the solarium, started to stand and set off the mobility alarm. The resident fell to the floor before staff assistance could be provided. The recommendation made to prevent further falls was a pressure alarm in the wheelchair (a recommendation made following the fall on 5/21/16). Review of a Progress Note dated 10/27/16 at 10:06 AM indicated Resident 43 was sitting in wheelchair in the solarium when staff heard the alarm sounding and found the resident on the floor next to the piano. The resident was bleeding from a laceration on the left eyebrow. There were no recommendations made in an attempt to protect the resident from further falls. Review of Progress Notes revealed the following related to Resident 43: -11/5/16 at 3:57 PM - Resistive with cares today, keeps scooting to the edge of the wheelchair, hits at staff as they attempt repositioning. 1:1 provided without success. Wheelchair changed to the geri-chair (a chair that fully reclines and does not allow the resident to stand) for safety; and -11/6/16 at 3:52 PM - The spouse was instructed that the reason for the geri-chair was for safety and that we are unable to provide constant 1:1's to assure the resident wouldn't scoot out of the chair. N. Review of Resident 11's MDS dated [DATE] revealed the resident had hallucinations and delusions. Review of Resident 11's current undated Care Plan revealed the resident required a wheelchair with assistance of 1 for mobility. Review of a Progress Note dated 9/2/17 revealed Resident 11 went outside after supper in the resident's wheelchair with possible assistance from a visitor. Another resident (Resident 23) reported to staff that Resident 11 went down the hill in the resident's wheelchair. Resident 11 put a foot down and stopped from rolling all the way to the street. Resident 23 felt Resident 11 was unsafe and was concerned that Resident 11 could have tipped out of the wheelchair while trying to stop. Interviews with the Administrator on 9/26/17 at 9:36 AM and on 9/27/17 at 11:50 AM, revealed Resident 11 liked to sit outside and often sat outside with Resident 23, without staff supervision. The Administrator stated on 9/2/17 Resident 11 was going to sit outside with Resident 23 and was able to get outside with the help of an unidentified visitor. The brakes were not locked on the wheelchair and the resident started to roll towards the parking lot but was able to get stopped. Further interview confirmed an assessment had not been completed to ensure Resident 11 was safe to sit outside without staff supervision; and no interventions had been put in place to prevent Resident 11 from going outside without staff supervision, since the incident on 9/2/17.",2020-09-01
364,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,325,G,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to revise current interventions or to develop new nutritional interventions to address ongoing significant weight loss for Resident 13. The facility census was 25 and the sample size was 27. Findings are: [NAME] Review of the facility policy Significant Weight Loss (undated) revealed a goal of identifying causes or factors contributing to significant unplanned weight loss and implementation of interventions as appropriate to stabilize weight. Review of the identified procedure revealed the following: -Review food intake records. -Interview the resident to identify possible causes and appropriate interventions. -Implement individualized nutritional interventions based on resident preferences. This may include but is not limited to; foods enhanced with extra calories or proteins. -High calorie or high protein supplements. -Possible use of an appetite stimulant if appropriate. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/24/17 revealed [DIAGNOSES REDACTED]. The resident's weight was 143 lbs. (pounds) and the resident was not on a prescribed weight loss regime. Review of Resident 13's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed on 5/28/17 the resident's weight was 142 lbs. Review of Resident 13's current Care Plan revised on 5/30/17 revealed the resident had the potential for nutritional problems related to pain and loss of appetite. The following interventions were identified: -Offer snacks as requested by the resident. -Provide and serve diet as ordered. -Registered Dietician (RD) to evaluate and make recommendations as needed. Review of Resident 13's Weights and Vitals Summary sheet revealed the following record of weights: 6/26/17- 138 lbs. 7/24/17- 143 lbs. 8/21/17- 134 lbs. (down 9 lbs. or a 6.3 % (percent) loss in 1 month) Review of a Nutrition Progress Note by the RD dated 8/22/17 at 1:06 PM, revealed the resident's current body weight was 133.5 lbs. with a significant weight loss of 6.8 % in 30 days. The resident was on a regular diet and had poor intakes averaging 25 to 100% at meals. The RD made a recommendation for the resident to receive Ensure (drink with added calories) 240 cubic centimeters (cc) twice a day to deter further weight loss. Review of Resident 13's Medication Administration Record [REDACTED]. Review of Resident 13's MAR indicated [REDACTED] -8:00 AM from 9/1/17 through 9/25/17 the resident consumed less than 50% of the supplement on 9/1/17 through 9/7/17, 9/9/17, 9/11/17 through 9/15/17, 9/20/17, 9/22/17, and 9/24/17 ( 16 out of 25 days) and, -12:00 PM from 9/1/17 through 9/25/17 the resident consumed less than 50% of the supplement on 9/1/17 through 9/7/17, 9/10/17 through 9/12/17, 9/15/17, 9/18/17 and 9/20/17 through 9/24/17 (16 out of 25 days). Review of Resident 13's Weights and Vitals Summary revealed the resident's weight on 9/25/17 was 121 lbs. (down 13 lbs. or 9.7% in 1 month and down 17 lbs. or a 12% weight loss in 3 months). Review of Resident 13's medical record revealed no evidence the Dietary Manager (DM) or the RD had addressed the resident's ongoing significant weight loss since 8/22/17. During an interview on 9/27/17 from 9:30 AM to 10:05 AM, the RD confirmed the following: -Resident 13 received the Ensure 240 cc only once a day from 8/23/17 through 8/31/17. The resident's intakes continued to decline and the resident was not always accepting the supplement. -Staff did increase the Ensure supplement to twice a day when the error was identified on 9/1/17 even though acceptance continued to be poor at times. -Resident 13 had not been interviewed since admission on 5/27/17 to determine dietary preferences. -No further nutritional interventions were developed or implemented despite the residents continued significant weight loss.",2020-09-01
365,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,329,D,0,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on interview and record review, the facility failed to ensure Resident 11 was free from the use of unnecessary medications related to the use of an antipsychotic (medication used to alter certain chemicals in the brain to effect changes in behavior, mood, and emotions). The sample size was 25 and the facility census was 27. Findings are: Review of the facility policy titled Guidelines for Gradual Dose Reductions dated 11/2007 revealed antipsychotic medications required a gradual dose reduction 2 times in the first year. After the first year a gradual dose reduction was required yearly. Review of Resident 11's Physician's Order dated 8/11/16 revealed an order to decrease Resident 11's [MEDICATION NAME] (an antipsychotic medication) to 12.5 milligrams 1 time daily. Review of Resident 11's Physician's Orders revealed no evidence to indicate a gradual dose reduction had been attempted and/or requested from the physician in the past year (since 8/11/16). During an interview with the Director of Nursing (DON) on 9/26/17 at 1:50 PM the DON confirmed a gradual dose reduction had not been attempted and/or requested from the physician in the past year.",2020-09-01
366,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,333,D,0,1,XTJ511,"**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 ensure Resident 29 was free from a potential significant medication error related to an anti-hypertensive medication (a medication used to treat high blood pressure). The sample size was 25 and the facility census was 27. Findings are: Upon observation on 9/27/17 at 8:05 AM, Registered Nurse (RN)-I administered [MEDICATION NAME] (a medication used to treat high blood pressure) 100 milligrams (mg) to Resident 29. Review of Resident 29's physician's orders [REDACTED]. Review of Resident 29's Blood Pressure Summary revealed on 9/13/17 at 9:29 PM the resident's blood pressure was 78/45 (low blood pressure is anything below 90/60). Further review revealed Resident 29's blood pressure was not re-checked until 9/20/17 (7 days later). Interviews with RN-I on 9/27/17 at 9:35 AM and at 11:02 AM confirmed Resident 29's [MEDICATION NAME] order was changed to 50mg 3 times daily on 9/2/17. Further interview confirmed Resident 29 had been receiving [MEDICATION NAME] 100mg 3 times daily instead.",2020-09-01
367,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,371,F,1,1,XTJ511,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview, the facility failed to assure food was prepared and served in a manner to prevent cross contamination. During observations of food preparation and service, dietary staff failed to wash hands at appropriate intervals and to assure potentially contaminated disposable gloves were not used for handling ready to eat foods. This had the potential to affect all residents residing in the facility. Facility census was 27 and the sample size was 25. Findings are: [NAME] During observation of preparation and service of the breakfast meal on 9/27/17 from 7:13 AM until 9:00 AM, the following was observed by Dietary Cook (DC)-F: -washed hands and donned a clean pair of disposable gloves, -opened a loaf of bread and with gloved hands, removed 2 slices of bread and placed inside the toaster, -without removing gloves, turned to the stove and proceeded to stir a pot containing hot cereal, -retrieved slices of bread from the toaster, buttered and then placed on the steam table, -opened the microwave oven and removed a glass bowl which contained scrambled eggs, stirred the eggs and then placed the bowl back inside the microwave, -removed gloves but failed to wash hands and then donned a clean pair of gloves, -opened a container of cold cereal, -used gloved hands to remove toast from the steam table and placed onto a resident's plate, -opened a Danish pastry and used gloved hands to place the pastry on a resident's plate, -used gloved hands to fan through a stack of resident diet cards, -used gloved hands to peel and slice a banana and then placed the banana on a resident's plate, and -removed gloves without washing hands and continued serving out plates of food for the breakfast meal. B. During interview on 9/27/17 at 9:33 AM, the Registered Dietician verified DC-F failed to wash hands at appropriate intervals during preparation and service of the breakfast meal and touched ready to eat foods while wearing soiled gloves. C. Review of the 7/21/16 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service, revealed sanitation practices included the following: -2-301.14 Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation .and: (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . (H) Before donning gloves for working with food; and (I) after engaging in other activities that contaminate the hands. -3-304.15 Single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food and discarded when interruptions occur in the operation.",2020-09-01
368,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,425,D,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10A1 Based on observation, record review and interview; the facility failed 1) to evaluate residents' ability to self-administer medications, 2) to obtain physician's orders [REDACTED]. This involved Residents 17 and 26. The total sample size was 25 and the facility census was 27. Findings are: [NAME] Review of the policy titled Self-Administration of Medications, revised on 12/2016 included the following: -the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; -nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken; -if the resident is willing and able to take responsibility for documenting their self-administration of medications, the resident will be instructed on how to complete a record of medication administration; -staff shall identify and give to the Charge Nurse and medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party; -the facility will re-order self-administered medications in the same manner as other medications; -nursing staff will routinely check self-administered medications and will remove expired, discontinued or recalled medications; -nursing staff will review the self-administered medication record on each nursing shift and transfer pertinent information to the Medication Administration Record [REDACTED] -the staff and practitioner will periodically reevaluate a resident's ability to continue to self-administer medications. B. Review of Resident 17's current Care Plan dated 5/19/17 revealed Tums (a chewable tablet antacid medication used to treat heartburn and upset stomach), Cough Drops (used to relieve coughing), and Tylenol (used to treat pain and fever) were ordered for bedside use and self-administered by the resident. Nursing interventions included the following: -monitor the resident's ability to safely self-administer medications on admission, re-admission, quarterly, with a change in medication orders, and with a significant change in condition; -review usage patterns by looking at inventory, and reordering patterns to assure compliance; and -monitor for changes in condition related to inappropriate medication use. Review of Resident 17's Medication Review Report (current physician's orders [REDACTED]. -Multivitamin-Mineral tablets (tab) 1 tab every (q) 24 hours (hr) as needed (prn); -Preparation H Ointment insert 1 unit rectally q 6 hr prn for hemorrhoid pain; -Tums Chewable Tablet 500 mg (milligrams) q 6 hr prn for upset stomach; -Tylenol (Acetaminophen) 500 mg 1 to 2 tab q 4 hr prn for pain There was no evidence in the resident's medical record that an evaluation was done to assess the resident's ability to self-administer medications. There was no documentation on the Medication Administration Record [REDACTED]. Observation of Resident 17's room on 9/26/17 at 7:57 AM revealed a basket and other storage containers on top of the resident's dresser that contained the following medications intermingled with toiletry items: -a bottle of Aleve PM (a nonsteroidal anti-inflammatory drug, NSAID, used for pain relief, and containing the sleep aid Diphenhydramine HCl) caplets; -a bottle of Equate (generic brand name) Allergy Relief (used to treat hay fever and other respiratory allergies [REDACTED]. -a bottle of Equate Antacid Chewable tablets (used to provide relief for heartburn or upset stomach); -a bottle of generic brand Men's Daily Multivitamins; and -a bottle of Acetaminophen (Tylenol-used to treat pain and/or fever) 500 mg tablets. There was also a tube of generic brand Hemorrhoid Cream on a shelf in the bathroom. There was no evidence of physician's orders [REDACTED]. During interview on 9/26/17 at 10:55 AM, Registered Nurse (RN)-E verified Resident 17 admitted to pain all the time in the leg effected by the stroke. RN-E further verified there was no system in place to monitor and document the resident's usage of Tylenol or any of the other self-administered medications. During interview on 9/27/17 at 9:30 AM, the Administrator verified Resident 17 was not evaluated to assess ability to safely self-administer medications. The Administrator further verified the resident purchased medications while out in the community and staff were not aware of all the medications at the bedside. C. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/23/17 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident's cognition was moderately impaired, the resident had identified almost constant pain which was described as moderate and the resident had shortness of breath and trouble with breathing when at rest, lying flat and with any exertion. Review of Resident 26's Physician order [REDACTED]. -Advair Diskus Aerosol Powder Breath Activated inhaler (a type of inhaler that delivers medication to the lungs during inhalation); 50 micrograms/dose 1 puff 2 times each day for COPD, and -Estrogen Cream 0.625 mg/grams; insert 1 application vaginally every night for itching. Observations on 9/25/17 at 10:03 AM, on 9/26/17 at 8:45 AM and on 9/27/17 at 8:30 AM revealed an Advair Diskus inhaler and a tube of Estrogen cream positioned on a bedside table in Resident 26's room. Review of Resident 26's medical record revealed no evidence the resident had a physician's orders [REDACTED]. During an interview on 9/27/17 at 11:00 AM, the Director of Nursing (DON) verified the resident did not have an order for [REDACTED].",2020-09-01
369,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,431,D,1,1,XTJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1, 12-006.12E7 Based on observation, record review and interview; the facility failed to assure Resident 17's bedside medications were labeled according to pharmaceutical standards, and stored in a secure manner to prevent potential use by others. The total sample size was 25 and the facility census was 27. Findings are: [NAME] Review of the policy titled Self-Administration of Medications, revised 12/2016 indicated self-administered medications must be stored in a safe and secure place that is not accessible by other residents. Observation of Resident 17's room on 9/26/17 at 7:57 AM revealed the door to the resident's room was left open while the resident was at breakfast. There was a basket and other storage containers on top of the resident's dresser that contained the following medications intermingled with toiletry items: -a bottle of Aleve PM (a nonsteroidal anti-inflammatory drug, NSAID, used for pain relief, and containing the sleep aid Diphenhydramine HCl) caplets; -a bottle of Equate (generic brand name) Allergy Relief (used to treat hay fever and other respiratory allergies [REDACTED]. -a bottle of Equate Antacid Chewable tablets (used to provide relief for heartburn or upset stomach); -a bottle of generic brand Men's Daily Multivitamins; and -a bottle of Acetaminophen (Tylenol-used to treat pain and/or fever) 500 milligram (mg) tablets. There was also a tube of generic brand Hemorrhoid Cream on a shelf in the bathroom and without the screw-on cap in place. None of the medications had prescription labels affixed to them. On 9/27/17 at 7:49 AM a follow-up observation of Resident 17's room revealed the room door was left open while the resident attended the breakfast meal. The medications observed the previous morning remained on top of the resident's dresser and on the bathroom shelf. During interview on 9/27/17 at 9:30 AM, the Administrator verified the resident's self-administered medications were to be secured.",2020-09-01
370,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2017-09-28,520,F,1,1,XTJ511,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview, the facility Quality Assurance (QA) Committee failed to maintain correction of previously cited deficiencies related to the management of significant weight loss, prevention of accidents, and self-administration of medications. This failure had the potential to affect the well-being of all residents. The total sample size was 25 and the facility census was 27. Findings are: [NAME] Review of facility deficiency statements from Quality Indicator Surveys (QIS) revealed repeated facility non-compliance with the following Federal (F) tags: -QIS 6/17/14 - F323 Failure to protect residents from falls; -Complaint Investigation 2/23/15 - F323 Failure to transfer residents in a safe manner; -QIS 7/21/15 - F323 Failure to protect residents from falls and F325 Failure to prevent weight loss; and -QIS 7/13/16 - F323 Failure to protect residents from elopement, F325 Failure to prevent weight loss, F425 Failure to assess and monitor residents' self-administration of medications, and F431 Failure to store medications in a secure manner. Review of the facility deficiency statements from the QIS completed on 9/28/17 revealed repeated facility non-compliance with the following F tags: -F323 - Failure to transfer residents in a safe manner, protect residents from falls, provide a safe smoking environment, assure residents were safe during outside privileges, and store hazardous chemicals in a secure manner; -F325 - Failure to prevent weight loss; -F425 - Failure to assess and monitor residents' self-administration of medications; and -F431 - Failure to store medications in a secure manner. During interview on 9/28/17 from 9:00 AM to 9:43 AM, the Director of Nursing (DON) and facility Administrator confirmed the QA Committee had not corrected the repeated deficient practices.",2020-09-01
371,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,580,D,0,1,K6L311,"**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 failed to notify the attending physician of a change in condition for 2 of 2 residents reviewed. This involved 27's low blood sugar results and failure to initiate Resident 32's medication as ordered. The facility census was 30. Findings are: [NAME] Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/16/18 revealed a [DIAGNOSES REDACTED]. Review of Resident 27's Progress Notes dated 8/12/18 at 2:00 AM revealed the resident used the call light before 1:00 AM and complained of not feeling well. Documentation indicated the resident was .noted to be clammy and warm. Not easy to rouse. Documentation further indicated the resident's blood sugar result was 49. The resident drank a liquid supplement and ate 4 peanut butter crackers. The resident's blood sugar result was 62 at 1:15 AM and 77 at 1:30 AM. Review of Progress Notes dated 9/15/18 at 5:14 AM revealed at approximately 2:00 AM, Resident 27 put on the call light and reported not feeling well. Documentation indicated the resident was clammy and the blood sugar result was 44. The resident was given orange juice, a pudding cup and some crackers. Approximately 30 minutes after consuming the juice, pudding and crackers, the resident's blood sugar was 76. There was no evidence Resident 27's attending physician was notified of the low blood sugar results during the night shifts on 8/12/18 and 9/15/18. Interview with the Director of Nurses (DON) on 11/19/18 revealed the physician was to be notified any time a blood sugar result was below 60. The DON confirmed Resident 27's low blood sugar results on the night shifts on 8/12/18 and 9/15/18 should have been reported to the attending physician. B. Review of Resident 32's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment identified the resident was cognitively intact and no behaviors were identified. Review of Resident 32's Care Plan (undated) revealed the resident was at risk for behaviors due to [DIAGNOSES REDACTED]. The care plan identified current behaviors which included resistance with cares and with taking medications. Nursing interventions included the following: -administer medications as ordered; -explain all procedures before starting and allow the resident 15 minutes to adjust to changes; -monitor behaviors and attempt to determine underlying causes for behaviors; and -arrange for psychiatric consult and follow up as needed. Review of a Nursing Progress Note dated 8/13/18 at 4:13 PM revealed the resident was admitted with orders for [MEDICATION NAME] (medication used to treat depression) 150 milligrams (mg) daily and for the resident to be seen by the psychiatrist on 9/19/18. Review of a Nursing Progress Note dated 9/5/18 at 5:35 PM revealed the resident was anxious and making comments about the staff taking things from the resident's room. Review of a Nursing Progress note dated 9/6/18 at 4:18 PM revealed the resident was anxious with multiple health complaints and the resident had refused to eat meals as felt the food was tainted. Review of a Nursing Progress Note dated 9/16/18 at 2:27 AM revealed the resident was paranoid with depressive behaviors. Review of a Progress Order Note revealed on 9/19/18 at 3:44 PM the resident was seen by the psychiatrist with new orders for Nuplazid (antipsychotic medication used for the treatment of [REDACTED]. Review of a Nursing Progress Note dated 9/23/18 at 7:11 PM revealed the resident had refused to come to the dining room for the evening meal as the resident felt it was a trap. All medications, food and fluids refused. Review of a Nursing Progress Note dated 9/25/18 at 10:41 AM revealed the resident was seen at the facility by the primary physician. The resident's physician indicated to continue current treatment and to initiate the Nuplazid as ordered by the psychiatrist when available. Review of a Nursing Progress Note dated 9/27/18 at 11:10 AM revealed the resident was outside with a staff member. When the staff attempted to bring the resident back into the facility, the resident sat on the ground and refused to get up. The resident indicated the resident did not want to be at the facility. Review of a Nursing Progress Note dated 9/30/18 at 2:39 PM revealed the resident had attempted to leave the facility as the resident wanted to go home. A new order was received for a wander-guard bracelet (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the door) and the bracelet was placed on the resident's wrist. Review of a Nursing Progress Note dated 10/15/18 at 2:01 AM revealed the resident continued to act paranoid and frequently refused medications, assist with cares and to eat meals as the resident did not trust anyone here. Review of a Nursing Progress Note dated 10/16/18 at 5:41 PM revealed the resident had a poor appetite and refused to drink fluids as felt the staff were putting something in the water. Review of a Nursing Progress Note dated 10/20/18 at 11:57 PM revealed the resident was refusing to take medications as felt someone was trying to poison the resident. Review of the resident's medical record from 9/19/18 through 10/22/18 revealed no evidence the resident had received the medication Nuplazid as ordered by the psychiatrist on 9/19/18 for the resident's behaviors. In addition, there was no documentation to indicate the resident's psychiatrist was notified the medication was not available or regarding the resident's escalating behaviors. Review of a Nursing Progress Note dated 10/22/18 (4 weeks and 5 days after the medication had been ordered) at 2:36 PM revealed a facsimile was sent to notify Resident 32's psychiatrist that the Nuplazid was not initiated as had not been available. An order was received to place the medication on hold until seen by the psychiatrist. Review of a Nursing Progress Note dated 10/23/18 at 5:24 PM revealed the resident had been seen by the psychiatrist with new orders to discontinue the Nuplazid and to start [MEDICATION NAME] (antipsychotic medication used for the treatment of [REDACTED]. During an interview on 11/19/18 at 11:14 AM, the Director of Nursing confirmed Resident 32's psychiatrist was not notified until 10/22/18 of the resident's escalating behaviors or that the medication ordered on [DATE] for the resident's behaviors had not been available for use and had never been administered.",2020-09-01
372,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,600,E,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.05(9) Based on record review and interview, the facility failed ensure interventions were in place to protect 4 residents (Residents 14, 12, 8 and 1) from Resident 7's verbal and physical abuse. The sample size was 22 and the facility census was 30. Findings are: [NAME] Review of the facility abuse policy titled What You Should Know About Reporting dated 3/27/17 included the following: -Verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; and -Physical abuse was defined as hitting, slapping, pinching and kicking and including controlling behavior. The policy further indicated the facility was to take immediate action to ensure the safety of the resident when abuse was suspected. B. Review of Resident 7's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/16/18 revealed [DIAGNOSES REDACTED]. Review of a Behavior Note dated 5/9/18 at 10:43 AM revealed Resident 7 complained about Resident 14 entering Resident 7's room and going through belongings. Resident 7 made threatening comments about Resident 14 and stated I will handle (Resident 14) myself, I will just crack (Resident 14) skull open and .I will drag (Resident 14) out of my room and punch (Resident 14) if I have to. Review of Resident 7's Care Plan dated 5/9/18 revealed an intervention to monitor Resident 7 closely down the south hall due to threatening statements of harm to another resident. The Care Plan indicated the Administrator was checking on alternate placement for Resident 7. Review of a Behavior Note dated 6/13/18 at 7:00 PM revealed the following: -Resident 14 entered Resident 7's room; -Resident 7 attempted to redirect Resident 14 out of the room in a mild but moderately loud voice; -Nursing Assistant (NA)-F witnessed the incident and reported Resident 7 pushed Resident 14 out into the doorway while trying to close the room door. Resident 14's foot was still in the doorway as Resident 7 attempted to close the door and Resident 14's foot was squeezed during the process; -Resident 14 sustained no injury; and -Resident 7 was upset about NA-F reporting the incident. There was no evidence additional interventions were developed to prevent further incidents between Resident 14 and Resident 7. C. Review of a Behavior Note dated 7/4/18 at 9:06 PM revealed Resident 7 had an .anger outburst in dining room at the beginning of evening meal and throws coffee cup. Documentation indicated no one was hit by the coffee cup and Resident 7 was asked to exit the dining room. Resident 7 agreed to leave without further argument. Resident 7 backed up the wheelchair and the anti-tip bar on the back of Resident 7's wheelchair ran over the top of Resident 12's shoe which caused Resident 12 to yell out in pain. Documentation further indicated Resident 12's yelling was what triggered Resident 7 to have the outburst. There was no evidence interventions were developed to address Resident 7's adverse behaviors while in the dining room. D. Review of a Behavior Note dated 9/28/18 at 11:45 AM revealed Resident 7 had an anger outburst directed toward another resident after breakfast. The other resident asked Resident 7 to move so the other resident could pass by. Resident 7 began yelling and using vulgar language towards the other resident. Resident 7 told the other resident that the other resident needed to .just die. Documentation indicated .Peer did respond verbally also at which time resident (Resident 7) threated to hit resident and advanced towards peer. Staff intervened and no contact was made between the residents. The police were notified and a local police officer did speak with Resident 7. Interview with the Administrator on 11/15/18 at 11:25 AM confirmed the police were notified on 9/28/18 after Resident 7 yelled and displayed threatening behaviors towards Resident 8. The Administrator reported Resident 7 was counseled regarding adverse behaviors by both the Administrator and the police. Review of Resident 7's Care Plan revealed additional interventions for the prevention of verbal/physical abuse in the dining room were not developed. E. Review of a Behavior Note dated 10/14/18 at 4:58 PM revealed Resident 7 was talking derogatorily to a dementia resident (Resident 1). There was no evidence further investigation was completed regarding Resident 7's derogatory remarks toward Resident 1 and additional interventions to prevent further verbal abuse were not developed.",2020-09-01
373,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,609,E,0,1,K6L311,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to ensure incidents of verbal and/or physical abuse by Resident 7 towards 4 residents (Residents 14, 12, 8 and 1) were reported to the State Agency. The sample size was 22 and the facility census was 30. Findings are: [NAME] Review of the facility abuse policy titled What You Should Know About Reporting dated 3/27/17 included the following: -Verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; and -Physical abuse was defined as hitting, slapping, pinching and kicking and including controlling behavior; and -All alleged violations involving mistreatment, neglect or abuse were to be reported immediately to the administrator of the facility and to other officials in accordance with State law. B. Review of Resident 7's Behavior Note dated 5/9/18 at 10:43 AM revealed Resident 7 complained about Resident 14 entering Resident 7's room and going through belongings. Resident 7 made threatening comments about Resident 14 and stated I will handle (Resident 14) myself, I will just crack (Resident 14) skull open and .I will drag (Resident 14) out of my room and punch (Resident 14) if I have to. Review of Resident 7's Behavior Note dated 6/13/18 at 7:00 PM revealed the following: -Resident 14 entered Resident 7's room; -Resident 7 attempted to redirect Resident 14 out of the room in a mild but moderately loud voice; -Nursing Assistant (NA)-F witnessed the incident and reported Resident 7 pushed Resident 14 out into the doorway while trying to close the room door. Resident 14's foot was still in the doorway as Resident 7 attempted to close the door and Resident 14's foot was squeezed during the process; and -Resident 14 sustained no injury. There was no evidence Resident 7's verbal and physical abuse towards Resident 14 was reported to the State Agency. C. Review of Resident 7's Behavior Note dated 7/4/18 at 9:06 PM revealed Resident 7 had an .anger outburst in dining room at the beginning of evening meal and throws coffee cup. Documentation indicated no one was hit by the coffee cup and Resident 7 was asked to exit the dining room. Resident 7 agreed to leave without further argument. Resident 7 backed up the wheelchair and the anti-tip bar on the back of Resident 7's wheelchair ran over the top of Resident 12's shoe which caused Resident 12 to yell out in pain. Documentation further indicated Resident 12's yelling was what triggered Resident 7 to have the outburst. There was no evidence Resident 7's anger outburst and potential physical abuse towards Resident 12 was reported to the State Agency. D. Review of Resident 7's Behavior Note dated 9/28/18 at 11:45 AM revealed Resident 7 had an anger outburst directed toward another resident after breakfast. The other resident asked Resident 7 to move so the other resident could pass by. Resident 7 began yelling and using vulgar language towards the other resident. Resident 7 told the other resident that the other resident needed to .just die. Documentation indicated .Peer did respond verbally also at which time resident (Resident 7) threated to hit resident and advanced towards peer. Staff intervened and no contact was made between the residents. The police were notified and a local police officer did speak with Resident 7. There was no evidence Resident 7's verbal abuse and threatening behavior towards Resident 8 was reported to the State Agency. Interview with the Administrator on 11/15/18 at 11:25 AM confirmed Resident 7's verbal and/or physical abuse towards Residents 14, 12, 8 and 1 were not reported to the State Agency.",2020-09-01
374,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,642,D,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-federally mandated comprehensive assessment tool used for care planning) was coded correctly related to use of an anticoagulant (medication used to slow down the clotting of blood) for 1 (Resident 10) of 22 sampled residents. The facility identified a census of 30. The findings are: Review of Resident 10's MDS dated [DATE] revealed the resident was coded as having an anticoagulant 7 days out of the 7 day look back period. Review of Resident 10's Medication Administration Record [REDACTED]. An interview conducted on 11/15/18 at 2:44 PM with the Director of Nursing (DON) confirmed Resident 10 was coded as being on an anticoagulant because the resident was on [MEDICATION NAME]. The DON confirmed that [MEDICATION NAME] was not an anticoagulant and the MDS should not have been coded for an anticoagulant. Review of the Resident Assessment Instrument (RAI) Manual (a manual used to guide the completion of the MDS) (MONTH) (YEAR) revealed the following: Chapter 3: MDS Items N0410: Medications Received- N0410E, Anticoagulant- do not code antiplatelet medications such as [MEDICATION NAME] here.",2020-09-01
375,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,677,D,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interview, the facility failed to provide toileting assistance/incontinence management and/or repositioning for 2 residents (Residents 4 and 30) who required assistance with activities of daily living. The sample size was 2 and the facility census was 30. Findings are: [NAME] Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/16/18 revealed a [DIAGNOSES REDACTED]. Review of Resident 4's current undated Care Plan revealed the resident had urinary incontinence. Interventions included the following: -Toilet before and after meals and activities and at bedtime. Offer to toilet when resident is anxious; -Change disposable briefs when damp/soiled and as needed; and -Check before and after meals, activities, at bed time and as required for incontinence. Observations of Resident 4 on 11/15/18 revealed the following: -At 7:20 AM Nursing Assistant (NA)-E wheeled the resident out of the whirlpool room and into the resident's room; -At 8:41 AM the resident was seated in the resident's room in a wheelchair; -From 8:44 AM until 9:35 AM the resident was seated in a wheelchair at the table in the dining room; -At 9:35 AM the resident was wheeled back to the resident's room by NA-D; -NA-D and NA-E transferred the resident out of the wheelchair and into bed at 9:37 AM. The resident was not provided the opportunity to use the toilet. NA-D and NA-E did not check the resident's disposable brief to determine whether or not the resident had been incontinent; -NA-D and NA-E transferred the resident out of bed and onto a commode at 11:10 AM. The resident's disposable incontinent brief was wet with urine. Interview with NA-E at 9:47 AM revealed Resident 4 was toileted following the whirlpool which was before breakfast. NA-E confirmed Resident 4 was not toileted following the breakfast meal. B. Review of Resident 30's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had short term and long term memory problems and was totally dependent with transfers and toileting. Review of Resident 30's current undated Care Plan revealed the resident had confusion related to [MEDICAL CONDITION] and did not understand the concept of the call light. The staff were to ensure toileting every 2 hours was enforced to encourage emptying of the bowel and bladder. Observations of Resident 30 on 11/15/18 revealed: - From 8:09 AM to 8:40 AM the resident was in the resident's room seated in the resident's wheelchair. The resident was asleep in the wheelchair. - At 8:40 AM the resident was assisted to the dining room by a staff member. - From 8:45 AM to 9:29 AM the resident was in the dining room for breakfast in the resident's wheelchair. - At 9:29 AM the resident was assisted back to the resident's room by a staff member. - From 9:31 AM to 10:44 AM the resident was in the resident's room seated in the resident's wheelchair. The resident was asleep in the wheelchair. - At 10:44 AM the resident was assisted to a church activity by a staff member. - From 11:12 AM to 11:34 AM the resident remained in the day area, with a family member, following the church service. The resident was asleep in the wheelchair. - At 11:38 AM the resident was assisted to the dining room by the resident's family member. - From 11:38 AM to 12:32 PM the resident was seated in the resident's wheelchair in the dining room for lunch. - From 12:32 PM to 1:13 PM the resident was in the resident's room seated in the resident's wheelchair. The resident was asleep in the wheelchair. - At 1:30 PM Nursing Assistant (NA)-B and NA-E assisted Resident 30 out of the resident's wheelchair with a mechanical sit-to-stand lift (device used to support a resident in a standing position during transfers, with the resident grasping handles on the lift and use of a sling behind the resident's back to assist in supporting the resident's body weight) to the bathroom. The resident was then transferred from the bathroom to the resident's recliner. NA-B stated the resident had been in the wheelchair since 6:30 AM (7 hours prior). During an interview with NA-B on 11/15/18 at 1:35 PM, NA-B was unsure why Resident 30 remained in the resident's wheelchair for 7 hours, even when sleeping. NA-B indicated this was the normal routine provided for Resident 30. Further interview revealed Resident 30's incontinence brief was checked and changed at 10:30 AM (4 hours after getting up), and the resident was then toileted at 1:30 PM (3 hours later). During an interview with the Director of Nurses (DON) on 11/15/18 at 1:45 PM, the DON confirmed residents should be repositioned every 2-3 hours.",2020-09-01
376,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,684,D,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observation, record review and interview, the facility failed to assess, monitor and provide care to Resident 12's [MEDICAL CONDITION]. The sample size was 1 and the facility census was 30. Findings are: Review of a physician progress notes [REDACTED]. The physician ordered application of [MEDICATION NAME] (a medicated cream used to prevent or treat a wound infection) to the scabbed area on the right cheek bone daily for 2 weeks and staff were to report if there was no improvement in the lesion. There was no evidence Resident 12's lesion on the right cheek was assessed and monitored. Review of a physician progress notes [REDACTED].Scabbed, [DIAGNOSES REDACTED] (abnormal redness of the skin) at base, scaly lesion on the right zygomatic arch area (cheekbone). The physician indicated no treatment was to be ordered for the facial lesion and the resident was encouraged not to pick at the scab. The physician further indicated the resident's fingernails were long. Review of Skin/Wound Notes dated 10/24/18 at 6:00 PM, 11/2/18 at 11:13 AM, 11/7/18 at 7:02 PM and 11/14/18 at 4:52 PM indicated Resident 12 had no skin issues. Resident 12 was observed to have a scabbed lesion on the right cheekbone on 11/14/18 at 8:01 AM and 12:20 PM. Observations on 11/15/18 at 8:14 AM revealed the upper portion of the scabbed lesion on Resident 12's right cheekbone had peeled off. A dark dry scab remained beneath the area on the resident's right cheek. Interview with Registered Nurse (RN)-C on 11/15/18 at 2:40 PM indicated weekly skin assessments were to be completed. RN-C confirmed Resident 12's skin assessments contained no documentation that the facial lesion was assessed and monitored. At 8:20 AM on 11/19/18, Resident 12 was observed with a scabbed lesion on the right cheekbone. The resident's fingernails were long and in need of trimming. Interview with the Director of Nurses on 11/19/18 at 9:15 AM confirmed there was no evidence Resident 12's facial lesion had been assessed and monitored.",2020-09-01
377,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,690,D,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1) Based on observations, record review and interviews; the facility failed to provide appropriate care and services for the prevention of urinary tract infections for 1 (Resident 10) of 1 resident sampled who had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). The facility census was 30. Findings are: [NAME] Review of the facility policy titled Infection Control Guidelines for Care of Indwelling Catheter (undated) identified the following steps for the prevention of urinary tract infections: -staff were to use a sterile drainage protector and catheter plug every morning when disconnecting the night drainage bag; -the night drainage bag was to be dated when it was changed and the staff were to change the drainage bag weekly; -the night drainage bag was to be kept in a cloth bag which was to remain attached to the towel rack in the resident's bathroom when the drainage bag was not in use; -if the night drainage bag was not stored with a new sterile drainage protector, then it was to be thrown away as it was considered contaminated. -the catheter was to be plugged with a sterile plug when not attached to the bag or not being drained. Cleanse the plug and the end of the drainage tube with an alcohol wipe after draining urine and before connecting to the catheter drainage bag; -staff to assure catheter drainage tube to be kept out of the resident's disposable urinary incontinence brief and away from the resident's genitals; -catheter to be drained every 2-3 hours when not attached to the catheter drainage bag; and -cleanse catheter insertion site with soap and water daily during catheter cares and as needed if the catheter becomes visibly soiled. Cleanse the catheter tubing from the insertion site towards the end of the catheter and away from the body. B. Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 08/29/18 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS identified the resident's cognition was severely impaired and the resident required extensive staff assistance with transfers, toileting and personal hygiene. Review of a physician facsimile (fax) from the urologist dated 8/24/18 revealed the resident was to have the suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the abdomen) changed every month. Staff were to remove the drainage plug every 2 hours and drain unless the catheter was attached to the drainage bag. Drainage bag was to be used throughout the night. Review of a Physician Visit Form dated 8/30/18 revealed the resident's catheter was changed at the urologist office. Review of Resident 10's current Care Plan dated 9/4/18 revealed the resident was at risk for complications from use of an indwelling suprapubic catheter due to [DIAGNOSES REDACTED]. In addition, the resident had a history of [REDACTED]. The following interventions were identified: -staff to monitor and record catheter output every shift; -catheter insertion site and catheter to be cleansed with soap and water during cares and when visibly soiled; -catheter to be drained into a graduate stored in the resident's bathroom every 2-3 hours when catheter was not attached to the drainage bag; and -when drainage bag disconnected in the morning, staff to place a new sterile drainage protector on the end of the tubing. If drainage bag is not stored with a new sterile protector, then the bag is to be considered contaminated and should be discarded. Review of a Physician Visit Form dated 9/27/18 revealed the resident was seen by the urologist and the suprapubic catheter was changed. Review of a Physician Visit Form dated 10/5/18 revealed a urinalysis was obtained and was concerning for an infection. Review of a physician order dated 10/8/18 revealed a new order for Bactrim (antibiotic used to treat infections) Double Strength (DS) 800-160 milligrams (mg) twice a day for 14 days for treatment of [REDACTED]. Review of a Physician Visit Form dated 10/25/18 revealed the resident was seen by the urologist and the suprapubic catheter was changed. Review of a Nursing Progress Note dated 10/26/18 at 2:51 AM revealed the resident had been complaining of pain to the catheter insertion site. When the drainage plug was removed, staff drained 250 cubic centimeters (cc) of dark red blood from the drainage bag and the resident continued to have complaints of pain. The resident's physician was notified and a new order was received to transfer Resident 10 to the emergency room for evaluation. The progress note further revealed the resident was then admitted to the hospital. Review of a Nursing Progress Note dated 10/28/18 at 4:25 PM revealed the resident was discharged from the hospital with a [DIAGNOSES REDACTED]. New orders were identified for [MEDICATION NAME] (antibiotic used to treat infections) 875-125 mg 1 tablet twice a day for 12 days. Review of Resident 10's Treatment Administration Record (TAR) dated 10/6/18 through 10/31/18 revealed staff were to document the resident's urinary output each shift. Further review of the resident's TAR revealed the following: -5:30 AM there was no documentation of the resident's urinary output on 10/8, 10/17, 10/20, 10/21, 10/23, 10/24, 10/25, 10/29, 10/30 and on 10/31/18; -1:30 PM there was no documentation of the resident's urinary output on 10/7, 10/10, 10/11, 10/12 and on 10/19/18; and -9:30 PM there was no documentation of the resident's urinary output on 10/6 and on 10/24/18. Review of a Physician Visit Form dated 11/5/18 revealed the resident was seen at the urologist office to have suprapubic catheter changed. Review of Resident 10's TAR dated 11/1/18 through 11/12/18 revealed staff were to document the resident's urinary output each shift. Further review of the resident's TAR revealed the following: -5:30 AM there was no documentation of the resident's urinary output on 11/1, 11/2, 11/3, 11/7, 11/8, 11/10 and on 11/11/18 -1:30 PM there was no documentation of the resident's urinary output on 11/4, 11/10 and on 11/11/18; and -9:30 PM there was no documentation of the resident's urinary output on 11/6/18. During an observation on 11/14/18 from 11:45 AM to 12:00 PM the resident was assisted by Nurse Aide (NA)-B into the resident's bathroom and onto the toilet. NA-B washed hands and put on clean disposable gloves. A graduated cylinder which was positioned directly on the back of the resident's toilet tank, was placed in the resident's lap without benefit of a barrier. NA-B removed the catheter plug, cleansed the opening of the catheter drainage tube with a pre-packaged alcohol pad and proceeded to drain urine from the tube into the graduated cylinder. After the catheter was drained, NA-B used the same alcohol pad and again cleansed the catheter drainage tube and replaced the catheter plug into the drainage tube. NA-B removed gloves and without washing or sanitizing hands, assisted the resident out of the bathroom and out to the dining room for the noon meal. During an observation of Resident 10 on 11/15/18 at 7:09 AM the resident was lying in bed in the resident's room. Resident 10's urinary catheter drainage bag and tubing were lying directly on the floor next to the resident's bed. During an observation of indwelling urinary catheter care on 11/15/18 from 7:12 AM until 7:30 AM, NA-B entered the resident's bathroom, washed hands and put on a clean pair of disposable gloves. NA-B removed a drainage plug, which was resting uncovered on a shelf in the resident's bathroom and took the plug to the resident's bedside. NA-B opened a pre-packaged alcohol pad, disconnected the catheter drainage tube from the catheter drainage bag, cleansed the drainage tube opening and then inserted the catheter plug from the resident's bathroom. After emptying the catheter drainage bag, NA-B placed the drainage bag into a cloth bag which was hanging from a towel rack in the resident's bathroom. There was no date observed on the catheter drainage bag to indicate when the drainage bag had last been replaced and there was no protector placed on the end of the drainage tube. NA-B then removed gloves and without washing hands or using a hand sanitizer started to dress Resident 10. NA-B finished Resident 10's morning cares but failed to complete catheter site cares. During interview on 11/15/18 at 11:54 AM, the Director of Nursing (DON) confirmed the following regarding Resident 10's suprapubic urinary catheter: -the nursing staff were to monitor and document urinary output every shift and confirmed there was missing documentation regarding the resident's urinary output; -the resident's cognition was severely impaired; -the resident only used a drainage bag at night as the resident would disconnect his catheter independently at times. The drainage bag was to be disconnected in the morning, the catheter drainage tube was to be cleansed with alcohol and a sterile plug was to be placed in the tube. The catheter drainage bag was to be stored in a cloth bag which was hanging on a towel rack in the resident's bathroom. The drainage bag was to have a sterile protector on the end of the tubing of the drainage bag. Drainage bag was to be dated to indicate when the bag was last changed and the bag was to be changed weekly; -NA-B should have followed the facility policy for care of an indwelling catheter to prevent the potential for cross contamination; and -the resident had been treated for [REDACTED].",2020-09-01
378,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,692,D,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on record review and interview, the facility failed to develop nutritional interventions for 1 (Resident 10) of 4 sampled residents with weight loss and/or nutritional needs. The facility census was 30. Findings are: [NAME] Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/29/18 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident's cognition was severely impaired but the resident was independent with eating. The resident's weight was 169 pounds (lbs.) and the assessment identified the resident was not on a prescribed weight lost regime. Review of Weights and Vitals Summary Sheet (document used to record the resident's weights) revealed Resident 10's weight on 9/5/18 was 165 lbs. (down 4 lbs. in 1 week). Review of Resident 10's current Care Plan dated 9/17/18 revealed the resident was at risk for nutritional problems related to [DIAGNOSES REDACTED]. -Monitor/record the resident's weekly weight and report to the resident's physician a 3 lb. weight loss in 1 week or a 5% weight loss in 1 month; and -Registered Dietician to evaluate and make recommendations as needed. Review of a Dietary Progress Note by the Registered Dietician (RD) dated 9/17/18 at 11:21 AM revealed the resident had a slight weight loss of 4 lbs. since admission. The note identified the resident was on a regular diet and the resident had no chewing or swallowing problems. The RD indicated if the resident's slow weight loss continued, then would start the resident on fortified (addition of added calories and nutrients to food items to improve nutrition and weight loss) food at meals. No further recommendations were identified. Review of Weights and Vitals Summary Sheet revealed the following regarding Resident 10's weights: -9/26/18 weight was 161 lbs. (down 8 lbs. or a 5% loss in 1 month). -10/17/18 weight was 159 lbs. (down 2 lbs. in 1 week) Review of Resident 10's medical record revealed no documentation to indicate the RD had reviewed the resident's weight loss or that any nutritional interventions were developed to address the resident's weight loss. Review of Weights and Vitals Summary Sheet revealed the resident's weight on 11/14/18 was 162 lbs. (up 3 lbs. in 1 month). Interview with the Dietary Manager on 11/15/18 at 10:17 AM confirmed no nutritional interventions had been developed to address the resident's weight loss.",2020-09-01
379,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,698,D,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to coordinate care and services in the provision of [MEDICAL TREATMENT] (a treatment option for people with [MEDICAL CONDITION]) treatments for 1 of 1 (Resident 15) residents reviewed who were receiving [MEDICAL TREATMENT] services. Monitoring and assessment of the resident related to [MEDICAL TREATMENT] treatments was not not provided. The facility census was 30. Findings are: [NAME] Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/21/18 indicated the resident was admitted with [DIAGNOSES REDACTED]. The resident was cognitively intact, independent in activities of daily living, and received [MEDICAL TREATMENT] treatments. Review of Resident 15's comprehensive Care Plan, initiated on 6/28/17, revealed a [DIAGNOSES REDACTED]. Nursing interventions included the following: -Dietary consult to regulate protein and potassium intake; -Teaching to resident, family and caretakers related to disease progression; s/sx (signs and symptoms) to be reported to the medical team; importance of compliance with the treatment plan, fluid restriction, dietary restrictions and energy conservation; and importance of compliance with medications and [MEDICAL TREATMENT] treatment; -Monitor changes in mental status; s/sx of fluid volume depletion or excess; s/sx of acute kidney failure; and -Monitor lab reports and notify the physician if serum potassium over 5.5. Review of Progress Notes revealed the following related to Resident 15: -8/30/18 at 1:55 PM - appointment with physician for follow up of doppler/US (Doppler ultrasound-a test used to measure the amount of blood flow through arteries and veins) study of fistula (the surgical connection of an artery to a vein, usually in the arm, that allows long-term access to needles during [MEDICAL TREATMENT], allowing blood to flow out to and return from the [MEDICAL TREATMENT] machine). Will have fistulogram (a special x-ray procedure used to check if a fistula is blocked or narrowing) next week; -9/5/18 at 8:07 PM - returned from procedure today. Has bandage to left antecubital (front part of the elbow) to be removed after 24 hours; -9/7/18 at 5:14 AM - dressing removed from incision from surgical site on left antecubital. Thrill (pulse or vibration indicating blood flow) palpable (felt by touch) at old fistula site and at antecubital incision site. Passed on to Charge Nurse. Stitch intact to incision site. No s/sx of infection. No drainage. Dry with well approximated edges; -9/20/18 at 3:21 PM - returned from physician's office for post fistula replacement; and -9/21/18 at 2:58 PM - sutures to left arm were removed at appointment yesterday. Review of the medical record from 9/21/18 through 11/8/18 revealed no further evidence of assessment of Resident 15's fistula, or other medical evaluations related to [MEDICAL TREATMENT] treatments. Review of the comprehensive Care Plan revealed revisions were made on 11/8/18 with additional nursing interventions that included the following: -AV (arteriovenous) fistula to left arm which is accessed at [MEDICAL TREATMENT]. No BP (blood pressure) to left arm; -Check blood flow through AV fistula by palpating (feeling) the thrill and listening for the bruit (a swishing sound associated with blood flow) with a stethoscope daily and prn (as needed). Any change noted in pitch may indicate a clot or narrowing of the fistula. This sound may change from a whooshing noise to a [MEDICATION NAME]-like sound. Inform the physician and [MEDICAL TREATMENT] Center if changes are noted; -[MEDICAL TREATMENT] at the [MEDICAL TREATMENT] Center every Monday, Wednesday and Friday morning; -Discourage resident from wearing tight-fitting shirts or jewelry that may restrict blood flow to the left arm due to the AV fistula; and -Monitor the AV fistula to the left arm at least daily for signs and symptoms of infection (pain, redness, swelling) and report to the physician if noted. There was no evidence in the medical record that nursing interventions related to care and assessment of Resident 15's AV fistula were initiated. During interview with Licensed Practical Nurse (LPN)-A on 11/14/18 at 1:28 PM, the following was revealed: -denied monitoring and/or assessments were completed related to Resident 15's [MEDICAL TREATMENT] treatments and AV fistula as everything is done there (at the [MEDICAL TREATMENT] Center); -the resident returned from [MEDICAL TREATMENT] with a pressure dressing (used to control bleeding at the fistula site) and removed the dressing independently the following morning; -verified a fistulogram was recently completed and the AV fistula was replaced; and -was unaware of recent revisions made to the resident's Care Plan. During interviews, the following was revealed: -11/14/18 at 2:59 PM, the Administrator verified there were no written policies/procedures related to care and management of residents receiving [MEDICAL TREATMENT]; and -11/19/18 at 7:17 AM, the Director of Nursing (DON) verified monitoring and assessment of the resident related to [MEDICAL TREATMENT] treatments needed to be established.",2020-09-01
380,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,725,E,0,1,K6L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and interview, the facility failed to provide sufficient numbers of nursing staff to answer call lights in a timely manner and/or provide assistance with activities of daily living (ADL). This affected 3 (Residents 9, 4 and 30) of 22 sampled residents. The facility census was 30. Findings are: [NAME] During an interview on 11/13/18 at 10:37 AM, Resident 9 identified a staffing concern related to call light response times. Resident 9 indicated sometimes in the morning before breakfast, it could take up to 25 minutes to have staff respond to the resident's call light. Observations of call light response times on 11/15/18 revealed Resident 9's call light was on at 7:44 AM. Resident 9's call light was observed to be on until 8:05 AM (21 minutes). Interview with Resident 9 on 11/15/18 at 8:27 AM confirmed the resident's call light had been on for quite a while and that the resident had needed to use the bathroom. Interview with the Administrator on 11/19/18 at 10:00 AM revealed the expectation for call lights to be answered within 3-5 minutes. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/16/18 revealed a [DIAGNOSES REDACTED]. Review of Resident 4's current undated Care Plan revealed the resident had urinary incontinence. Interventions included the following: -Toilet before and after meals and activities and at bedtime. Offer to toilet when resident is anxious; -Change disposable briefs when damp/soiled and as needed; and -Check before and after meals, activities, at bed time and as required for incontinence. Observations of Resident 4 on 11/15/18 revealed the following: -At 7:20 AM Nursing Assistant (NA)-E wheeled the resident out of the whirlpool room and into the resident's room; -At 8:41 AM the resident was seated in the resident's room in a wheelchair; -From 8:44 AM until 9:35 AM the resident was seated in a wheelchair at the table in the dining room; -At 9:35 AM the resident was wheeled back to the resident's room by NA-D; -NA-D and NA-E transferred the resident out of the wheelchair and into bed at 9:37 AM. The resident was not provided the opportunity to use the toilet. NA-D and NA-E did not check the resident's disposable brief to determine whether or not the resident had been incontinent; -NA-D and NA-E transferred the resident out of bed and onto a commode at 11:10 AM. The resident's disposable incontinent brief was wet with urine. Interview with NA-E at 9:47 AM revealed Resident 4 was toileted following the whirlpool which was before breakfast. NA-E confirmed Resident 4 was not toileted following the breakfast meal. C. Review of Resident 30's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had short term and long term memory problems and was totally dependent with transfers and toileting. Review of Resident 30's current undated Care Plan revealed the resident had confusion related to [MEDICAL CONDITION] and did not understand the concept of the call light. The staff were to ensure toileting every 2 hours was enforced to encourage emptying of the bowel and bladder. Observations of Resident 30 on 11/15/18 revealed: - From 8:09 AM to 8:40 AM the resident was in the resident's room seated in the resident's wheelchair. The resident was asleep in the wheelchair. - At 8:40 AM the resident was assisted to the dining room by a staff member. - From 8:45 AM to 9:29 AM the resident was in the dining room for breakfast in the resident's wheelchair. - At 9:29 AM the resident was assisted back to the resident's room by a staff member. - From 9:31 AM to 10:44 AM the resident was in the resident's room seated in the resident's wheelchair. The resident was asleep in the wheelchair. - At 10:44 AM the resident was assisted to a church activity by a staff member. - From 11:12 AM to 11:34 AM the resident remained in the day area, with a family member, following the church service. The resident was asleep in the wheelchair. - At 11:38 AM the resident was assisted to the dining room by the resident's family member. - From 11:38 AM to 12:32 PM the resident was seated in the resident's wheelchair in the dining room for lunch. - From 12:32 PM to 1:13 PM the resident was in the resident's room seated in the resident's wheelchair. The resident was asleep in the wheelchair. - At 1:30 PM Nursing Assistant (NA)-B and NA-E assisted Resident 30 out of the resident's wheelchair with a mechanical sit-to-stand lift (device used to support a resident in a standing position during transfers, with the resident grasping handles on the lift and use of a sling behind the resident's back to assist in supporting the resident's body weight) to the bathroom. The resident was then transferred from the bathroom to the resident's recliner. NA-B stated the resident had been in the wheelchair since 6:30 AM (7 hours prior). During an interview with NA-B on 11/15/18 at 1:35 PM, NA-B was unsure why Resident 30 remained in the resident's wheelchair for 7 hours, even when sleeping. NA-B indicated this was the normal routine provided for Resident 30. Further interview revealed Resident 30's incontinence brief was checked and changed at 10:30 AM (4 hours after getting up), and the resident was then toileted at 1:30 PM (3 hours later). During an interview with the DON on 11/15/18 at 1:45 PM, the DON confirmed residents should be repositioned every 2-3 hours.",2020-09-01
381,PARK VIEW HAVEN NURSING HOME,285073,309 NORTH MADISON STREET,COLERIDGE,NE,68727,2018-11-19,880,E,0,1,K6L311,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.17A, and 175 NAC 12-006.17B Based on observations, record review and interview: the facility failed to prevent potential cross contamination between residents as hands were not washed at appropriate intervals during the provision of indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) cares for Resident 10 and the facility failed to complete monthly infection control surveillance. The total sample size was 22 and current census was 30. Findings are: [NAME] Review of the facility policy titled Hand-washing/hand hygiene (undated) revealed the facility considered hand hygiene the primary means to prevent the spread of infection. The policy indicated staff were to wash hands with an antimicrobial or a non-antimicrobial soap and water when hands were visibly soiled and after contact with a resident with infectious diarrhea. An alcohol-based hand rub containing at least 62% (percent) alcohol or soap and water could be used for the following situations: -before and after direct contact with residents; -before donning gloves; -before and after handling an invasive device; -after contact with bodily fluids; and -after removing soiled gloves. B. During an observation on 11/14/18 from 11:45 AM to 12:00 PM, Resident 10 was assisted by Nurse Aide (NA)-B into the resident's bathroom and onto the toilet. NA-B washed hands and put on clean disposable gloves. NA-B proceeded to drain the resident's indwelling urinary catheter. NA-B then removed gloves and without washing or sanitizing hands, assisted the resident out of the bathroom and to the dining room for the noon meal. During an observation of indwelling urinary catheter care for Resident 10 on 11/15/18 from 7:12 AM until 7:30 AM, NA-B entered the resident's bathroom, washed hands and put on a clean pair of disposable gloves. NA-B disconnected the catheter drainage tube from the catheter drainage bag and inserted the catheter plug into the catheter drainage tube. NA-B proceeded to empty the catheter drainage bag in the resident's bathroom. NA-B then removed gloves and without washing hands or using a hand sanitizer started to dress Resident 10. Interview with the Director of Nursing on 11/15/18 at 11:54 AM, confirmed NA-B was expected to wash/sanitize hands following provision of urinary catheter cares and after removal of soiled gloves. C. Review of the facility's Infection Control Surveillance log dated 9/6/18 to 11/2/18 revealed no evidence to indicate surveillance had been completed from (MONTH) (YEAR) through (MONTH) (YEAR). During an interview with the Administrator on 11/19/18 at 8:55 AM, the Administrator confirmed infection control surveillance was not completed from (MONTH) (YEAR) to (MONTH) (YEAR).",2020-09-01
382,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2018-08-21,658,D,1,1,23B311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.10.A2 Based on observation, record review and interview the facility failed to ensure staff followed [DEVICE] medication administration consistent with facility policy and acceptable standards of practice while performing medication administration. This had the potential to affect one resident, (Resident #52). The census was 64. Findings are: An observation on 08/20/18 at 07:00 AM of medications given by [DEVICE] (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) for Resident 52, revealed LPN (Licensed Practical Nurse) A preparing the medications individually in medication cups after crushing each pill individually and then placing a small amount of of applesauce, (enough to cover the bottom of the medication cup) on top of each pill. LPN A then placed 5 cc of water into each medication cup. LPN A checked placement of the [DEVICE] and then gave each medication separately through the [DEVICE]. The mixture did not flow easily down the syringe and LPN A placed the plunger of the syringe into the syringe and pushed the medications down through the [DEVICE] and then pulled them back, removed the plunger and the medication mixture did drain down the syringe and [DEVICE]. An interview on 08/20/18 at 07:10 AM with LPN A revealed the applesauce was placed in the medications to help suspend the medications. An interview on 8/20/18 at 09:10 AM with the DON (Director of Nursing) confirmed that DON knew LPN A used applesauce when giving [DEVICE] medications and that LPN A is the only nurse that uses applesauce when giving [DEVICE] medications. A record review of Medications Through an Enteral Tube Competency dated 1/2010 revealed to prepare the medications and dilute crushed and powdered medications with warm water. A record review of Order Summary Report dated (MONTH) 14, (YEAR) revealed no orders for applesauce to be placed with the medications for [DEVICE]. On 08/20/18 at 03:58 PM an interview with DON confirmed there was no order for adding applesauce to the medications for the [DEVICE]. On 08/20/19 a record review of [DEVICE] medication administration guidelines revealed no recommendations of using applesauce with [DEVICE] medication administration routinely. On 8/22/18 a record review of ASPEN (American Society for [MEDICATION NAME] and Enteral Nutrition ([DEVICE])), Safe Practices for Enteral Nutrition Therapy, dated (MONTH) (YEAR) revealed practice recommendations to crush pills into a fine powder and mix with purified water.",2020-09-01
383,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2018-08-21,758,D,1,1,23B311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to have physicians orders stating the end date of PRN (as needed) [MEDICAL CONDITION] medications for residents. This had the potential to affect 2 residents, (Resident # 53 and 60). The census was 64. Findings are: On 08/16/18 at 02:31 PM a record review of Resident 53's physician orders [REDACTED]. On 08/20/18 at 01:47 PM an interview with the DON (Director of Nurses) confirmed there was no 14 day limit on Resident # 53 [MEDICATION NAME]. Record review of Resident 60's Physicians Orders dated 8/12/18 revealed Lorazapam ( a [MEDICAL CONDITION] medication to treat anxiety) .5 mg orally every 8 hours as needed for Anxiety/Agitation related to Restlessness and Agitation give Lorazapam 0.5-1 mg p.o.(by mouth), q (every) 8 hours PRN (as needed). Interview with the Director of Nursing on 08/20/18 at 1:37 PM confirmed that there was no 14 day limit on Resident 60's [MEDICATION NAME].",2020-09-01
384,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2018-08-21,880,D,1,1,23B311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number 175 NAC 12-006.17D Based on observation, record review and interview, the facility failed to ensure staff followed hand hygiene practices consistent with the facility's policy and acceptable standards of practice when performing a [DEVICE] dressing change. This had the potential to affect 2 residents, (Residents # 52 and 53). The census was 64. On 08/20/18 at 09:48 AM an observation of [DEVICE] (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) care for Resident 52 by LPN (Licensed Practical Nurse) A revealed LPN A washed hands, donned gloves, removing the old dressing from the site, cleansed the [DEVICE] site, dried the site and placed a clean dressing around the [DEVICE]. LPN A removed gloves and washed hands. On 08/20/18 at 10:05 AM an observation of [DEVICE] care of Resident 53 revealed RN (Registered Nurse) B washed hands and put on gloves. RN B removed the dressing from around the [DEVICE], cleansed around the [DEVICE], dried the area and placed a clean dressing around the [DEVICE]. RN B removed gloves and washed hands. Record review of Skills Checklist-Enteral Feeding Tube Exit Site Care, [DEVICE] dated (YEAR), revealed staff is to perform hand hygiene, put on gloves and gently remove dressing. Remove and discard gloves, perform hand hygiene and put on new gloves. On 08/20/18 at 01:47 PM an interview with the DON (Director of Nursing) confirmed staff should wash their hands and change gloves after removing the old dressing. A record review of Directions to Change a Dressing, MedStar Visiting Nurse Associationdated (YEAR) on website, revealed hand hygiene should be performed and clean gloves donned after removing the old dressing and after cleansing the wound area, before placing the clean dressing and when finished with the dressing change.",2020-09-01
385,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2017-09-14,309,D,0,1,9G1D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on record review, observation and interview, the facility failed to provide care to meet the needs of a resident receiving [MEDICAL TREATMENT] services by not following up on [MEDICAL TREATMENT] recommendations for one resident. (Resident 32). This had the potential to affect 1 of 1 resident reviewed that was receiving [MEDICAL TREATMENT]. The facility census was 62. Findings are: Record review of Resident 32's Progress Notes dated 8/31/17 at 1:11 PM by the Director of Nurses (DON) revealed the following information: Spoke with [MEDICAL TREATMENT] center. 1500cubic centimeters (cc) fluid restriction confirmed. Observation on 9/13/17 at 10:16 am, a 480cc glass of ice water was sitting on a bedside table in Resident 32's room. Interview on 9/13/17 at 10:20am, with Registered Nurse (RN) A revealed that Resident 32 did not have an order for [REDACTED].>Interview on 9/14/17 at 11:00am, with the DON confirmed the expectation that orders from the [MEDICAL TREATMENT] unit were to be sent to the primary care physician. The order for 1500cc fluid restriction had not been sent to the primary care physician for confirmation. When asked how the DON became aware of the order, the DON stated the spouse of Resident 32 had brought it to the DON and the DON had called the [MEDICAL TREATMENT] unit for confirmation.",2020-09-01
386,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2018-11-07,689,D,1,0,YUX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.097b Based on interviews and record reviews; the facility failed to complete an investigation to determine causal factors and develop interventions that correspond with the causal factors for a fall, for 1 of 3 sampled residents (Resident 3). The facility Census was 67. Findings are: An interview on 11/7/18 at 12:21 PM with the Administrator confirmed that the unwitnessed fall documentation dated 9/10/2018 at 12:30 AM with a revision date of 11/7/18 at 11:12AM on the predisposing causal environmental, physiological, and situational factors had all been answered with none. An interview on 11/7/18 at 1:45 PM with the DON (Director of Nurses) confirmed that the intervention for the fall on 9/10/18 was to prop pillow to the right side of the bed for repositioning and toileting at 12:00 AM and 4:00 AM. The DON revealed that the root cause of the fall was disease process and Resident 3 had more confusion at times. The DON confirmed that the incontinence at the time of the fall and pattern of incontinence had not been investigated or documented as the root cause of the fall. An interview on 11/7/18 at 1:45 PM with the Administrator confirmed that the investigation was done and the root cause was cognitive loss. The Administrator confirmed that Resident 3 had moderately impaired cognition. Record review of the IDT (Interdisciplinary Team, a team of professional disciplines that work together to provide the greatest benefit for residents) Review Meeting document dated 10/9/18 at 12:30 AM revealed; 1. Resident 3 was unable to tell staff what they were doing at the time of the fall. 2. Resident 3 had been found kneeling at the bedside. 3. Resident 3 was alert and oriented to person, place at the time of the fall assessment. 4. Resident 3 was barefoot at the time of the fall. 5. Resident 3 was last toileted at bedtime prior to the fall. 6. Resident 3 was unassisted at time of fall. 7. Resident 3 had an antidepressant and [MEDICATION NAME] 8 hours prior to fall. 8. Recreation of last hours before the fall Resident 3 had been in bed at 11:00PM and at 11:30PM. At 12:00 AM, Resident 3's call light was responded to and the resident was unaware of why it was on. At 12:30 AM Resident 3 had been found on floor next to the bed in a kneeling position. 9. The IDT review meeting notes identified the root cause of cognitive loss. 10. The review of the initial interventions put in place by the charge nurse at the time of the incident was not addressed. The systems or process issues contributing to the fall and patterns or trends contributing to the fall were not addressed. 11. An intervention was added, to offer toileting at 12:00AM and 4:00PM. Record review of MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) Significant change dated 9/13/18 the Section C. C0500 the BIMS (Brief Interview for Mental Status, a tool used to assess cognition) score for Resident 3 was a nine. The Score of 9 indicated moderate impairment for cognition. Record review of care planned interventions with an initiation date of 9/10/18 revealed the staff was to offer prop pillows to Resident 3's right side at night. An intervention initiated on 9/11/18 revealed toileting was to be offered at 12:00AM and 4:00AM. Record review of Fall Prevention policy with a Revision date of 07/2017 revealed; Post fall actions were to investigate falls as they occur, collect factual evidence related to the fall, collect and study the cause of the fall using Root Cause Analysis process and determine what can be done to prevent it from happening again.",2020-09-01
387,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2018-11-07,943,D,1,0,YUX411,"> Licensure Reference Number 175 NAC 12-006.2(8) Based on record review and interview, the facility failed to send in a written investigation within 5 working days after reporting an incident to Adult Protective Services. This had the potential to affect one resident. (Resident 1). Sample size was 3. The facility census was 67. Findings are: Record review of the facility Investigation Report of Injury of Unknown Origin revealed that the incident was called into Adult Protective Services involving Resident 1 on (MONTH) 24th (YEAR) at 1:43 AM. Further review of the document revealed that the facility did not send there investigation report into the State Agency until (MONTH) 1, (YEAR). Six days after the incident was called into Adult Protective Services. Interview with the Administrator on 11/7/2018 at 1:40 PM confirmed that the facility failed to send in the Investigation Report within 5 working days after the incident had occurred. That the incident was called into Adult Protective Services on 10/24/2018 and the facility did not send in a report to the State Agency until 11/1/2018.",2020-09-01
388,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,550,D,0,1,ZY2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(21) Based on observation, record review and interview; the facility failed to ensure that lift slings were not visible for 2 residents, Residents 30 and 56 and the facility failed to ensure that Resident 42 was treated with dignity during perineal care, transfers with the hoyer lift, and dining. The facility census was 59. Findings are: [NAME] Observation on 11/18/19 from 11:30 AM-12:15 PM in the dining room revealed Resident 30 sitting at dining room table in wheelchair with the lift sling visible from the back of the wheelchair. Observation on 11/19/19 from 11:35 AM-12:10 PM in the dining room revealed Resident 30 sitting at dining room table in wheelchair with the lift sling visible from the back of the wheelchair and Resident 56 sitting at dining room table in wheelchair with lift sling visible from both sides of the wheelchair. Record review of Residents 30's Comprehensive Care Plan revealed no stated preference for leaving the lift sling visible while up in wheelchair. Record review of Resident 56's Comprehensive Care Plan revealed that lift sling was to be left under Resident in wheelchair on [MEDICAL TREATMENT] days-M-W-F and doesn't state a preference for non-[MEDICAL TREATMENT] days. Interview on 11/21/19 at 2:45 PM with DON (Director of Nursing) confirmed that having lift slings visible from wheelchairs would be a dignity issue and should be tucked in so they do not show. The DON also confirmed that current care plans for Resident's 30 and 56 did not state a preference for leaving lift slings in while up in wheelchair. B. Record review of policy titled Incontinent/Peri Care Competency (while in bed) dated 07/2009 revealed the following: -Step 6. Position the resident and clothing/linen items to allow access but also provide privacy to the resident. Avoid unnecessary exposure. An interview on 11/18/19 at 9:00AM with Resident 42 and resident's family member voiced concerns about when residents brief is changed or when the resident is transferred the resident is often left exposed with private areas showing. An observation on 11/19/19 from 11:00AM- 11:30AM revealed NA (Nursing Assistant) B and RN- (Registered Nurse) A entered resident's room. Hand hygiene was not preformed; both NA and RN applied gloves. NA B pulled resident gown up above waist area. RN- A preformed perineal care (cleaning of private area) by wiping with remoistened wet wipe on right side of the groin then down the middle genital area with a new wipe. RN-A removed the gloves. The resident was tuned to the resident's left side, a soiled brief was rolled up; back perineal (cleaning of buttocks) care was performed. NA- B removed the gloves, RN- A pulled hand sanitizer out of pocket and shared with NA - B. Resident's gown was left up at waist level and resident private area was exposed through out the observation. NA- B and RN- A applied gloves; resident was turned to left side again sling( a mesh fabric device used to attached to mechanical lift)( mechanical lift- device used to raise and lower residents from bed, wheelchair to restroom) was placed under resident, resident was turned opposite direction and the sling [MEDICATION NAME] out. The sling was then brought up between residents legs (at the groin) resident gown remained up and the resident continued to be exposed. NA-B and RN- A removed their gloves and sanitized hands with hand sanitizer. The sling was then hooked to the mechanical lift and the resident was transferred into wheelchair. During the lift the resident's front and back private areas were completely exposed. Resident was placed into wheelchair and then adjusted to sitting up straight. NA- B pulled gown down and applied sheet to lap area. Resident then drove electric wheelchair to the bathhouse. The sling was attached to mechanical lift and resident was lifted into the whirlpool chair. The residents private areas were completely exposed during the transfer. An interview on 11/19/19 at 11:35AM with ADON ( Assistant Director of Nursing) confirmed the resident should have had the genital areas covered to provide resident with dignity and respect. C. Record review of an undated Facility Mission statement Dignity In Life and Vision include Quality of Life- We will create a living environment that radiates, love , peace, spiritual contentment, dignity and safety, while encouraging personal independence. An observation on 11/18/19 at 12:10 PM revealed NA-D wearing gloves while assisting Resident 42 to eat lunch. An interview on 11/18/19 at 12:15 PM with NA -D confirmed that NA D wore gloves to prevent touching the residents food. An interview on 11/18/19 at 1:46 PM with Resident 42 reveled resident felt uncomfortable when nursing assistant wore gloves while assisting with dining. An interview on 11/19/19 at 3:39PM with Administrator confirmed gloves are not to be worn during assisting residents to dine.",2020-09-01
389,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,583,D,0,1,ZY2K11,"Licensure Reference Number 175 NAC 12-00.05 (20) Based on observation and interview, the facility failed to ensure that Resident 10's private information was protected during medication administration. This affected 1 resident out of 4 residents sampled. The facility census was 59. Findings are: An observation on 11/ 20/19 from 8:05 AM - 8:10 AM revealed LPN (Licensed Practical Nurse) [NAME] left a computer screen open to Resident 10's medication profile on a pain assessment screen and the narcotic book open to Resident 10's page. LPN [NAME] walked away from the medication cart into patient's room and was not in eye sight of the computer or narcotic book. An interview on 11/21/19 at 2:30PM with ADON (Assistant Director of Nursing) confirmed the computer screen needs to be hidden when nurse is not at cart to provide privacy.",2020-09-01
390,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,585,D,0,1,ZY2K11,"Licensure Reference Number 175NAC 12-006.06B Based on record review and interview, the facility failed to ensure that resident grievances (formal complaints) were logged on the monthly complaint/grievance log for 1 resident (Resident 57). This had the potential to cause grievances to go unresolved. The facility census was 59. Findings are: Record review of the facility policy titled Complaint/Grievance Policy and Procedure dated 8/2017 revealed Step 1: Upon receipt of a verbal or written complaint/grievance a team member will initiate and complete the complaint/grievance section of the Complaint/Grievance Report form entirely. Step 2: The Complaint/Grievance Report form will then be given to the Grievance Officer (the designated staff person overseeing the grievance process) and logged onto the Monthly Complaint/Grievance Log. Step 3: Within 3 days of receiving a grievance, the Grievance Officer will designate the responsibility of investigating and resolving the grievance to the department supervisor. The Grievance Officer will also assign a due date for completion. Step 8: The Grievance Officer is responsible for maintaining compliance with the Complaint/Grievance process. Record review of the facility complaint/grievance reports for Resident 57 revealed that one grievance was received by the facility on 2/1/19 and that one grievance was received by the facility on 2/26/19. Record review of the facility Monthly Complaint/Grievance Log revealed that the grievances received by the facility on 2/1/19 and on 2/26/19 from Resident 57 were not logged on the facility Monthly Complaint/Grievance Log. Interview with the facility Social Services Director (SSD) at 2:50 PM on 11/20/19 confirmed that the SSD is the facility Grievance Officer. The SSD confirmed that the grievances for Resident 57 received on 2/1/19 and 2/26/19 were not recorded on the facility complaint/ grievance log.",2020-09-01
391,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,644,D,0,1,ZY2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Level II PASARR (Pre-Admission Screening and Resident Review) screen was completed for 1 resident, Resident 44, out of 5 residents sampled. The facility census was 59. Findings are: Record review of Resident 44's admission PASARR revealed a Level 1 PASARR screen dated 4/3/17. Record review of Resident 44's Social Services Review Note dated 10/23/19 at 11:35 revealed that Resident 44 has [DIAGNOSES REDACTED]. Record review of Resident 44's Quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 10/3/19 included the following [DIAGNOSES REDACTED]. Interview on 11/10/19 at 4:55 PM with Administrator confirmed that a Level II PASARR screen had not been requested and that SSD (Social Service Director) was submitting one today.",2020-09-01
392,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,657,D,0,1,ZY2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].09C1c Based on record review and interview, the facility failed to ensure that the Comprehensive Care Plan was reviewed and revised to include the current Advance Directive and orders for continuous oxygen for 1 resident, Resident 5, of 15 residents sampled. The facility census was 59. Findings are: Record review of Resident 5's signed Advance Directive dated [DATE] revealed (DNR) Do Not Resuscitate. Record review of Resident 5's Physician order [REDACTED]. Record review of Resident 5's Comprehensive Care Plan (a document outlining how to care for a resident) revealed that CPR (Cardio [MEDICAL CONDITION] Resuscitation) should be performed in any situation of [MEDICAL CONDITION] regardless of the attendant circumstances. Interview on [DATE] at 2:55 PM with SSD (Social Service Director) confirmed that Resident 5's Comprehensive Care Plan had not been revised to include updated Advance Directive of Do Not Resuscitate. Record review of Resident 5's Physician order [REDACTED]. Record review of Resident's 5's Comprehensive Care Plan (a document outlining how to care for a resident) revealed no mention of continuous oxygen use. Interview on [DATE] at 2:48 PM with DON (Director of Nursing) confirmed that Resident 5's Comprehensive Care Plan should have been revised to include order for continuous oxygen use.",2020-09-01
393,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,658,D,0,1,ZY2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09 Based on observation, record review, and interview, the facility failed to ensure that the physician's orders [REDACTED]. The facility census was 59. Findings are: Record review of the physician's orders [REDACTED]. Observation on 11/19/19 at 11:37 AM revealed that Resident 57 was up in a wheelchair at a dining room table. No air splint was on the resident's left ankle. Observation on 11/20/19 at 10:05 AM revealed that Resident 57 was up in a wheelchair in the 300 hallway just outside of the facility spa (a room where baths and showers are provided for residents). Certified Nursing Assistant (CNA) F asked the resident about comfort and offered to reposition the resident's leg/foot pedals. Resident 57 requested that CNA F elevate the legs. CNA F elevated Resident 57's legs to approximately 45 degrees per visual measurement. No air splint was in place on the resident's left ankle. Resident 57 stated that the staff have not been putting the splint on. Observation on 11/21/19 at 8:32 AM revealed that Resident 57 was up in a wheelchair in the resident's room. No splint was on the resident's left ankle. Observation on 11/21/19 at 9:10 AM revealed that Resident 57 was up in a wheelchair in the facility activity room. Resident 57 had no splint on the left ankle. Observation on 11/21/19 at 1:10 PM revealed that Resident 57 was up in a wheelchair at a dining room table. No splint was on the resident's left ankle. Resident 57 confirmed that the left ankle splint was not put on. Observation on 11/21/19 at 2:35 PM revealed that Resident 57 was up in a wheelchair just outside of the facility dining room with no splint on the left ankle. Registered Nurse (RN) A confirmed that Resident 57 had an order for [REDACTED]. RN A asked Resident 57 where the splint was and the resident stated that it was in the resident's room. RN A obtained permission to push Resident 57 in the wheelchair to the resident's room to locate the splint. Observation on 11/21/19 at 2:39 PM in the room of Resident 57 revealed that RN A asked Resident 57 where the splint was in the room. The resident stated that it was under the green item beside the dresser. RN A located the splint and removed the left shoe of the resident and applied the splint to the resident's left ankle. Interview on 11/21/19 at 2:41 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) in the ADON office confirmed that Resident 57 had an active order for the air splint to be applied to the left ankle when up for support.",2020-09-01
394,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,688,D,0,1,ZY2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09 Based on record review and interview, the facility failed to ensure that the facility policy for Restorative Nursing (nursing care focused on restoring and maintaining an optimal level of function) documentation was followed for 2 residents (Resident 57 and Resident 42). The facility census was 59. Findings are: [NAME] Record review of the Admission Record for Resident 57 revealed that the resident had a [DIAGNOSES REDACTED]. Record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) revealed that Resident 57 had a restorative maintenance program in place for nursing to provide passive range of motion (another person exercises a resident's limbs and joints for them by physically moving a part of the body) to all extremities 3 times weekly and active range of motion (a resident exercises each limb/joint by moving them on their own) to all extremities 3 times weekly. Record review of the facility policy titled Restorative Nursing Standard dated 9/2019 revealed that the Restorative Nurse will write a monthly note in the interdisciplinary notes (progress notes that are part of the resident medical record) for each resident on a restorative program. For a resident only on the maintenance component of the restorative program a quarterly (once every 3 months) note is sufficient. The note will include the resident's progress, functional status/progress toward goal achievement, assistive devices used and response to treatment and changes made in the resident's restorative program. Record review of the medical record for Resident 57 revealed a Restorative Program Note dated 11/19/18 at 2:57 PM that documented that the resident is on a maintenance restorative program to prevent decline. Active and passive range of motion done 3 times per week to extremities. The medical record contained no restorative progress notes after 11/19/18. Interview on 11/21/19 at 8:53 AM with the facility Restorative Nurse confirmed that restorative notes are to be documented quarterly in the resident medical record for residents on a maintenance restorative program. The facility Restorative nurse confirmed that Resident 57 is on a maintenance restorative program. Interview with the facility Restorative Nurse on 11/21/19 at 9:48 AM confirmed that there were no restorative notes in the medical record for Resident 57 after 11/19/18 and that quarterly notes had not been documented as required by the facility policy. B. An interview on 11/1 8/19 at 1:56PM with Resident 42 revealed that the resident's left hand movements have decreased and no physical therapy or restorative care was being provided. Observation on 11/18/19 at 2:00PM revealed Resident 42's left hand started to spasm after extending fingers and placing hand on electric wheelchair remote. Record review of Resident 42's 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 10/3/19 revealed the following: Section C- BIMS (Brief Interview of Mental Status) Score of 12 reveals resident has mild cognitive impairment. Section G - Resident requires extensive assistance with 2 + persons help with the following activities dressing, bed mobility, transfers, toileting. Complete dependence with bathing. Eating -1 person assistance. Locomotion on and off unit - independent when resident is in electric wheelchair. H- Resident is always incontinent of bowel and bladder and wears brief. No catheter. J- Resident receives pain medication and has pain assessment completed every shift and has non - pharma logical interventions available as well. Record review of Nursing Assistance Task revealed that Resident 42 had orders for PROM (Passive Range of Motion) to BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities) 2 times a day for 15 minute sessions each. Record review of Nursing Assistant Documentation dated 10/01/19-11/20/19 revealed the resident received PROM to BUE and BLE but not 15 minutes two times a day. Record review of Physical therapy notes dated 11/02/17 revealed that Resident 42 had not seen therapy since this date and was receiving restorative therapies. Record Review of Restorative Progress Note dated 1/18/19 revealed Resident 42 was on a maintenance restorative program to prevent contractures and decline. Active and passive ROM done daily, resident was cooperative and tolerated well. An interview on 11/21/19 at 2:00PM with Restorative Manager confirmed that the last restorative progress note completed for Resident 42 was 1/18/19. Record review of Policy Titled Restorative Nursing Standard dated 09/2019 revealed the restorative nurse will write a monthly note in the interdisciplinary notes for each resident on a restorative program. For residents, only on the maintenance component of the restorative program a quarterly note is sufficient. The note will include resident's progress, functional status/progress toward goal achievement, assistive devices used and response to treatment and changes made in programming. The restorative nurse will update the Care Plan as warranted.",2020-09-01
395,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,761,E,0,1,ZY2K11,"Licensure Reference Number 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to ensure medications were not left unattended and accessible to residents. This had the potential to affect 4 residents (Residents 24, 15, 13, and 16). The facility census was 59. Findings are: An observation on 11/20/19 from 7:40 AM - 7:47 AM revealed LPN (Licensed Practical Nurse) C performed hand hygiene, removed medications from cassettes, completed medication checks, placed medication in plastic cup, and locked medication cart. Nurse turned to the left and took few steps to resident and administered resident's medications. Nurse was faced away from medication cart and medications were not within eye sight. Resident 53's medications in cassettes and drawer were left on top of medication cart unattended and accessible. Record review of document titled Medication Aide Procedure Checklist - Oral medications dated 2010 revealed: - Step 6 Return the medication container to storage. -Step 7 Secure the other Medications. An interview on 11/21/19 at 2:30 PM with the ADON (Assistant Director of Nursing) confirmed that medications should be placed in a locked storage place after medications are removed.",2020-09-01
396,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,812,F,0,1,ZY2K11,"Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to ensure hair nets enclosed all hair for 4 staff persons who were preparing and/or serving food from the kitchen to prevent potential food borne illness. This had the potential to affect all residents that ate food prepared in the facility kitchen. The facility census was 59. Findings are: Observation on 11/20/19 from 9:22 AM-9:39 AM in facility kitchen revealed that hair nets did not completely enclose all hair for the FSS (Food Service Supervisor), RD (Registered Dietician) and Dietary Staff [NAME] Observation on 11/20/19 from 11:10 AM-11:34 AM in facility kitchen revealed hair nets not completely covering all hair for Dietary Staff H and Dietary Cook I. Record review of the Nebraska Food Code, Effective date 7/21/16, Hair Restraints 2-402.11 Effective revealed; (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENs; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Interview on 11/21/19 at 10:35AM with Dietary Supervisor confirmed that hair nets should fully cover all hair.",2020-09-01
397,DAVID PLACE,285074,260 SOUTH 10TH STREET,DAVID CITY,NE,68632,2019-11-21,880,D,0,1,ZY2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview, the facility failed to perform hand hygiene according to standards of practice and facility policy to prevent cross contamination during medication administration and dressing change. This affected Resident 10. The facility census was 59. Findings are: [NAME] An observation on 11/20/19 from 8:05AM- 8:10 Am revealed LPN (Licensed Practical Nurse) -E prepare medication for Resident 10 and not perform hand hygiene. Removed medications from cassettes (plastic containers that hold medications) place medications in cup. LPN-E knocked on resident's door, did not perform hand hygiene and proceeded with giving resident medications and then applied gloves and administered eye drops. LPN-E removed gloves and then entered residents restroom, turned on water faucet, wet hands and wrists, applied soap and washed hands together for 8 seconds, rinsed hands, dried with paper towel, turned faucet off with new paper towel. Record review of Policy/Procedure titled Hand Hygiene Competency dated 02/2017 revealed procedure step for HAND HYGIENE USING ANTIMICROBIAL SOAP AND WATER: -Check for paper towels before starting hand hygiene procedure. -Turn on water and wet hands. Water should be warm not hot or cold. - Apply soap. Using friction, rub hands together, clean under and around nails/jewelry and between fingers (minimize use of jewelry). Wash up onto wrists (approximately 2 inches above wrists). -Lather and rub hands together for full 20 seconds. - While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. Do not shut off water. Leave it running. - Dry hands well with paper towels. When finished drying hands, discard paper towel and take a clean paper towel to shut off water faucet. Discard paper towel. HAND HYGIENE USING HAND SANITIZER Procedure/ how to hand rub -Apply a palmful of product in a cupped hand, covering all surfaces. - Rub hands palm to palm. -Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. -Palm to palm with fingers interlaced. - Back of fingers to opposing palms with fingers interlocked. -Rotational rubbing of left thumb clasp in right palm and vice versa. -Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. - Once dry, your hands are safe. Note when hand sanitizer can be used - Hands should be free of dirt or organic material - - if visibly soiled- use soap and water - Duration of entire procedure 20 to 30 seconds. B. Record review of the physician's orders [REDACTED]. Observation on 11/20/19 at 10:54 AM revealed that Licensed Practical Nurse (LPN) [NAME] received permission to enter the room of Resident 10. LPN [NAME] entered the resident's bathroom and applied soap to dry hands and then placed the hands under water and scrubbed the hands for 14 seconds over the sink and then rinsed the hands. LPN [NAME] put on disposable gloves and removed the dressing from the right elbow of Resident 10. A skin tear was noted on the right elbow with a scab over it. LPN [NAME] sprayed wound cleanser onto a gauze and cleaned the skin tear area on the right elbow. LPN [NAME] performed hand washing with alcohol based hand sanitizer and then applied new disposable gloves. LPN [NAME] measured the skin tear at 2cm in length using a wound measuring guide (a plastic sheet with a ruler printed on it). LPN [NAME] removed the disposable gloves, performed hand washing with alcohol based hand sanitizer, and then applied new disposable gloves. LPN [NAME] applied a steri strip (a sterile piece of medical tape used to close wounds and help the edges grow back together) across the skin tear and then a second steri strip to make an X over the skin tear. LPN [NAME] then placed a strip of non-adhering wound dressing over the skin tear and then applied a [MEDICATION NAME] foam dressing over the skin tear. LPN [NAME] removed the disposable gloves and used a sharpie marker and documented the date and initials on the dressing. LPN [NAME] entered the resident's bathroom and applied soap to dry hands and then wet the hands and scrubbed for 2 seconds. LPN [NAME] then applied more soap to the hands and performed scrubbing for 10 seconds and then rinsed the hands. Interview on 11/21/19 at 10:13 AM with the facility Infection Control Nurse confirmed that the procedure for hand washing is to wet the hands prior to applying soap and to then scrub with friction for 20 seconds before rinsing the hands.",2020-09-01
398,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,584,E,0,1,5HF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18(1) Based on observation and interview, the facility failed staff to ensure the cleanliness of the interior of ventilation systems and the ceiling tiles surrounding the ventilation systems covers in 10 (Resident rooms 118, 307, 413, 418 and the connecting bathrooms for rooms [ROOM NUMBERS], 210 and 212, 214 and 216) of 39 occupied resident rooms in the facility. The facility census was 55. Findings are: Observation on 02/11/19 between 09:30 AM and 09:45 AM with the facility Maintenance Director (MD), the facility Environmental Services Director (ESD) and the facility Administrator revealed the following concerns: - Dust covered interior of the ventilation systems in resident bathrooms in rooms 118, 307, 413, 418 and the connecting bathrooms for rooms [ROOM NUMBERS], 210 and 212, 214 and 216. - Light brown water stains were present on the ceilings surrounding the exterior of the ventilation covers in the connecting bathrooms for rooms [ROOM NUMBERS], 210 and 212, 214 and 216. Interview on 02/11/19 at 09:40 AM with the MD confirmed that the interior of the ventilation systems in the residents bathrooms were dust covered and were not routinely cleaned or blown out. The MD confirmed that light brownish stains from condensation were present on the ceilings surrounding the exterior of the ventilation covers in the connecting bathrooms for rooms [ROOM NUMBERS], 210 and 212, 214 and 216. Interview on 02/11/19 at 09:51 AM with the ESD confirmed that the exterior cover of the ventilation systems in the residents bathrooms were cleaned once a week on Mondays but that the interior was not cleaned because the feather duster was unable to go through the slats in the ventilation cover.",2020-09-01
399,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,609,E,1,1,5HF111,"> Licensure Reference Number 175 NAC 12-006.02(8) Based on record reviews and interviews, the facility staff failed to report an incident of resident to resident abuse to the required State Survey Agencies within the required time frames in accordance with State law for 2 incidents (an incident that involved Residents 14 and 205)and (an incident that involved Residents 10 and 4) of 4 facility investigations reviewed. The facility census was 55. Findings are: [NAME] Record review of the facility Policy and Procedures for Abuse and Neglect dated 1/17/17 revealed that incidents of abuse would be reported to the Corporate Nurse Consultant and Adult Protective Services (APS) within 2 hours if the incident resulted in serious bodily injury or within 24 hours for all other events. The policies revealed that a completed internal investigation report would be sent to the Department of Health and Human Services Investigations (DHHS) within 5 working days of the incident. Record review of a facility Investigation Summary dated 5/27/18, that involved Residents 14 and 205, revealed a physical altercation had occurred between Resident 14 and Resident 205 which resulted in no injuries to either resident. The facility staff notified APS within 24 hours of the incident. The facility investigation did not contain evidence that the completed investigation report had been sent to DHHS investigations within 5 working days of the incident. Interview on 02/06/19 at 10:53 AM with the facility Director of Nursing and the Corporate Nurse Consultant confirmed that there was no verification of proof or fax confirmation that the completed investigation had been sent to DHHS. B. Review of Resident 4's Progress note dated 11/10/2018 revealed at 3:30 AM The Charge Nurse was called to Resident 10's room by the Nursing Assistant (NA). The NA reported to the charge nurse that NA had heard Resident 10 yelling for help. On entering the room the NA observed Resident 4 in Resident 10's room sitting on the side of Resident 10's bed, Resident 4's hands were under the covers, rubbing Resident 10's legs. Resident 4 was redirected out of Resident 10's room. NA then observed Resident 4 wandering in the hall and attempted to redirect Resident 4. Resident 4 then entered Resident 10's room and began grabbing Resident 10's feet. Resident 10 asked Resident 4 to let go and Resident 4 became verbally abusive and cursing at Resident 10. Interview on 02/06/19 at 3:06 PM with the Director of Nursing (DON) revealed a call was received by the DON during the night regarding Resident 4's behaviors and did not call it in to the state agency at that time. After reviewing the documentation and investigating the incident was not called to the state agency. Interview on 2/6/2019 at 3:10 PM with the DON revealed the incident should have been called to the state agency and then investigated per the facility policy.",2020-09-01
400,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,623,D,0,1,5HF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide notice in writing for 2 of 4 residents sampled (Residents 4 and 6) or their personal representatives regarding the reason for discharge to the hospital. The facility census was 55. Findings are: [NAME] Review of progress notes for Resident 4 revealed Resident 4 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident 4's electronic medical record (EMR) revealed no letter explaining to Resident 4 or Resident 4's representative the reason for the transfer and no documentation was located in the progress note that this was explained. Interview on 02/11/19 at 1:32 PM with the Social Services Designee (SSD) revealed no letters were sent to Resident 4 or Resident 4's representative when Resident 4 was admitted to the hospital and the SSD was unaware of the requirement. B. Review of Resident 6's census record in the EMR revealed Resident 6 was hosptalized on [DATE] and 1/23/2019. Review of Resident 6's electronic medical record (EMR) revealed no letter explaining to Resident 6 or Resident 6's representative of the reason for the transfer and no documentation in the progress note that this was explained. Interview on 02/11/19 at 1:28 PM with the SSD revealed no letters were sent to Resident 6 or Resident 6's representatives when Resident 6 was admitted to the hospital on both admissions.",2020-09-01
401,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,625,D,0,1,5HF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a copy of the bed hold policy at the time of discharge to the hospital for 3 residents (Residents 4, 6, and 9) of 3 sampled residents. The facility census was 55. Findings are: [NAME] Review of progress notes for Resident 4 revealed Resident 4 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident 4's Electronic Medical Record (EMR) revealed no bed hold notification was located in the EMR and no documentation the Bed hold had been discussed with Resident 4 or Resident 4's personal representative. Interview on 02/11/19 at 01:32 PM with the Social Services Designee (SSD) revealed a copy of the bed hold policy was not given to Resident 4 or Resident 4's representative when the Resident 4 was admitted to the hospital. B. Review of Resident 6's census record in the EMR revealed Resident 6 was hosptalized on [DATE] and 1/23/2019. Review of Resident 6's electronic medical record (EMR) revealed no bed hold documentation for Resident 6 or Resident 6's representative and no documentation in the progress note that this was explained. Interview on 02/11/19 at 1:28 PM with the SSD revealed no bed holds were issued prior to the end of December. Resident 6 was admitted to the hospital on [DATE]. The SSD revealed resident was not given a bed hold notification because of Resident 6's payer source. C. Record review of Resident 9's Progress Notes dated 10/20/18 and 11/4/18 revealed that Resident 9 was sent to the hospital. A Progress Note for Resident 9 dated 10/20/18 and 11/4/18 revealed that Resident 9 had been admitted at that time. The Progress Notes did not contain information that the resident or family had been informed of bed hold policies, bed hold had been discussed at the time of transfer or decisions made related to holding Resident 9's bed until readmission. Interview on 2/11/19 at 12:30 PM with Social Services Director (SSD), Nurse Consultant, and the Director of Nursing (DON) confirmed that Resident 9's family did not receive bed hold policy information at the time of transfer to the hospital and had not been asked if they wanted to hold the bed.",2020-09-01
402,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,759,D,0,1,5HF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interviews; the facility failed to ensure a medication error rate of less than 5% related to special timing of medications for 3 medications of 25 medications observations. The error rate was 12%. The facility census was 55. Findings are: [NAME] Review of the facility policy titled Administering Medications dated 10/2011 revealed the following: - Mediations must be administered in accordance with the orders, including any required time frame. - Medications must be administered within their prescribed time, unless otherwise specified. (Example, before and after meal orders) - The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Observation on 02/07/19 at 8:03 AM of medication administration for Resident 30. Registered Nurse (RN)-A prepared Resident 30's medication for administration. [MEDICATION NAME] (a medication for low [MEDICAL CONDITION] hormone levels) was included in the medications provided to Resident 30 with other scheduled medications. Review of the pharmacy label on the medication container revealed [MEDICATION NAME] 125 micrograms at least 30 minutes before meals. Observation on 2/7/2019 at 8:03 AM revealed Resident 30 had eaten hot cereal, omelet, toast and juice and was in the process of drinking coffee. Interview on 02/11/19 at 10:55 AM with the Nurse consultant revealed the [MEDICATION NAME] should have been given before meals. B. Observation on 2/7/2019 at 8:45 AM revealed Resident 153 was in the process of eating breakfast when Licensed Practical Nurse (LPN)-B provided Resident 153 with Resident 153's morning medication including [MEDICATION NAME] (a medication used for relieve painful swelling of a joint). Review of Resident 153's pharmacy label on the [MEDICATION NAME] container revealed [MEDICATION NAME] was to be given after meals. Interview on 02/11/19 at 10:55 AM with the Nurse consultant revealed if a medication is ordered after meals the medication should be given after the resident is finished eating. C. Interview on 02/11/19 at 08:34 AM with Resident 22 revealed Resident 22 had not eaten breakfast. RN-C confirmed Resident 22 had not been to breakfast yet. Observation on 2/11/2019 at 8:34 AM revealed RN-C administered [MEDICATION NAME] (Anti-[MEDICAL CONDITION]) to Resident 22. Review of the pharmacy label revealed [MEDICATION NAME] was to be given with meals. Interview on 02/11/19 at 10:55 AM with the Nurse consultant revealed Resident 22 should have consumed some food prior to receiving the medication. Interview on 02/11/19 at 10:55 AM with the Nurse consultant revealed medications were not given at the designated times and if a discrepancy between the physician's order and the pharmacy label the order should be clarified.",2020-09-01
403,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,812,F,0,1,5HF111,"Licensure Reference Number 175 NAC 12-006.11E Based on observations and interviews, the facility failed to ensure that vegetables were fresh, foods were discarded on or before expiration date, floors were maintained in a clean manner in the walk in freezer, and fluid spills were wiped up in the reach in refrigerator. The pan drying rack was visibly soiled with dust and kitchen grease. The action had the ability to affect all residents that ate foods prepared in the facility kitchen. The facility census was 55. Findings are: Observation on 2/5/19 between 08:30 AM and 08:40 AM with the Director of Food Service (DFS) identified the following sanitation issues in the facility kitchen: -A box containing cabbage in various stages of decay. -Meat dripping meat juices onto the floor in the walk in freezer. -An open can of liquid dated 12/3/18. -Liquid spills in the reach in refrigerator. Interview on 2/5/19 at 08:30 AM with DFS confirmed that the vegetables were not fresh, meat juices were on the floor directly beneath meat in the walk in freezer, the open can of liquid had not been discarded on or before the expiration date and there were liquid spills in the reach in refrigerator. Observation on 2/6/19 with DFS at 12:36 PM revealed dust and kitchen grease on the pan drying rack and this was confirmed by DFS. Per interview on 2/11/19 at 11:20 AM with the Registered Dietitian confirmed all residents eat food prepared by the facility kitchen. Record Review of the Nebraska Food Code 3-302.11 (7) revealed that food shall be protected from cross contamination by storing damaged, spoiled or recall food being held in the food establishment. Record review of the Nebraska Food Code 3-305.11 revealed that food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust or other contamination. Record review of the Nebraska Food Code 4-602.12 revealed that nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues.",2020-09-01
404,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2019-02-11,838,C,0,1,5HF111,"Based on record review and interview, the facility failed to develop a comprehensive facility assessment. The facility census was 55. Findings are: Review of the facility assessment dated (MONTH) 6 (YEAR) and Reviewed with Quality Assurance Performance Improvement (QAPI) committee on (MONTH) 10 2019 revealed no information was included regarding how the facility determines the staffing needs based on resident census and acuity. Review of the Facility Assessment revealed no information was included regarding outside services that have contracts or memorandums of understanding with the facility and what services they provide to the facility during regular business hours and non-business hours. Interview on 02/11/19 at 10:59 AM with the Administrator revealed staffing level needs and how to determine staffing levels were not included in the Facility Assessment and no documentation of contracts with outside agency for services when needed were contained in the Facility Assessment.",2020-09-01
405,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2016-12-14,309,D,0,1,8GLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 12-006.09D Based on record review and interviews, the facility failed to ensure that communication occurred between the [MEDICAL TREATMENT] center and the facility to ensure the continuity of care for 1 (Resident 96) of 1 residents reviewed. The facility census was 62. Findings are: Review of the undated Facility [MEDICAL TREATMENT] Guideline revealed: Residents receiving [MEDICAL TREATMENT] are transported routinely out of the center. Communication was essential for continuity of care. Communication between the outpatient [MEDICAL TREATMENT] provider and the center should include: -written communication in the form of medication lists and physician visit/discharge form, -An identification of the type of vascular access with any issues with patency or signs of infection. Record review of Resident 96's face sheet revealed that Resident 96 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 96's hospital discharge orders dated 11/21/16 revealed Resident 96 was to go to outpatient [MEDICAL TREATMENT] (a treatment to filter the blood of waste when the kidneys can no longer do so) on Mondays, Wednesdays and Fridays. Review of Resident 96's physician orders, telephone orders, physician progress notes [REDACTED]. An interview with Resident 96 on 12/13/16 at 9:29 AM revealed that Resident 96 could recall only a couple times where the resident had taken paperwork to the [MEDICAL TREATMENT] center from the facility but didn ' t usually take any paperwork. Review of the Brief Interview for Mental Status Assessment completed on 12-2-16 revealed the resident scored a 15/15 which indicated the resident was cognitively intact. An interview with the Director of Nursing (DON) on 12/13/16 at 12:50 PM revealed that the facility staff were to send a physician visit sheet with Resident 96 to the [MEDICAL TREATMENT] center at every visit for communication back and forth with the center. An interview with Registered Nurse (RN) A on 12/13/16 at 12:28 PM revealed that Resident 96 went to [MEDICAL TREATMENT] three times a week and that the facility staff did not send any paperwork with the resident except on the first of the month and that if there was something the [MEDICAL TREATMENT] center wanted the facility to know then they should call the facility. An interview with Licensed Practical Nurse (LPN) B on 12/13/16 at 1:00 PM revealed that if a resident was on [MEDICAL TREATMENT] the facility staff would send paperwork on the first of the month but not after that. LPN B stated that the staff used to send paperwork with the resident for every [MEDICAL TREATMENT] visit but they've stopped doing that over the past few months. An interview on 12/13/16 at 1:25 PM with RN D, the Charge Nurse for the [MEDICAL TREATMENT] Center where Resident 96 received [MEDICAL TREATMENT] services, revealed that the [MEDICAL TREATMENT] Center staff had never received forms from the facility to communicate with the facility regarding Resident 96's condition or [MEDICAL TREATMENT] with Resident 96's visits three times a week.",2020-09-01
406,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2016-12-14,329,D,0,1,8GLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interviews, the facility failed to evaluate and identify target behaviors for the use of psychoactive medication for 1 (Resident 96) of 5 residents reviewed. The facility census was 62. Findings are Review of Resident 96's face sheet revealed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 96's physician orders [REDACTED]. -[MEDICATION NAME] (an antipsychotic medication) 2 mg daily, -[MEDICATION NAME] (an antidepressant medication) 40 mg daily, -[MEDICATION NAME] 25 mg daily. Pharmacy admission medication regimen review completed on 11-21-16 for Resident 96 revealed that Resident 96 had received psychoactive medications and should have ongoing behavior monitoring, with specified target behaviors. Review of the Behavior Documentation from 11/21/16 to 12/13/16 for Resident 96 revealed no behaviors had occurred and identified no target behaviors for the resident. An interview conducted on 12/13/16 at 12:28 PM with Registered Nurse (RN) A revealed that Resident 96 had not had any behaviors and was unaware if Resident 96 had any target behaviors. Review of Resident 96's progress notes, care plan and physician notes revealed no evaluation of the reason for use of psychoactive medications and no target behaviors were identified. An interview with RN D the Clinical Coordinator on 12/13/16 at 1:49 PM revealed that Resident 96 had not been evaluated for use of the psychoactive medications and target behaviors were not identified until 12/13/16. RN D revealed that Resident 96 admitted to the facility on [DATE] on the medications and the evaluation and identification of target behaviors should have been identified prior to 12/13/16.",2020-09-01
407,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2016-12-14,431,D,0,1,8GLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E7 Based on record review and interviews, the facility failed to ensure that a medication label and the medication administration record (MAR) matched the physician order for [REDACTED]. The facility census was 62. Findings are: Review of the facility policy titled Medication Labeling with a date of (MONTH) 2013 revealed: Policy: Prescription medications must have a pharmacy label that accurately reflects the most current dose and directions for use. [NAME] All medications received from the pharmacy should be checked for proper labeling immediately upon receipt. B. Each prescription medication label includes: 5) Specific directions for use, including dose of medication, route of administration, and frequency and/or duration of administration. Record review of Resident 96's face sheet revealed the resident admitted to the facility on [DATE]. Review of Resident 96's discharge orders from the hospital dated 11-21-16 revealed Resident 96 was to receive Trazodone (an antidepressant medication) 50 mg (milligrams) 1/2 tab daily. Review of the MAR (Medication Administration Record) for Resident 96 in (MONTH) and (MONTH) (YEAR) revealed Trazodone 0.25 mg daily for depression. Review of Resident 96's medication card for Trazodone revealed a label that read: Trazodone 50 mg, take 1/2 tab (0.5 mg) at bedtime. An interview with Registered Nurse (RN) A on 12-13-16 at 1:19 PM confirmed that the label on the Trazodone Medication Card for Resident 96 did not match the physician order or the MAR. An interview with the Registered Nurse Consultant on 12/31/16 at 1:48 PM confirmed that the MAR and label should have read Trazodone 50 mg 1/2 tab daily to match the physician order.",2020-09-01
408,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2017-12-14,609,E,1,1,736311,"> Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report completed investigations to the required State Agency within 5 working days for 4 (Residents 32, 42, 9 and 28) of 8 investigations reviewed. The facility census was 46. Findings are: [NAME] Record review of the facility Policy and Procedures on Abuse Neglect dated revised 1/7/17 revealed the The Campus Administrator and Director of Nursing should ensure the investigation of the incident is completed within 5 working days. By the 5th day of the investigatory period (from the date of the report) the campus Administrator will notify the appropriate agencies listed as outlined in Appendix A as required by state and federal statues. Appendix A 3. Timeframes: Complete the internal investigation within 5 working days of the notification of the allegations. Send the completed internal investigation to the Department of Health and Human Services (DHHS) investigations. [NAME] Record review of a facility investigation of a fall with significant injury that involved Resident 32 revealed that a thorough investigation into the incident had been completed by the facility. The fax confirmation sheet dated 11/14/17 revealed that the investigation had been sent to Adult Protective Services (APS). The investigative report for Resident 32 had not been sent to DHHS. B. Interview on 12/12/17 at 11:24 AM with the Director of Nursing (DON) and the facility Nurse Consultant confirmed that the investigative report for Resident 32 had not been sent to DHHS and was accidentally sent to APS by mistake. The DON confirmed it should have been sent to DHHS within 5 working days and had not been sent. C. Record review of a facility investigation into a fall with a significant injury that involved Resident 42 dated 4/10/17 revealed a thorough investigation into the incident had been completed by the facility. The facility investigation had a handwritten note at the top of the first page that indicated it had been faxed on 4/14/17 at 1:30 PM. There was no indication as to where the investigation had been faxed. There was no fax confirmation sheet available to show that it had been sent to DHHS within 5 working days. D. Interview on 12/12/17 at 11:25 AM with the DON confirmed that the investigative report for Resident 42 did not show where the investigative report had been sent and that there was no fax confirmation sheet to show that it had been sent to DHHS. E. Record review of Resident 9's report of abuse to facility staff on 10/16/17, revealed that the facility did notify the state agency of Resident 9's allegation of abuse. F. Record review of the facility investigation of the allegation of abuse, for Resident 9, confirmed that an investigation was performed, on the 10/16/17 allegation of abuse. Record review of the facility documentation revealed that the facility failed to send the completed investigation report to the required state agency within the mandatory 5 working days. [NAME] Interview 12/12/17 11:24 AM with the Director of Nursing and the facility nurse consultant confirmed that the investigative report, for Resident 9, had not been sent to DHHS and was accidentally sent to a different state agency, by mistake. Confirmed it should have been sent to DHHS within the 5 working days and was not sent. H. Record review of Resident 9 report of abuse to facility staff on 9/12/17, revealed that the facility did notify the state agency of Resident 9's allegation of abuse. I. Record review of the facility investigation of the allegation of abuse, confirmed that an investigation was performed, on the 09/12/17 allegation of abuse. [NAME] Record review of the facility documentation revealed that the facility failed to send the completed investigation report to the required state agency within the mandatory 5 working days. K. Interview 12/12/17 11:24 AM with the Director of Nursing and the facility Nurse Consultant confirmed that the investigative report, for Resident 9, had not been sent to DHHS and was accidentally sent to a different state agency, by mistake. Confirmed it should have been sent to DHHS within the 5 working days and was not sent. L. Record review of Resident 28 report of fall with injury on 1/27/17, revealed that the facility did notify the state agency of Resident 28's fall with injury requiring emergency services at the hospital and found to have non displaced rib fractures to the 8th, 9th and 10th right ribs, and sutures to right elbow to secure a skin tear. M. Record review of the facility investigation of the allegation of the fall with injury for Resident 28, confirmed that an investigation was performed. N. Record review of the facility documentation revealed that the facility failed to send the completed investigation report for Resident 28 to the required state agency within the mandatory 5 working days. O. Interview 12/12/17 11:24 AM with the Director of Nursing and the facility Nurse Consultant confirmed that the investigative report had not been sent to DHHS and was accidentally sent to a different state agency, by mistake. Confirmed it should have been sent to DHHS within the 5 working days and was not sent.",2020-09-01
409,REGENCY SQUARE CARE CENTER,285076,3501 DAKOTA AVENUE,SOUTH SIOUX CITY,NE,68776,2017-12-14,759,D,1,1,736311,"**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 1of 1 Residents (Resident 19). The medication error rate was 10.7%. The facility census was 46. Observation, on 12/13/17 at 07:52 AM, Facility Licensed Practical Nurse (LPN) A administered to Resident 19, in the dining room after completing breakfast, the following medications: [REDACTED] -[MEDICATION NAME] 625 mg (milligram) one tablet by mouth (fiber tablet to assist to prevent/relieve constipation) -[MEDICATION NAME] Sodium Capsule 88 mcg (microgram) ([MEDICAL CONDITION] replacement medication) by mouth -Potassium Chloride 20 meq (milliequivalent) 1 tablet by mouth (supplement to replace loss of potassium) Record review of Resident 19's Physician orders [REDACTED]. -[MEDICATION NAME] 850 mg one tablet by mouth -[MEDICATION NAME] Sodium Capsule 88 mcg, Give on an empty stomach -Potassium 20 meq 1 packet by mouth Interview with LPN A, on 12/13/17 at 09:52 AM, confirmed that the [MEDICATION NAME] was the wrong dosage, that the [MEDICATION NAME] was not given on an empty stomach as ordered, and that the Potassium medication was not in the correct form. Interview with the facility Director of Nursing (DON), on 12/13/17 at 10:00 AM, confirmed that the LPN did not follow the 5 rights of medication administration, as per standard of care, and that the physician orders [REDACTED].",2020-09-01
410,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,550,D,1,1,B6BN11,"> Licensure Reference Number 175 NAC 12-006.05(21) Based on observations and interviews, the facility failed to ensure the urinary catheter bag was not visible to the community for 1 resident (Resident 15) of 3 residents sampled and failed to ensure 1 resident's (Resident 94) name was not on their clothing in a visible location of 40 residents sampled. The facility staff identified the census at 170. The findings are: [NAME] An observation conducted on 2-5-18 at 1:15 PM revealed Resident 15 was in bed with their catheter bag hanging on the side of the bed visible from the hallway. An observation conducted on 2-6-18 at 2:41 PM revealed Resident 15 was in bed with their catheter bag hanging on the side of the bed visible from the hallway. An observation conducted on 2-7-18 at 10:07 AM revealed Nursing Assistant (NA) O emptied the catheter bag and hung it back on the side of the bed without covering the bag to hide it from view. An observation conducted on 2-7-18 at 4:01 PM revealed Resident 15 was in bed with their catheter bag hanging on the side of the bed visible from the hallway. An observation conducted on 2-8-18 at 2:51 PM revealed Resident 15 was in bed with their catheter bag hanging on the side of the bed visible from the hallway. An interview conducted on 2-8-18 at 3:00 PM with the Administrator revealed that Resident 15's catheter bag should have been covered so that it could not be seen by the community. B. An observation conducted on 2-5-18 at 10:29 AM revealed Resident 94 had a pair of white socks on with their name written in black ink across the cuff of the socks. An observation conducted on 2-7-18 at 10:29 AM revealed Resident 94 was sitting in the hallway with a pair of white socks on with their name and room number written across the sock on top of their foot. An observation conducted on 2-12-18 at 8:39 AM revealed Resident 94 was sitting in the hallway with a pair of blue slipper socks on with their name written in black ink across the top of the sock on their right foot. An interview conducted on 2-12-18 at 9:05 AM with NA P revealed that the residents' socks were to be labeled on the bottom of the foot and their clothing labels should not have been visible to the public eye. A review of Resident 94's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 12-6-17 revealed that Resident 94 was dependent on staff for dressing.",2020-09-01
411,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,580,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number NAC 175 12-006.04C3a(6) The facility failed to notify the physician of a change of condition for ongoing diarrhea for Resident 411, and of blood sugars greater than 400, as per physician order [REDACTED]. The facility census was 170. Findings are: Clinical reference from National Nursing Home Quality Improvement Campaign reveals: Early Identification and containment of C.difficile infection (CDI), dated 12/28/16. *[DIAGNOSES REDACTED]icile infection (CDI) is a common cause of acute diarrhea in nursing homes. * Individuals with CDI serve as a source for bacterial spread to others, through the contamination of caregiver hands and shared equipment. * Contamination of a resident's skin and environment is greater when a resident has diarrhea from CDI but hasn't started on appropriate treatment. * Early identification of CDI can limit the spread of CDI by reducing the time from symptom onset to starting therapy. * Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination. * Contact precautions include use of gowns/gloves and dedicated equipment during care of residents with new diarrhea. Record review of Resident 411's Face Sheet, undated, revealed that Resident 411 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Dysphasia , Chronic [MEDICAL CONDITION] Fibrillation, and [MEDICAL CONDITION] affecting left side. Record review of Resident 411's Bowel record revealed that Resident 411 had loose bowel movements: 5 times on 1/20/18, 8 loose stools on 2/21/18 4 on 1/22/18, 8 on 1/23/18 2 large loose on 1/24/18 , 2 large loose on 1/25/18 2 large loose on 1/26/18. Record review of Nurses notes revealed the following 1/17/18 8:30 AM Resident 411 was incontinent of bowel and bladder. 1/18/18 4:00 AM Resident 411 was incontinent of stools x 2 this night, unable to check dipstick of urine. 1/20/18 9:00 AM Resident 411 was alert and able to verbalize needs. Resident 411 complained of loose stools and upset stomach this am, clear liquid diet offered, abdomen was soft . 1/21/18, 9:00 AM Resident denies nausea this am but continues to have poor appetite. 1/26/18 7:10 PM Received new orders from Physician for Resident 411 to screen stool for c- diff. Record review of lab report, for Resident 411, dated Collection date 1/28/18 at 6:30 PM. revealed that the Stool is positive for [MEDICAL CONDITION]., facility notified on 1/30/18 . Record review of nursing note dated 1/30/18 at 1:00 PM for Resident 411's, revealed that lab results for [MEDICAL CONDITION] positive faxed to clinic and called to clerical staff for Resident 411's physician. Record review of Physician order, for Resident 411, dated 1/30/18 at 10:00 PM revealed that Resident 411 was to start [MEDICATION NAME] 125mg every 6 hours x 14 days. Interview with Staff Nurse C on 2/7/18 at 7:30 AM reveled that it takes less than 24 hours to obtain a physician order [REDACTED]. Staff Nurse C confirmed that 2 days time to obtain a sample for lab is an extended period of time. Staff Nurse C revealed that the facility does not place residents in precautions without a confirmed lab sample of the infection. Staff Nurse C revealed that liquid diarrhea is a sign of[DIAGNOSES REDACTED], and until sample is verified they would not place resident on precautions. Staff Nurse C confirmed that Resident 411 had liquid loose stools several times per day starting on 1/20/18 and that physician was not notified until 1/26/18, and confirmed that stool sample was not obtained until 1/28/18, and results were not verified with physician until 1/30/18. Staff Nurse C confirms that there was a delay in treatment for [REDACTED]. B. Record review of Resident 101's quarterly Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/20/17 revealed a [DIAGNOSES REDACTED]. Record review of Resident 101's Physician order [REDACTED]. Record review of Resident 101's Diabetic Flow sheets dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed that Resident 101's blood sugar had exceeded 400 on 1/6/18, 1/27/18, 1/29/18 and 2/2/18. The blood sugars were: - 1/6/18: 404 - 1/27/18: 464 - 1/29/18: 402 - 2/2/18: 412 Record review of Resident 101's Medical Record revealed no information that the MD had been informed of the blood sugars that had exceeded 400 on 1/6/18, 1/27/18, 1/29/18 and 2/2/18. Interview on 02/8/18 at 9:24 AM with the Director of Nursing (DON) confirmed that there was no documentation in Resident 101's medical record that the MD had been notified of the blood sugars over 400 as per the parameters in the physicians order. The DON confirmed that Resident 101's MD should have been notified of the blood sugars that exceeded 400 as identified in the physician orders.",2020-09-01
412,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,584,E,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure that equipment was operational , ceiling, walls and ventilation covers were clean and in good repair and rooms were homelike in 14 (Resident rooms 200, 310, 401, 408, 504, 505, 507, 601, 704, 707, 709 , 710, 711, 801) of 92 occupied rooms. This had the potential to affect 24 residents that resided in those rooms. The facility census was 170. Findings are: Observation on 2/8/18 between 1:30 PM and 2:00 PM with the facility Administrator (ADM) and the facility Maintenance Director (MD) revealed that following environmental concerns in the facility: - Drain slow in the sink in room [ROOM NUMBER]. - Water damaged stained areas around the ceiling light /ventilation system in the bathroom of room [ROOM NUMBER]. - Dust covered ventilation covers in resident bathrooms in rooms 504, 505 and 507. - Rooms were not decorated to create a homelike environment in rooms 505, 601, 704, 707, 709, 710, 711. - Cracked wall behind the toilet in room [ROOM NUMBER]. Interview on 02/8/18 at 02:00 PM with the MD confirmed that the ventilation's system covers were dust covered in rooms 504, 505 and 507, that the sink in room [ROOM NUMBER] drained slowly, the wall behind the toilet in room [ROOM NUMBER] was cracked and there was a water stain on the ceiling in the bathroom of room [ROOM NUMBER]. The MD confirmed that the areas of concern had not been identified prior to the environmental tour and needed to be cleaned and repaired. Interview on 02/8/18 at 02:10 PM with Social Services Assistant A confirmed that the rooms were not decorated to create a homelike environment and that facility staff had not contacted family specifically to bring in items to make the rooms more homelike.",2020-09-01
413,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,609,D,1,1,B6BN11,"**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 staff failed to report allegations of sexual misconduct to the facility administrative staff for investigation and reporting to the required State Agencies for 1 (Resident 101) of 5 facility investigations reviewed. The facility census was 170. Findings are: Record review of the facility Policy and Procedures for Abuse, Neglect and Exploitation dated Sept (YEAR) under section H , reporting suspected violations, of the policy revealed the following: 1. Any suspected, observed or reported violation of the resident safety policy shall be reported immediately to the supervisor and the administrator per facility policy. 2. The supervisor on duty shall immediately report any alleged violations of this resident safety policy to the administrator /Designee or Director Of Nursing/Designee. The administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to other officials in accordance with state law including to the State Survey and Certification agency. The procedure for investigation revealed the following: 1. Administrator or designee on duty will assess the resident and assure proper documentation of the date, time, and location of the reported incident. 2. The supervisor will do everything possible to protect the residents welfare and safety from harm during the investigation. 3. An incident report will be filled out. 4. The physician and family will be notified as soon as possible. 5. The Administrator or Director of Nursing is responsible to notify their Regional Nursing Supervisor to report alleged violation of the resident safety policy to assure prompt investigation and corrective action are in place. 13. The results of all investigations must be reported to the Administrator or designee and to other officials in accordance with state law (including the State Survey and Certification agency) within 5 working days of the incident and, if the alleged violation is verified, must continue to take appropriate corrective action. Record review of Resident 101's admission Face Sheet (no date) revealed an admission date of [DATE] and admission [DIAGNOSES REDACTED]. Record review of Resident 101's quarterly Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/20/17 identified that Resident 101 exhibited moderately impaired cognition with a Brief Inventory of Mental Status (BIMS) score of 12, had fluctuating episodes of inattention and disorganized thinking, exhibited verbal behavioral symptoms directed toward others 4-6 days per week and was independent with ambulation both in room and in the corridor. Record review of Resident 101's Nurses Notes (NN) dated 11/19/17 at 9:30 AM revealed that Resident 101 was observed kissing another resident. This was witnessed by a Nursing Assistant. Licensed Practical Nurse (LPN) H spoke with and redirected Resident 101 and documented the incident in Resident 101's progress notes. Record review of Resident 101's NN dated 12/6/18 revealed that Resident 101 was found in the dining room with a hand up a (gender) residents nightgown. Resident 101 was redirected and it did not happen again. LPN H documented the incident in Resident 101's Nurses Notes. Record review of the facility investigations reports since the last survey ( 10/20/16) revealed no investigations into those documented incidents of resident to resident sexual misconduct. Interview on 02/08/18 at 08:35 AM with the facility Administrator revealed there had been no reports of any resident to resident sexual behaviors for Resident 101. The Administrator confirmed that there was documentation in Resident 101's NN and that the Administration should have been notified immediately so an investigation and report could be done per the facility policy. The ADM confirmed that those incidents had not been reported to administration by staff so that an investigation could be done and a report made to the required State Agencies.",2020-09-01
414,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,610,D,1,1,B6BN11,**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 staff failed to investigate inner thigh bruising for 1 (Resident 118) of 5 residents. The facility staff identified a census of 170. Findings are: Record review of a undated Face Sheet revealed Resident 118 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 118's Nurse's Notes (NN) dated 11-16-2017 revealed spots were noted to Resident 118's inner thighs that measured 1 centimeter (cm) by 4 cm. According to the NN dated 11-16-2017 a spot on the upper inner thigh is light purple and the spot to the lower inner thigh looked light brown in color. Review of Resident 118's medical record revealed there was not an investigation to the cause of the inner thigh spots. On 2-12-2018 at 9:05 AM an interview was conducted with the Director of Nursing (DON). During the interview review of the NN dated 11-16-2017 was reviewed. The DON Reported there was not an investigation of the inner thigh spots and should have been investigated.,2020-09-01
415,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,623,D,1,1,B6BN11,"> Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to notify the resident or responsible party in writing of reason for involuntary discharge for 1 resident (Resident 307) of 1 resident sampled. The facility staff identified the census at 170. The findings are: A review of Resident 307's Social Services Progress Note dated 12-29-17 revealed that Resident 307 was sent to the emergency room for evaluation due to voicing thoughts of suicide. A review of Resident 307's Social Services Progress Note dated 12-30-17 revealed that Resident 307 was sent to the hospital with the intent to not allow the resident to return to the facility due to concerns about the Resident 307's safety and the safety of the other residents. A review of Resident 307's medical record revealed no letter written to the Resident 307 or their representative notifying them of the reason for the involuntary discharge from the facility. An interview conducted on 2-12-18 at 2:19 PM with the Administrator revealed that a letter was not sent to Resident 307 or their representative explaining the reason for the involuntary discharge, the resident's right to appeal to the State agency, contact information of the State agency, how to apply for an appeal hearing, and the contact information for the State Ombudsman.",2020-09-01
416,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,625,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide a copy of the bed hold policy at time of discharge to the hospital for 1(Resident 29) of five sampled residents. The facility had a total census of 170 residents. Findings are: A review of resident census record revealed Resident 29 was admitted to the facility on [DATE] with a Medicaid payer source. Resident 29 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE], and discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. A review of Resident 29's medical record did not reveal documentation of Resident 29 being provided with a copy of the facility bed hold policy for any of the discharges to the hospital. In an interviews on 2/12/18 at 1:46 PM and 2:08 PM, Admission Coordinator reported residents are given a copy of the bed hold policy on admission but residents with a Medicaid payment source are not given a copy of the bed hold policy each time the resident is discharged to the hospital. A review of undated facility policy titled Bed Hold Policy revealed residents are to receive a copy of the bed hold policy upon admission to the facility and when the resident is transferred to an acute care hospital.",2020-09-01
417,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,657,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.09C Based on record review and interview, the facility failed to include 1 (Resident 29) of 59 residents in development of the comprehensive care plan and failed to revise the comprehensive care plan related to resident to resident altercation for 1 (Resident 101) of 59 residents. The facility had a total census of 170 residents. Findings are: [NAME] A review of resident census record revealed Resident 29 was admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. In an interview on 2/7/18 at 12:55 PM, Resident 29 reported that Resident 29 had not been involved in a care planning meeting. A review of Resident 29's medical record did not reveal any documentation of Resident 29's attendance at a care plan meeting or refusal to attend. In an interview on 2/8/18 at 11:07 AM, Registered Nurse B reported Resident 29's care plan meeting had been completed while Resident 29 was in the hospital. The quarterly care plan meeting would be held next week. B. Record review of Resident 101's admission Face Sheet (no date) revealed an admission date of [DATE] and admission [DIAGNOSES REDACTED]. Record review of Resident 101's quarterly Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/20/17 identified that Resident 101 exhibited moderately impaired cognition with a Brief Inventory of Mental Status (BIMS) score of 12, had fluctuating episodes of inattention and disorganized thinking, exhibited verbal behavioral symptoms directed toward others 4-6 days per week and was independent with ambulation both in room and in the corridor. Record review of Resident 101's Nurses Notes (NN) dated 11/19/17 at 9:30 AM revealed that Resident 101 was observed kissing another resident. This was witnessed by a Nursing Assistant. Licensed Practical Nurse (LPN) H spoke with and redirected Resident 101 and documented the incident in Resident 101's progress notes. Record review of Resident 101's NN dated 12/6/18 revealed that Resident 101 was found in the dining room with a hand up a (gender) residents nightgown. Resident 101 was redirected and it did not happen again. LPN H documented the incident in Resident 101's Nurses Notes. Record review of Resident 101's Comprehensive Care Plan (CCP) dated 9/12/17 identified that Resident 101 had Dementia with behaviors, was confused but enjoyed socializing with others, had moderately impaired cognition, showed a decline in psychosocial well being due to [DIAGNOSES REDACTED]. Interventions included: - Activity staff will remind Resident 101 of daily activities and encourage resident to try new ones. - Offer reading materials in room. - Assist in developing a daily routine. - Provide a daily and monthly calendar of events. - Encourage to ask questions. - Encourage to participate in facility life ad per preferences. - New admission and working to adjust to placement in new environment. - Attempt to engage resident in activities of interest. - Encourage family and friends to visit. - Re-orient to the facility environment. - Redirect resident when experiencing increased agitation and a desire to wander. - Allow enough time in quiet environment. - Educate staff on best approaches and interventions with resident. - Provide distractions from behaviors by offering food, allowing time in room alone, provide with supportive words and validation of feelings. A review of a revised CCP dated 2/8/18 revealed that the CCP for Resident 101 had been revised on 2/8/18 to include inappropriate behaviors towards others (e.g. inappropriate touching/kissing). Interview on 02/08/18 at 8:35 AM with the facility Administrator confirmed that Resident 101's CCP had not been revised prior to 2/8/18 and did not include specific information related to resident to resident sexually inappropriate behaviors prior to that date.",2020-09-01
418,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,677,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.09D1c Based on observation, interview, and record review, the facility failed to provide assistance with personal cares for 1 (Resident 61) of 12 sampled residents and failed to assist residents with facial hair growth management for 3 (Residents 15, 94, and 106) of 12 sampled residents. The facility had a total census of 170 residents. Findings are: [NAME] Resident 61 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 61's care plan revealed a problem dated 3/15/17 of requiring assistance from staff to meet activities of daily living needs. Approaches listed included needs assist of one with oral care and assist of one for personal hygiene and toileting. Observations on 2/7/18 at 9:24 AM revealed Resident 61 had just been transferred to wheelchair and Nurse Aide [NAME] assisted with combing Resident 61 hair. Resident 61 was not observed to receive assistance with brushing teeth. In an interview on 2/7/18 at 9:24 AM Resident 61 confirmed Resident 61 did not receive assistance with brushing teeth. Observations on 2/12/18 at 9:50 AM revealed Nurse Aide [NAME] removed Resident 61's brief. Resident 61 was observed to be incontinent of urine and stool. Resident 61 had dried bowel movement on upper left buttock. Stool was also observed on Resident 61's sheet and the bowel movement on the sheet had been covered with a wash cloth. Nurse Aide [NAME] provided peri care for Resident 61. The Assistant Director of Nursing was called to the room and reported follow up would be completed. In an interview on 2/12/18 at 9:50 AM, Resident 61 reported the dried stool and wash cloth over the bowel movement on the fitted sheet had been left by the night shift. In an interview on 2/12/18 at 11:22 AM, Nurse Aide [NAME] reported checking Resident 61 to determine if Resident 61 was wet at the beginning of the shift and was unaware of dried bowel movement or soiled sheet until care were provided at 9:50 AM. In an interview on 2/12/18 at 1:56 PM, the Director of Nursing confirmed oral care is to be provided to resident twice per day. A review of physician progress notes [REDACTED]. The physician progress notes [REDACTED]. A review of dental progress note dated 10/26/17 revealed Resident 61 had poor oral hygiene with heavy plaque and moderate calculus. B. An observation conducted on 2-5-18 at 12:52 PM revealed Resident 15 had noticeable facial hair growth on their chin. An observation conducted on 2-6-18 at 2:41 PM revealed Resident 15 had noticeable facial hair growth on their chin. An observation conducted on 2-7-18 at 10:07 AM revealed Resident 15 had noticeable facial hair growth on their chin. An observation conducted on 2-8-18 at 12:52 PM revealed Resident 15 had noticeable facial hair growth on their chin. An interview conducted on 2-8-18 at 12:52 PM with Resident 15 revealed that the resident was not aware of the facial hair growth and reported that it had been a while since anyone had assisted them with removing facial hair. A review of Resident 15's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 1-24-18 revealed that Resident 15 required extensive assistance with personal hygiene. C. An observation conducted on 2-5-18 at 10:32 AM revealed Resident 94 had noticeable black and gray facial hair growth on their chin and upper lip. An observation conducted on 2-7-18 at 7:19 AM revealed Resident 94 had noticeable black and gray facial hair growth on their chin and upper lip. An observation conducted on 2-7-18 at 4:05 PM revealed Resident 94 had noticeable black and gray facial hair growth on their chin and upper lip. An observation conducted on 2-8-18 at 7:19 AM revealed Resident 94 had noticeable black and gray facial hair growth on their chin and upper lip. An observation conducted on 2-8-18 at 11:24 AM revealed Resident 94 had noticeable black and gray facial hair growth on their chin and upper lip. An interview conducted on 2-8-18 at 11:24 AM with Licensed Practical Nurse (LPN) M confirmed that Resident 94 had facial hair growth on their chin and upper lip. LPN M reported that the staff would take care of the facial hair as soon as Resident 94 was finished with lunch. A review of Resident 94's MDS dated [DATE] revealed that Resident 94 required extensive assistance with personal hygiene. D. An observation conducted on 2-5-18 at 4:28 PM of Resident 106 revealed the resident had noticeable facial hair growth on their chin. An observation conducted on 2-6-18 at 8:30 AM of Resident 106 revealed the resident had noticeable facial hair growth on their chin. An observation conducted on 2-8-18 at 9:45 AM of Resident 106 revealed the resident had noticeable facial hair growth on their chin. An interview conducted on 2-8-18 at 9:45 AM with Resident 106 revealed that the facility staff were not assisting the resident to shave and that the resident was not intending to grow a beard. An observation conducted on 2-12-18 at 8:55 AM of Resident 106 revealed the resident had noticeable facial hair growth on their chin. A review of Resident 106's MDS dated [DATE] revealed that Resident 106 required extensive assistance with personal hygiene. An interview conducted on 2-12-18 at 9:05 AM with Nursing Assistant (NA) P revealed that all nursing staff were responsible to assist residents with shaving and management of facial hair.",2020-09-01
419,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,679,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D5b Based on observation, record review and interview; the facility failed to provide individualized activities based on resident interest for 1 (Resident 101) of 7 residents reviewed for the provision of activities. The facility census was 170. Findings are: Record review of Resident 101's admission Face Sheet (no date) revealed an admission date of [DATE] and admission [DIAGNOSES REDACTED]. Record review of Resident 101's Interview for Activity Preferences dated 9/13/17 revealed that it was somewhat important to have books, newspapers and magazines to read, to listen to music, to be around animals/pets, to keep up with the news, to do things with groups of people, to do favorite activities and to go outside when the weather is good. A note at the bottom of the assessment indicated that Resident 101 enjoyed talking, watching movies, playing poker and pool. Record review of Resident 101's quarterly Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 12/20/17 identified that Resident 101 exhibited moderately impaired cognition with a Brief Inventory of Mental Status (BIMS) score of 12, had fluctuating episodes of inattention and disorganized thinking, exhibited verbal behavioral symptoms directed toward others 4-6 days per week and was independent with ambulation both in room and in the corridor. Record review of Resident 101's Activity assessment dated [DATE] identified that Resident 101 exhibited adequate hearing and vision, verbalized clearly and conversed appropriately, was alert and oriented to person, place and time, ambulated independently, appeared anxious and wandered, interacted easily with others, knew others in the facility, was a loner, enjoyed leisure activities, was interested in group activities depending on the activities and spent time relaxing alone. The resident identified interest in games, current events, exercise, movies , Television, group activities, puzzles, reading in room, bingo on the unit, nature and animals. Record review of Resident 101's Comprehensive Care Plan (CCP) dated 9/12/17 identified that Resident 101 had Dementia with behaviors, is confused but enjoys socializing with others. Moderately impaired cognition, shows a decline in psychosocial well being due to [DIAGNOSES REDACTED]. Behavioral Symptoms: resident displays behaviors of yelling, verbal aggression, threatening staff and resisting cares. Interventions included: - Activity staff will remind Resident 101 of daily activities and also encourage resident to try new ones also. - Offer reading materials in room. - Assist in developing a daily routine. - Provide a daily and monthly calendar of events. - Encourage to ask questions. - Encourage to participate in facility life ad per preferences. , - New admission and working to adjust to placement in new environment. - Attempt to engage resident in activities of interest, - Encourage family and friends to visit. - Re-orient to the facility environment, - Redirect resident when he is experiencing increased agitation and a desire to wander. - Allow enough time in quiet environment. - Educate staff on best approaches and interventions with resident. - Provide distractions from behaviors by offering food, allowing time in room alone, provide with supportive words and validation of feelings. Observations of Resident 101's activity involvement on the following dates and times on the secured unit of the facility revealed the following: - 02/05/18 at 09:52 AM sleeping in bed, no activity going on in the unit. - 02/05/18 at 11:36 AM sleeping in bed, no activity going on in the unit. - 02/05/18 01:31 PM sleeping in bed under the covers, no activity going on in the unit. - 02/05/18 at 02:57 PM sleeping in bed, no activity going on in the unit. - 02/05/18 at 03:26 PM resting in bed in room, no activity going on in the unit. - 02/06/18 at 08:01 AM up in the dining area eating breakfast, looked around at other residents, no verbal staff to resident interactions. - 02/06/18 at 10:22 AM sleeping in bed, no activities going on in the unit. - 02/06/18 at 3:50 PM sleeping in bed, television (TV) on in room, no organized activities going on, only 1 staff in the unit at that time cleaned the tables. - 02/07/18 at 07:36 AM up and dressed in room, walked to the dining table and sat and was served. no verbal staff to resident interactions. - 02/07/18 at 09:52 AM watching TV in room, in the main activity area there was a movie and snacks being provided. No staff invited Resident 101 to attend the activity or provided encouragement to attend. Interview with Resident 101 on 02/07/18 at 09:52 AM revealed that Resident 101 stated I like to be in my room and want to watch my TV in here, I don't want to go to that activity. Observation on 02/07/18 at 12:26 PM revealed that Resident 101 ate lunch, interacted verbally with the staff. Resident 101 remained at the table after lunch was completed and watched the TV by the table in the dining room. Observation on 02/07/18 at 01:00 PM revealed that Resident 101 sat and watched TV in the small lobby area of the unit with 3 other residents. No staff were present to provide interaction and no other activities were being provided on the unit at that time. Observation 02/07/18 at 03:22 PM revealed Resident 101 in the activity area, sitting at a table while a question and answer game was going on. Resident 101 got up and walked around the room and then sat back down. Resident 101 did not respond verbally but did look at the staff who were talking. Staff attempted to engage him but the resident did not respond. Interview on 02/08/18 at 08:40 AM with Activity staff Q revealed that the main activity schedule that was for the facility was to be followed in the secured unit and that some activity changes could happen due to how well the residents were doing in the unit. Record review of the Febuary (YEAR) monthly activity schedule revealed that the following activities were scheduled: Monday 2/5/18: - 9:30 exercise and ball toss - 10: 15 sing a long, - 1:00 mail delivery and visits Tuesday 2/6/18: - 9:30 Ball toss and exercise - 10:15 worship - 1:00 mail delivery and visits - 2:30 wheel of fortune. Wed 2/7/18: - 9:30 exercise and ball toss, - 10:15 Rosary - 1:00 Mail delivery and visits - 2:30 Fontenelle forest - 3:30 visiting. Observations on 2/5/18, 2/6/18 and 2/7/18 revealed that those activities were not provided on the secured unit of the facility Interview on 2/8/18 at 9:27 AM with the Activity Director confirmed that the activities on the calendar should have been provided in the secured unit. Staff should have provided activities of interest to Resident 101 and encouraged participation in activities.",2020-09-01
420,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,686,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D2a Based on observation, interview and record review; the facility failed to provide interventions and ensure interventions were present to prevent pressure ulcers for 1 of 5 residents sampled (Resident 8). The facility census was 170. Record review of the undated facility Nursing Policy and Procedure for Pressure Ulcer Prevention revealed the following: Purpose: To prevent the development of Pressure Ulcers 3. Residents who are unable or require assistance with turning will be repositioned at a minimum of every two hours. 4. Change the resident's position frequently while sitting up in chair. Frail residents may need to be positioned more frequently. 8. Examine skin for early signs of breakdown from appliances. 9. Protect at risk areas by using heel protectors, pillows, special mattresses etc. as indicated. 10. If resident is incontinent, cleanse soiled area with soap and water, apply skin barrier ointment and change soiled linen and clothing. 11. Report any signs of skin irritation and pressure to the Charge Nurse immediately. Record review of the Resident 8's Nurse's notes dated 2/11/18 at 2 pm revealed that Resident 8's family came to visit the resident and were providing incontinence cares to Resident 8. Family member reported to staff that Resident 8 had an open area on sacrum. The nurses notes revealed that the facility obtained orders and provided care to open area. Observation on 2/12/18 at 10:15 AM revealed that Resident 8 received wound care to a Stage II Pressure Ulcer to coccyx. The old dressing was removed to reveal moderate amount of dark drainage. Resident 8 received treatment per Resident 8's physician order [REDACTED]. Interview with Nurse S on 2/12/18 at 10:32 AM revealed that Resident 8 was high risk for Pressure Ulcer development . Nurse S revealed that Resident 8 was dependent on others for cares and nutrition, Resident 8 was unable to reposition or feed self. Observation on 2/12/18 at 2:19 PM of Resident 8's pressure reducing cushion in Resident 8's wheel chair, revealed wrinkles were present, a cut in the plastic was present and lack of pressure support . Interview with ADON (Assistant Director Of Nursing) and Nurse S on 2/12/18 at 2:19 PM confirmed that the pressure reducing cushion was in poor repair and would not have relieved pressure to the resident's coccyx. The ADON and Nurse S confirmed that the pressure relieving cushion was ineffective and contributed to Resident 8's Pressure Ulcer Development.",2020-09-01
421,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,689,G,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 12-006.09D7 Based on observations, interview, and record review, the facility failed to implement interventions to protect 1 (Resident 59) of 9 sampled residents with falls. The facility had a total census of 170 residents. Findings are: Resident 59 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 2/7/18 at 9:09 AM and 1:05 PM revealed Resident 59 being fed breakfast and lunch in bed by Nurse Aide I. In an interview on 2/7/18 at 1:05 PM, Nurse Aide I reported Resident 59 was not getting up in chair due to not having a cushion for Resident 59's wheelchair. Observations on 2/8/18 at 9:06 AM revealed Resident 59 being fed breakfast in bed by Nurse Aide [NAME] In interviews on 2/8/18 at 7:28 AM and 9:06 AM, Nurse Aide J reported Resident 59 had slid out of wheelchair and Resident 59 had not been getting up. Nurse Aide J reported waiting until new wheelchair came in to get Resident 59 up. In an interview on 2/7/18 at 2:06 PM, Registered Nurse N reported physical therapy was trying to find a wheelchair for Resident 59 due to sliding out of the wheelchair. A review of Post Fall assessment dated [DATE] revealed Resident 59 was observed slid down out of wheelchair with back resting against foot pedals. Resident 59 received a 5.6 x 1.9 cm (centimeter) skin tear with redden bruising around edges to left lower arm and a 4.7 x 3.5 cm skin tear with reddened bruising around edges to left arm near elbow. A review of Interdisciplinary Therapy Screen dated 1/31/18 revealed Resident 59 was identified having a potential risk related to wheelchair positioning. The comments section stated Resident 59 was appropriate for occupation therapy due to need for wheelchair positioning assessment. In an interview on 2/8/18 at 8:36 AM, Occupational Therapist K reported that a physician's orders [REDACTED]. In an interview on 2/8/18 at 10:10 AM, Physical Therapist L confirmed a screen had been completed on 1/31/18 and orders requested for an evaluation. Physical Therapist L reported no recommendation had been made for Resident 59 to stay in bed due to being unsafe in chair. A review of Occupational Therapy Initial Evaluation dated 2/8/18 revealed Resident 59 required occupational therapy services to address sitting tolerance and postural control. Occupational Therapy Initial Evaluation identified a short term goal for Resident 59 of completion of a trial in a customized wheelchair to improve postural stability and upright positioning.",2020-09-01
422,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,690,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D3 Based on observations, interviews, and record reviews; the facility failed to evaluate bowel incontinence for implementation of a toileting plan for 1 resident (Resident 44) of 5 residents sampled and failed to change the catheter bag for 1 resident (Resident 41) of 3 residents sampled. The facility staff identified the census at 170. The findings are: [NAME] A review of Resident 44's undated Face Sheet revealed Resident 44 was admitted to the facility on [DATE]. A review of Resident 44's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 11-15-17 revealed that the resident was frequently incontinent of bowel and was not on a toileting plan. A review of Resident 44's Monthly Nursing Summary dated 11-16-17, 12-16-17, and 1-28-18 revealed that Resident 44 was always incontinent of bowel. A review of Resident 44's Incontinence assessment dated [DATE] revealed that the resident had a history of [REDACTED]. An interview conducted on 2-12-18 at 9:09 AM with the Director of Nursing (DON) revealed that the nursing staff had not completed an evaluation of Resident 44's bowel incontinence, but thought that Occupational Therapy may have. An interview conducted on 2-12-18 at 9:55 AM with Occupational Therapist R revealed that Resident 44 was seen by Occupational Therapy for wheelchair placement only and had not been evaluated for incontinence. B. An observation conducted on 2-5-18 at 11:34 AM of Resident 41's bathroom revealed a catheter bag with orangish brown staining dated 12-18-17 in a trash bag that was hanging next to the toilet. An interview conducted on 2-7-18 at 9:53 AM with Licensed Practical Nurse (LPN) S confirmed the catheter bag that was hanging in Resident 41's bathroom was dated 12-18-17. LPN S reported that catheter bags were to be changed out at least monthly. A review of Resident 41's Care Plan dated 2-27-17 revealed an intervention to change the catheter and bag per the physician's orders [REDACTED]. A review of Resident 41's (MONTH) Treatment Administration Record revealed an order to change the resident's catheter every 3-4 weeks. A review of Resident 41's Nursing Progress Note dated 1-12-18 revealed that the resident's indwelling catheter was changed. A review of Resident 41's Hospital Discharge Summary dated 1-10-18 revealed that Resident 41 was hospitalized [DATE] to 1-10-18 and was treated for [REDACTED]. A review of the facility's Catheter Care Policy and Procedure dated (MONTH) 2002 revealed the following: Indwelling and Suprapubic Catheter Change: Urinary drainage bags will be changed when the indwelling catheter is changed and as needed because of accumulation of sediment, discoloration of the bag, odor, leakage.",2020-09-01
423,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,693,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D 6 Based on observation, interview and record review, the facility failed to provide oral cares to one of one sampled (Resident 136) ,who requires intake totally by tube feeding, and receives nothing by mouth . Record review of the facility Nursing Policy and Procedure for Oral Hygiene, undated, revealed: Purpose: *To ensure cleanliness. *To prevent odor. *To improve appetite. *To ensure a sense of well-being. *To prevent dental cavities, tartar deposits, gum inflammation and deterioration. *To prevent the spread of micor-organisms. *To stimulate circulation of blood in gums. Frequency: *Every morning before breakfast *Every evening at bedtime *At least every two hours on all residents not taking oral nourishment. Observation of Resident 136's Face Sheet revealed that Resident 136 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 136's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) on 12/13/17, revealed Resident 136's BIMS stands for 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. It is a required screening tool used in nursing homes to assess cognition. Scores are 13-15 points: the person is intact cognitively, 9-12 points: the person is moderately impaired, and 0-7 points: the person is severely impaired was 12. Record reveal of Nurse's Note dated 12/22/17, revealed that Resident 1326's dental status was a requirement of assist of one person to with oral cares. Has upper denture with own teeth on the bottom. Requires feeding by tube, and is NPO ( Nothing by mouth). Resident 136 performs basic personal hygiene tasks with assist of one. Record review of Resident 136's Physician orders [REDACTED]. Record review of Resident 136'6 Comprehensive Plan of Care, dated 12/22/17 revealed that Resident 136's problem was the presence of tube feeding with risk of nutritional problems, dysphagia residual of a Stroke. Goal for Resident was to be free of complications of continuous tube feeding (aspiration), and approach dated 123/22/17 was to provide oral cares when NPO, observe for dryness, caries, etc . Observation on 2/7/18 from 9:40 AM till 10:05 AM, with Staff members LPN N and Nursing Assistant (NA) X, revealed NA X assisting with morning cares, and LPN N administering nutrition by feeding tube, and feeding tube cares to Resident 136. Resident 136's lips were dry and skin was visible flaking, upon opening mouth to speak, visible whit liquid thick and sticky was present from roof of mouth to teeth. The teeth has visible yellow substance present. Interview with NA X on 2/7/18 at 10:10 AM confirmed that oral care had not been provided during this shift. NA X revealed that if Resident 136 had wanted to have oral care assisted, then Resident 136 would ask and NA X would assist if needed. Observation of Resident 136 on 2/7/18 at 10:37 revealed resident lips to be dry with visible flaking of skin present and upon opening the mouth to speak, present was thick white striations from top of gums to lower gums coving teeth. Resident 136's teeth had dried, yellow matter visible. Interview with LPN N, on 12/7/18 at 10:15 AM confirmed that Resident 136's lips were dry and oral care had not been performed. Interview with 2/7/18 at 1:53 PM with NA Y and NA Z regarding oral cares for a resident who was NPO, revealed that they would not know how often to perform oral care, NA Y revealed that maybe on the Nurses should do it if they were NPO, NA Z revealed that oral care should be done at least 2 x day if NPO. Interview with the facility Director of Nursing (DON) on 2/7/18 at 2:00 PM confirmed that it was the facility policy, to provide oral care, to a resident who was NPO, every two hours.",2020-09-01
424,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,697,G,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to implement and evaluate the effectiveness of the pain management program for 1 (Resident 156), and failed to evaluate the effectiveness of as needed pain medications for 1 (Resident 256) of 5 sampled residents. The facility staff identified a census of 170. Findings are: [NAME] Record review of a Face Sheet dated 1-24-18 revealed Resident 156 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 156's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 2-07-2018 revealed the facility staff assessed the following about Resident 156: -Brief Interview of Mental Status (BIM'S) was a 15. According to the MDS Manuel, a score of 13 to 15 indicate intact cognition. -Required Limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene. - No pain issues were identified for Resident 156. Record review of Resident 156's Comprehensive Care Plan (CCP) dated 1-27-2018 Resident 156 had a problem area of pain. The goal identified for Resident 156 was to be able to verbalize or demonstrate minimal pain or discomfort. Interventions to manage Resident 156's pain included administering pain medication and evaluating the effectiveness, assess for non verbal signs of pain such as guarding, moaning and grimacing. Assessing pain characteristics, asking the resident to be specific regarding the duration, location and the quality of the pain. Medicate and offer to medicate for pain prior to physical activities such as Activities of Daily Living (ADL's) or Therapy. Offer non-pharmaceutical means of relief, such as, repositioning, elevation of extremities on pillows, relaxation-quite music, and 1 to 1's. Record review of Nursing Assessment and Re-Admission sheet dated 1-15-2018 revealed Resident 156 had pain to a leg, foot, Shoulder, hip and back pain described as stabbing and shooting pain. The relieving factor was the administration of pain medication. Record review of NAAR dated 1-30-2018 revealed Resident 156 had leg and foot pain with the relieving factor was the administration of pain medication. Record review of Resident 156's Nurse's Notes (NN) dated 1-31-2018 with a time of 9:00 PM revealed Resident 156 refused to get out of bed, c/o (complained of) Pain). According to the NN dated 1-31-2018, pain medication was given. Record review of Resident 156's medical record revealed there was no evidence the facility staff had evaluated the effectiveness of the pain medication. Record review of Resident 156's NN dated 2-1-2018 with a time of 5:30 AM revealed Resident 156 was crying and expressing frustration c/o severe pain to bilat ( both) LE's ( lower extremities) with pain medication being administered. Record review of Resident 156's record that included the Medication Administration Record [REDACTED]. Record review of Resident 156's NN dated 2-2-2018 with the time identified as 8:00 AM revealed Resident 156 continues to cry loudly and to refuse cares. Record review of Resident 156's MAR for 2-2-2018 revealed at 9:50 AM pain medication and an anti-anxiety medication was administered to Resident 156. Further review of the MAR indicated [REDACTED]. Record review of Resident 156's NN dated 2-3-2018 with a time identified as 5:00 AM revealed Resident 156 was difficult to reposition in bed and change an adult brief related to Resident 156 yelling out in pain. Further review of Resident 156's NN dated 2-3-2018 at 5:00 AM revealed Resident 156 yelled out pain description, I hurt all over, its sharp pain. The NN dated 2-3-2018 at 5:00 AM revealed Resident 156 continued to cry and yell out with all cares with Resident 156 stating just let me die. Observation on 2-07-2018 at 8:45 AM revealed Resident 156 needed to use the bathroom. Registered Nurse (RN) C and Nursing Assistant (NA) D came into Resident 156's room and Resident 156 reported the need to use the bathroom. Resident 156 chose to use a bed pan instead of using the bathroom due to increased anxiety for the use of a mechanical lift. NA D with the assistants of another NA started to roll resident to the side. Resident 156 was observed to have facial grimacing reporting (gender) knee hurt and reported a pain level of an 8 to 9 on a scale of 0 to 10 with 10 being the worst pain. RN C asked Resident 156 if Resident 156 wanted pain medication with Resident 156 stating, yes. RN C obtained Resident 156's pain medication and administered to Resident 156. Observation with RN C on 2-07-2018 at 9:35 AM revealed NA D with another NA prepared to transfer Resident 156 using a mechanical lift. NA D placed the sling for the transfer under Resident 156 requiring Resident 156 to roll side to side. Resident 156 yelled out, oh that hurts my back. NA D explained the task of the transfer to Resident 156. NA A attached the sling to the mechanical lift and started to lift Resident 156 up. Resident 156 started to yell Oh my back, my back and started to cry. Resident 156 reported it feels like my back is broke. NA D started to raise Resident 156 up with Resident 156 yelling oh that hurts, stop. let me rest. Resident 156 stated put a sock in my mouth so I don't scream. On 2-07-2018 at 9:54 AM an interview was conducted with NA D. During the interview, NA D reported Resident 156 is always painful. NA D reported Resident 156 pain has been getting worse and this had been reported to the nurses. NA D reported Resident 156 is more painful when moved and that Resident 156's pain seems to be getting worse. On 2-07-2018 at 11:15 Am an interview was conducted with the Medical Records Manager (MRM). During the interview the MRM reported Resident 156 did not have a pain management flow sheet started for Resident 156. On 2-07-2018 at 1:25 PM an interview was conducted with RN C. During the interview when asked if Resident 156 had been pre-medicated prior to the ADL's being completed. RN C stated no, further reported Resident 156 should have been pre-medicated. When asked what Resident 156's acceptable pain level was, RN reported not knowing what was acceptable to Resident 156. On 2-08-2018 at 7:56 AM an interview was conducted with Resident 156 related to Resident 156's pain management. During the interview Resident 156 reported the goal for acceptable pain level was a 5 based on a scale of 0 to 10 with the 10 being the worst pain. Resident 156 reported (gender) pain level are between and 8 and 9 with movement. On 2-08-2018 at 10:45 AM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview LPN G reported that all pain medication should be evaluated for the effectiveness. Record review of an undated Policy and Procedure for Pain Assessment and management revealed the following information. -Purpose: All Residents will be assessed for pain and identified by nursing staff. Residents with pain will receive individual interventions aimed at reducing chronic and/or acute discomfort utilizing current standards of practice for pain control. -Procedure: -2. develop an individualized care plan for pain management. -3. Pain Management Flow Sheet will be placed in each residents medication record for assessment and documentation of intermittent and breakthrough pain. -4. Pain assessment will be done using the 0 to 10 pain scale based on the residents cognitive status. -6. Interventions to treat residents pain will be implemented to manage pain effectively. -7. Evaluate effectiveness of PRN (as needed) [MEDICATION NAME] within an hour of time administered and document effectiveness on the back of the MAR indicated [REDACTED]. B. Resident 256 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 2/7/18 at 2:21 PM, Resident 256 reported having pain at a level 10 (pain rating scale of 1-10) and reported having received a pain pill an hour ago. Resident 256 reported not getting relief from pain. A review of Resident 256's 2/2018 Medication Administration Record [REDACTED]. A review of Narcotic count record for Resident 256 revealed Resident 256 received [MEDICATION NAME] 5 mg 19 times between 2/1/18 and 2/7/18. A review of 2/2018 Resident 256 Medication Administration Record [REDACTED]. A review of the back side of the Medication Administration Record [REDACTED]. A review of Resident 256 PRN Pain Management Flow Sheet revealed documentation of [MEDICATION NAME] given 4 times as follows: 1 time on 2/4/18, twice on 2/5/18 and once on 2/7/18. The flow sheet identifies pain location, pain level, [MEDICATION NAME] given, and if [MEDICATION NAME] is effective. In an interview on 2/8/18 at 10:41 AM, Licensed Practical Nurse M reported pain flow sheet is to be completed when a resident asks for a pain medication. In an interview on 2/8/18 at 12:10 PM, Staff Development Registered Nurse reported no other PRN Pain Management Flow Sheet could be located for Resident 256. A review of undated policy titled Pain Assessment and Management revealed the following: -the Pain Management Flow sheet will be used for assessment and documentation of intermittent and breakthrough pain. -The effectiveness of PRN [MEDICATION NAME] will be evaluated within an hour of administration and documented on back of Medication Administration Record [REDACTED]",2020-09-01
425,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,755,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.12E4 Based on observation, interview, and record review; the facility failed to ensure expired medications were not available for use for Resident 150 and expired insulin was not available for use for Residents 53 and 140, and medications were not pre-set in the medication cart. The facility staff identified the census at 170. The findings are: An observation conducted on 2-6-18 at 10:35 AM of the 500 Hall medication cart revealed a package of Odansetron (an anti-nausea medication) for Resident 150 with an expiration date of 4/2017 and 2 medication cups containing applesauce and pills sitting loosely one of the drawers. An interview conducted on 2-6-18 at 10:35 with Licensed Practical Nurse (LPN) V confirmed that the Odansetron was expired and was still available for resident use and that the medication cups with applesauce and pills should not have been there. An observation conducted on 2-6-18 at 10:42 AM of the South Medication Room revealed a vial of Humalog dated as opened on 1-5-18 for Resident 53. An interview conducted on 2-6-18 at 10:42 AM with LPN V revealed that insulin vials were considered expired 28 days after opening. LPN V confirmed the Humalog was expired and was still available for resident use. An observation conducted on 2-6-18 at 10:48 AM of the North Medication Room revealed a vial of [MEDICATION NAME] dated as expired on 2-5-18 for Resident 140. An interview conducted on 2-6-18 at 10:48 AM with LPN M confirmed the Humalog was expired and was still available for resident use. A review of the facility Administering Drugs Policy and Procedure dated 8/2010 revealed the following: Procedure: 2. Medications are to be administered at the time they are prepared. No drugs are to be pre-poured or pre-set.",2020-09-01
426,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,760,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure 1 (Resident 156) of 6 sampled residents was free of a significant medication error. The facility staff identified a census of 170. Findings are; Record review of a Face Sheet dated 1-24-18 revealed Resident 156 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 156's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 2-07-2018 revealed the facility staff assessed the following about Resident 156: -Brief Interview of Mental Status (BIM'S) was a 15. According to the MDS Manuel, a score of 13 to 15 indicate intact cognition. Record review of Resident 156 Medication Administartion Record (MAR) for (MONTH) (YEAR) revealed Resident 156 had orders for Humalog Insulin with unit doses being adjusted with the results of blood surgar levels. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Observation on 2-08-2018 at 9:12 AM revealed Resident 156 was in bed and awake. Resident 156 was obsevered not to have any breakfast. On 2-08-2018 at 9:12 AM an interview was conducted with Resident 156. Resident 156 reported not having breakfast yet and had ordered a hard boiled egg. On 2-08-2018 at 9:39AM an interview was conducted with Licensed Practical Nurse (LPN) M. During the interview LPN M reported Humalog is a short acting insulin. LPN M reported Resident 156's insulin was given around 7 AM. LPN M further reported the insulin should have been given within an hour of Resident 156 eating. LPN M was a significant medication error for Resident 156. Record review of [NAME]'s Drug Guide for Nurses, 15th edition, page 697 and 698 revealed the following information: -Insulins Rapid Acting: -Humalog. -Nursing Implementation: - administer insulin within 15 minutes before or immediately after a meal.",2020-09-01
427,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,790,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.14 Based on record review and interview, the facility failed to assist with arranging dental care for 1 (Resident 97) of 1 sampled residents. The facility had a total census of 170 residents. Findings are: Resident 97 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. In an interview on 2/6/18 at 8:32 AM, Resident 97 reported that Resident 97 had lost some teeth but did not have any dentures. A review of Resident 97's Admission Resident assessment dated [DATE] revealed Resident 97 had some missing teeth and broken, loose or carious teeth. A review of Resident 97's Minimum Data Set (a comprehensive assessment used for care planning) dated 12/9/17 revealed Resident 97 had some obvious or likely cavities or broken natural teeth. A review of Resident 97's care plan revealed a problem related to chewing dated 12/13/17 with a goal of having a diet that is of safe texture and consistency. A review of 12/12/17 Nutrition Progress note for Resident 97 revealed Resident requested a mechanical soft diet and identified Resident 97 reported having difficulty with chewing due to missing teeth. In an interview on 2/8/16 at 1:16 PM, Registered Nurse B reported that Registered Nurse B had not followed up with Resident 97 to find out if Resident 97 wanted to be seen by a dentist.",2020-09-01
428,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,880,F,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12.006.17 Based on observation, record review and interview, the facility failed to have an effective infection control program in place to identify infectious organisms with tracking and trending, the facility failed to implement effective isolation procedures for Resident 411, and the facility failed to perform hand hygiene between glove changes, during catheter care, for Resident 41 and failed to change gloves and perform hand hygiene, during cares for Resident 15. This had the potential to affect all residents who reside in the facility. The facility census was 170. Findings are: [NAME] Clinical reference from National Nursing Home Quality Improvement Campaign reveals: Early Identification and containment of C.difficile infection (CDI), dated 12/28/16. *[DIAGNOSES REDACTED]icile infection (CDI) is a common cause of acute diarrhea in nursing homes. * Individuals with CDI serve as a source for bacterial spread to others, through the contamination of caregiver hands and shared equipment. * Contamination of a resident's skin and environment is greater when a resident has diarrhea from CDI but hasn't started on appropriate treatment. * Early identification of CDI can limit the spread of CDI by reducing the time from symptom onset to starting therapy. * Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination. * Contact precautions include use of gowns/gloves and dedicated equipment during care of residents with new diarrhea. Clinical Reference from United States Department of Health and Human Services Centers for Disease Control and Prevention : Isolation precautions for[DIAGNOSES REDACTED]icile to include: Rapid identify and isolate patients with[DIAGNOSES REDACTED]icile. Appendix F Contact Precautions Signs alert visitors to STOP, Visitors Check in at Nursing Station, Gloves and Gown worn at all times, Clean all surfaces with Bleach Products and Wash hands with Soap and Water. Observation on 2/6/18 at 3:50 PM Resident 441 had a tray table sitting to the left of the entrance to the room, also in the hallway were the medication cart and linen hampers. The tray table had 2 boxes sitting on it and a bag with yellow paper in it. The door to Resident 441's room was open and there was nothing to indicate that Resident 411 had an illness that was contagious of any form. The boxes on the tray table had procedure gloves and masks present, the yellow paper in the bag were gowns. Interview with Licensed Piratical Nurse (LPN) W, on 2/6/18 at 3:55 PM confirmed that Resident 441 was in isolation for CDI. Interview with LPN W revealed that the tray table outside of the door was to alert others that Resident 441 was in isolation. LPN W revealed that visitors should stop and the nursing station before entering the room so that staff can verbally inform them of precautions to be used to visit Resident 441. LPN W revealed that the facility does not post a sign to alert others that they should not enter Resident 441's room without gown and gloves, or to wash their hands with soap and water because gel is not effective. Interview on 2/6/17 at 4:00 PM with the facility Director of Nursing (DON), confirmed that the facility practice was to no place signs for isolation. Interview with DON confirmed that Resident 441 was incontinent of stool with active CDI. The DON confirmed that there was no STOP sign to alert visitors to speak with the nursing staff before entering the room for Resident 441, and that the community was at risk for contracting the CDI d/t it being highly contagious. B. Observation on 2/6/18 at 3:50 PM , a tray table was found to be sitting to the left of the entrance a room. also in the hallway were the medication cart and linen hampers. The tray table had 2 boxes sitting on it and a bag with yellow paper in it. The door to Resident 441's room was open and there was nothing to indicate that Resident 411 had an illness that was contagious of any form. The boxes on the tray table had procedure gloves and masks present, the yellow paper in the bag were gowns. Interview on 2/6/18 at 3:55 PM with LPN W revealed that the tray table was the facility isolation set up. LPN W also revealed that a resident with watery stools is not placed on any precautions or isolation until it is confirmed that CDI is present. Interview with 1 Medication aide, and 2 NA's on 2/8/16 from 3: 20 PM till 3: 40 PM revealed that they were unaware that using gel hand sanitizer would be ineffective to kill CDI bacterium, they were unaware of the length of time that the spores from CDI can live on a surface and that that bleach solutions was to be used to clean with. Record review of the facility Infection Control Program and tracking log, for the past 6 mo, revealed that the facility does not track the cultures that are performed during the month, therefore does not track the organism during that month. The facility receives a lab end of month report with the organisms associated with Resident Infection at that time. Interview with the facility Staff Development Coordinator/ Infection Control Nurse on 2/12/18 at 2:02 PM confirmed that the facility did not have effective plan to identify residents with communicable disease, or isolate to prevent and controlling communicable disease for all residents, staff, volunteers, visitors and other individuals providing service, and not following accepted national standards. The facility Infection Control Nurse confirmed that 10 days had gone by from Resident having loose watery stools until [DIAGNOSES REDACTED]. The Infection Control Nurse confirmed that there was no tracking of infection cultures surveillance to identify trending of organisms in the facility and antibiotic stewardship. C. An observation conducted on 2-7-18 at 10:15 AM revealed Licensed Practical Nurse (LPN) T completed perineal cares on Resident 15, and without removing their gloves, retrieved moisture barrier cream from the resident's counter and applied it to the residents wounds and surrounding skin. A review of the facility's Perineal Care Policy and Procedure dated 12/2006 revealed the following: Procedure: 16. Rinse all cleansed areas where soap and water was used, dry thoroughly. 17. Remove gloves and wash hands. 18. Put on clean gloves. 19. Apply moisture barrier cream to buttocks. D. An observation conducted on 2-7-18 at 9:35 AM revealed Nursing Assistant (NA) U entered Resident 41's room to complete catheter cares. NA U washed their hands and applied gloves and entered bathroom to retrieve the urine disposal container and placed it on the bedside table. NA U removed their gloves, and without performing hand hygiene, applied another pair of gloves. NA U then cleansed Resident 41's perineal area then removed their gloves. Without performing hand hygiene, NA U applied another pair of gloves and adjusts the resident's catheter leg straps and removed gloves. Without performing hand hygiene, NA U applied another pair of gloves and cleans the catheter tubing with alcohol wipes and removes their gloves. Without performing hand hygiene, NA U applied another pair of gloves and emptied the resident's catheter bag. An interview conducted on 2-7-18 at 9:53 AM with LPN S confirmed that NA U did not perform hand hygiene between glove changes. LPN S reported that the expectation was for staff to wash or sanitize hands between gloves. A review of the facility's undated Gloves Policy and Procedure revealed the following: Procedure: 4. Wash hands after removing gloves. Gloves do not replace hand washing.",2020-09-01
429,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-02-12,923,D,1,1,B6BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-007.04 D Based on observation, interview and record review; the facility failed to maintain a working ventilation system in 2 (rooms [ROOM NUMBERS]) resident bathrooms on 2 of 10 resident hallways. This had the potential to affect 4 residents that resided in those rooms. The facility census was 170. Findings are: Observation on 2/8/18 between 1:30 and 2:00 PM with the facility Maintenance Director and Administrator revealed no working ventilation systems in the bathrooms of resident rooms [ROOM NUMBERS] on the 300 hall and 400 hall of the facility. A one ply square of toilet paper was held flat against the ventilation system cover in the bathrooms of rooms [ROOM NUMBERS]. The ventilation system in those rooms did not hold the paper to the outside of the ventilation system which indicated that there was no air draw and the ventilation system did not work. Interview on 02/8/18 at 2:00 PM with the facility Administrator and the Maintenance Director confirmed that the ventilation system did not work in rooms [ROOM NUMBERS]. Record review of a Work Room List dated 12/12/17 of biweekly exhaust checks revealed that the column for the bi weekly exhaust checks was blank. Interview on 02/8/18 at 02:27 PM with the Maintenance Director confirmed that the ventilation system in resident rooms had not been routinely checked to ensure that they were operational.",2020-09-01
430,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-04-01,604,D,1,0,G4ZC11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (8) Based on observation, record review and interview; the facility failed to identify a reclining wheelchair as a potential restraint for 1 (Resident 1) of 1 sampled resident. The facility staff identified a census of 150. The findings are: Review of Policy for Restraints dated 12/2009 revealed the policy is to abide by the residents right to be free from any physical restraint. The policy states potential entrapment risks is any device that restricts the mobility of a resident. Each resident must be assessed on an individual basis. A Physical Restraint Assessment Form will be completed upon application of a restraint and reviewed quarterly to ensure assistive devices are consistent with the resident's needs. Observation on 4/1/2019 from 11:00 AM to 11:20 AM revealed Resident 1 was sitting in the dining room in a wheelchair that was fully reclined back with the foot rest in an up position. Resident 1's feet were dangling. Observation 4/1/19 at 12 Noon revealed Resident 1 sitting in the dining room in a wheelchair that was fully reclined back. Record review of Resident 1's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/27/2019 revealed the facility staff assessed Resident 1's functional status as supervision for bed mobility and transfers and extensive assist with toileting. The MDS was coded for supervision for walking in the room and walking in the corridor. Review of the Comprehensive Care Plan updated 3/6/2019 revealed a problem addressing Activity of Daily Living (ADL) Potential with a goal of Resident 1 will demonstrate improved activity tolerance as evidenced by no reports of weakness and able to perform ADLs within physical limitations. The interventions included: 1. Ambulates with a walker with supervision 2. Transfers with one assist and use of gait belt 3. Encourage independence in as many activities as possible to maintain dignity and independence. Record review of a Nursing Progress Note for Resident 1 dated 03/19/2019 03:29 AM revealed Resident 1 was up in chair in hallway. Resident 1 was wandering into other Resident rooms, and has been in chair in the hallway as Resident 1 refuses to go to bed and for close observation. Interview conducted on 4/1/2019 at 11:05 AM with Certified Nursing Assistant (C.N.[NAME]) A and C.N.[NAME] B revealed that resident 1 hasn't been walking since the fall when Resident 1 was having behaviors. C.N.[NAME] A revealed they keep Resident 1 in the wheelchair reclined because he tries to get up unassisted. Interview conducted on 4/1/2019 at 1:00 PM with Administrator revealed there are no restraints in the facility. Interview with ADON and RN C on 4/1/2019 at 02:10 PM confirmed the facility staff had not identified the reclining wheelchair as a potential restraint and therefore an assessment had not been completed. ADON confirmed the policy revealed a restraint to be any device that restricts the mobility of a resident and that a reclining wheelchair could potentially be considered a restraint.",2020-09-01
431,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,583,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observations and interview; the facility staff failed to ensure resident privacy during personal care and treatment for 1 (Resident 139) of 11 residents. The facility staff identified a census of 161. Findings are: [NAME] Observation on 5-20-2019 at 12:37 PM of personal care revealed Nursing Assistant (NA) H and NA I using a mechanical left transferred Resident 139 from a wheelchair into bed. Resident 139's roommate was in the room. Further observation revealed Resident 139 had become incontinent of urine through Resident 139's pants. Without pulling privacy curtains NA H and NA I pulled Resident 139's pants down and off. NA H and NA I donned gloves and NA I removed the soiled brief assisted Resident 139 onto the right laying positions NA H using a wipe cleansed Resident 139's buttocks area, removed the soiled gloves, applied another pair. NA H applied a barrier cream to residents 139's buttocks with the privacy curtain open. On 5-20-2019 at 1:30 PM an interview was conducted with NA H. During the interview NA H confirmed Resident 139's roommate was in the room and Resident 139's privacy curtain was not pulled around resident 139 to ensure privacy. B. Observation on 5-20-2019 at 2:00 PM of a treatment for [REDACTED]. LPN P without closing Resident 139's privacy curtain pulled Resident 139's pants down to complete the treatment. LPN P completed the treatment and then pulled up Resident 139's pants. On 5-20-2019 at 2:10 PM an interview was conducted with LPN P. During the interview LPN P confirmed Resident 139's privacy curtain had not been drawn to ensure Resident 139 privacy.",2020-09-01
432,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,584,E,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E3 LICENSURE REFERENCE NUMBER 175 NAC 12-007.01A [NAME] Based on observation, interview, and record review, the facility failed to ensure water temperatures were maintained to prevent potential scalds in 4 of 8 bathhouses and the facility failed to ensure the kitchen floor was clean. The facility census was 161. FIndings are: On 05/15/19 at 2:10 PM during inspection of the bath house with the Maintenance Director (MD) revealed that the bath house in the 100 hall was 118 degrees. The 400 hall room [ROOM NUMBER] was 117.8 degrees. The 500 hall in the SPA the sink was 127.0 degrees, the tub and shower combo was 123.8 and in the stand alone shower the temperature was 117.8 degrees. The 900 hall bath taken by the MD was 111.7 degrees. Record review of the water temperature log dated (MONTH) 17, 2019 and titled SJV (St. Joseph Villa) Room Work list revealed the 100 hall shower to be 113.2 degrees. The 300 hall whirlpool temperature was 116.9 degrees and the 500 hall shower was 114.6 degrees. The (MONTH) 21, 2019 water temperature log revealed the 300 hall shower to be 118.7 degrees, the 700 hall south whirlpool to be 118.6 degrees and the 700 hall shower south to be 119.5. Interview with the MD on 5/15/19 at 3:49 PM revealed the MD did not know what the proper temperatures should be for the facility. B. On 5/15/2019 observation of the initial tour of the kitchen revealed the kitchen floor had debris of food items, grime build up and the floor was sticky when walked upon. On 5/15/19 at 9:58 AM during the initial kitchen tour an interview was conducted with the kitchen manager. During the interview the kitchen manager confirmed the floor was sticky and soiled. A review of the policy titled Cleaning Instructions: Floor reveals that the Guideline is Floors will be kept clean and sanitary, washed daily or as needed. On 5/16/2019 at approximately 2:15 PM revealed an interview with the kitchen supervisor confirmed that the floor should not have been sticky or soiled.",2020-09-01
433,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,623,D,0,1,N8PL11,"Based on record review and interview, the facility failed to ensure that Resident 118's guardian was informed of a transfer to hospital. This had the potential to affect 1 of 3 residents reviewed. The census was 161. Findings are: On 5/15/19 a record review of progress notes for Resident 118 revealed, on 03/15/2019 at 09:19 PM Resident 118 was transferred to UNMC ER via 911 squad. Call out to guardian and message left. 05/21/19 09:25 AM a record review of Progress Notes for Resident 118, dated 4/16/19 at 10:38 AM revealed this staff did speak to guardian. Per guardian, guardian was not aware that Resident 118 had been treated at the hospital. On 5/21/19 at at 10:38 AM Social Services (SS) confirmed they had not contacted the guardian for Resident 118.",2020-09-01
434,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,642,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on record review and observation, the facility failed to ensure accuracy of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) related to antipsychotic drug usage for 1 (Resident 69) of 69 Residents reviewed. The facility census was 161. Findings are: Record review of Resident 69's MDS dated [DATE] revealed that Resident 69 had received an antipsychotic medication for 7 days. Record review of Resident 69's current physician orders [REDACTED]. Record review of order history for Resident 69, for the dates of 1/1/18 through 5/22/19, revealed an end date of 9/27/18 for [MEDICATION NAME] (an antipsychotic medication used to treat mental/mood conditions) 12.5mg orally at bedtime. Interview on 05/22/19 at 12:20 PM with MDS Coordinator confirmed that 3/6/19 MDS was coded inaccurately since Resident 69's antipsychotic had been discontinued on 9/27/18.",2020-09-01
435,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,655,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure baseline care plans were provided for two residents (204 and 304) or their responsible party. This had the potential to affect 2 residents out of 2 residents reviewed. The facility census was 161. Findings are: On 05/20/19 at 01:10 PM a record review of progress notes revealed Resident 304 was admitted on [DATE]. No baseline careplan was charted. On 05/20/19 at 02:23 PM an interview with minimal data sheet coordinator (MDSC) revealed the charge nurses are responsible for initial care plan and are supposed to go over it with the resident. MDSC did not go over the baseline care plan with Resident 304 or Resident 304's family. On 05/21/19 at 08:30 AM an interview with Registered Nurse (RN) Q revealed RN Q did do some of the baseline care plan, RN Q did not talk to the resident or representative about the care plan. On 05/21/19 at 09:00 AM an interview with the Director of Nursing (DON) revealed the MDSC is responsible for the base line care plan and talking to the family. On 05/21/19 at 11:35 AM an interview with MDSC revealed they do not keep a copy of the baseline care plan, they do not go over the baseline care plan with residents or the resident representative. The baseline care plan comes from the computer and updates with the new orders as they are put in, it pulls from the orders and the care plan. They give it to families at care conference, however they do not keep a written copy of it nor of the care plan signed by the families. The charge nurses are responsible for the baseline care plan. B. Review of Resident 204's medical record revealed Resident 204 admitted to the facility on [DATE]. Record review of Resident 204's Care Plan Summary sheet revealed a completing date of 5-05-2019. Record review of Resident 204's medical record that included Resident 204's Care Plan and progress notes revealed there was not evidence the facility staff had provided a summary of the baseline care plan to Resident 204 or Resident 204's representative. On 5-21-2019 at 11:20 AM an interview was conducted with Registered Nurse (RN) [NAME] During the interview RN G reported base line care plans are not provided to the residents or representative.",2020-09-01
436,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,657,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interviews, the facility failed to ensure quarterly care plan conferences were completed for 3 Residents (Resident 69, 51 and 25) and to update one care plan to reflect a discontinued antipsychotic medication for Resident 69. The facility census was 161. Findings are: Record review of Resident 51's Care Conference Summary revealed quarterly care plan conferences were held on 9/27/18 and 12/19/18. Record review of Resident 69's Care Conference Summary revealed a quarterly care plan conference was held on 12/19/18. Record review of Resident 25's Care Conference Summary revealed a quarterly care plan conference was held on 3/7/18. Interview with MDS coordinator on 05/22/19 at 07:48 AM confirmed that no care plan conferences for Resident 25 had been conducted since 3/7/18 and for Residents 51 and 69 since 12/19/18. Record review of Care Plan for Resident 69 with a revised date of 12/13/18 revealed a problem stating Resident 69 received [MEDICATION NAME] (an antipsychotic medication used to treat mental/mood conditions) 25mg at bedtime for dementia with behaviors. Record review of Resident 69's current physician orders [REDACTED]. Record review of order history revealed that Resident 69 used [MEDICATION NAME] until discontinued on 9/27/18. Interview with MDS coordinator on 05/22/19 at 07:48 AM confirmed that the care plan for Resident 69 had not been updated to reflect that Resident 69's [MEDICATION NAME] had been discontinued on 9/27/18.",2020-09-01
437,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,661,D,0,1,N8PL11,LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C3 Based on record review and interview; the facility staff failed to complete a discharge summary to include a recapitulation for 2 (Resident 300 and 83) of 3 sampled residents. The facility staff identified a census of 161. Findings are: [NAME] Record review of Resident 300 medical record revealed Resident 300 discharged to another facility on 2-14-2019. Further review of Resident 300's medical record revealed there was not a recapitulation of Resident 300's at the facility. On 5-22-2019 at 11:00 AM an interview was conducted with the Medical Records Director (MRD). During the interview the MRD confirmed a recapitulation of Resident 300's stay at the facility. B. On 5/22/19 at 10:00 AM a record review of Resident 83's discharge summary revealed there was no recapitulation of residents stay. On 05/22/19 at 11:07 AM an interview with Medical Records Director (MRD) revealed there is not a recapitulation of resident's stay for Resident 83.,2020-09-01
438,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,695,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LISCENSURE REFERNCE NUMBER 175 NAC 12-006.09D6 Based on observation, record review and interview, the facility failed to obtain orders for oxygen for Resident 202. The facility staff identified a census of 161. Findings are: On 5/20/19,7:50AM,an observation of Liscensed Practical Nurse(LPN) F came into Resident 202 room and applied oxygen to Resident 202's nostrils. Record review of Resident 202 Physican orders revealed that there was not a signed order for the use of [REDACTED] On 5/20/19, 1:26 PM, an interview conducted with the Director of Nursing (DON) was unable to provide evidence of a signed physican order for [REDACTED].>",2020-09-01
439,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,697,D,0,1,N8PL11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation and interview; the facility staff failed to implement a pain management program for 1(Resident 139) 1 residents. The facility staff identified a census of 161. Findings are: Observation on 5-20-2019 at 12:37 PM of personal care revealed Nursing Assistant (NA) H and NA I using a mechanical left transferred Resident 139 from a wheelchair into bed. During the transfer Resident 139 face turned and Resident 139 yelled out. Resident 139 was observed to be incontinent of urine. NA H and NA I pulled Resident 139's pants down and off. NA H and NA I started to Resident 139 onto a right laying position when Resident 139 yelled out stating oh that hurts'. NA H and NA I did not stop and report to the nurse Resident 139 was in pain. NA H and NA I reposition Resident 139 from side to side to change soiled sheets. Resident 139 was observed to have a redden face and moan out with each repositioning. NA H and NA I did not stop and report to the nurse Resident 139 was in pain. On 5-20-2019 at 1:03 PM an interview was conducted with NA H. During the interview NA H confirmed Resident 139 was painful. When asked what should be done when a Resident 139 is painful, NA H reported not being sure.",2020-09-01
440,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,726,E,0,1,N8PL11,LICENSURE REFERENCE NUMBER 175 NAC 12-006.04B2 Based on record review and interview; the facility failed to ensure 34 of 72 Nursing Assistants (NA) had competency evaluations completed. The facility staff identified a census of 161. Findings are: Record review of competency evaluations for the facility NA's revealed the facility staff were not able to provide evidence 34 of the 72 nursing assistants had been evaluated to ensure the facility NA were knowledgeable in the provision of resident care. On 5-21-2019 at 4:03 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview RN A confirmed 34 of the facility NA's did not have competcies evaluations completed.,2020-09-01
441,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,730,E,0,1,N8PL11,LICENSURE REFERENCE NUMBER 175 NAC 12-006.04B2a Based on record review and interview; the facility failed to ensure 25 of 36 Nursing Assistants (NA) had completed the required 12 hours of in-service education. The facility staff identified a census of 161. Findings are: Record review of documentation of 36 NA's in-service record revealed 25 NA's did not have the required 12 hours of in-service education. On 5-22-2019 at 8:20 AM an interview was conducted with Registered Nurse (RN) B. During the interview RN B confirmed 25 NA's did not have the required 12 hours of in-service education.,2020-09-01
442,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,755,E,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12E8 Based on observation and interviews, the facility failed to ensure medication carts were secured, security of narcotic medications, and failed to ensure a medication was destroyed properly. This had the potential to effect 21 Residents on 300 hall, and 26 Residents on 900 hall and 8 residents on 1000 hall. The facility census was 161. Findings are: Observation on 5/15/19 at 11:30 AM of medication cart unattended and unlocked on the 900 hallway. Interview on 5/15/19 at 11:33 AM with LPN M confirmed that the medication cart should have been locked while unattended. Observation on 5/21/19 at 11:49 AM of Nurses Cart on 300 hallway was unattended and unlocked. Interview on 5/21/19 at 11:51 AM with LPN K confirmed that the medication cart was left unattended and unlocked and that medication cart should be locked when unattended. Observation on 5/15/19 at 1:15PM of 1000 hall med cart revealed that medication cart was unattended and locked with one medication cassette for Resident 142 containing [MEDICATION NAME] (a narcotic medication used to treat pain) sitting on top of the medication cart. Interview on 5/15/19 at 1:20PM with LPN L confirmed that medication should not have been left out on the medication cart unattended. Observation on 5/20/19 at 9:08 AM of medication provision by MA N for Resident 8 revealed that all medications were taken except one pill, which Resident 8 refused. MA N brought medication back to the medication cart and identified the pill and then put the pill in the trash container located on the side of the medication cart. Interview on 05/21/19 at 03:15 PM with DON (Director of Nursing) stated refused medications should be destroyed and the process is to notify the nurse, put the medication in an envelope and place with medications for pharmacy to destroy. DON confirmed that throwing a pill in the trash container would not be the appropriate way to destroy a medication.",2020-09-01
443,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,756,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure physician follow-up was done from pharmacy recommendations from pharmacy reviews for 2 residents (Residents 80, 74). This had the potential to affect 2 residents out of 4 residents reviewed. The facility census was 161. Findings are: [NAME] On 4/22/19 at 10:00 AM a record review of Resident 74's pharmacy review sheet revealed a recommendation to evaluate Trazadone. On 5/22/19 at 3:30 PM a record review of a follow up visit dated 4/12/19 revealed The Advanced Practice Registered Nurse (APRN) stated to change indications of Trazadone to sleep agent. No evaluation was charted. On 5/22/19 at 3:45 PM the DON confirmed there was no other documentation concerning the evaluation of Trazadone. B. Record Review of the pharmacy recommendations titled [MEDICATION NAME]- Pharmacy Consultation for Resident 80 revealed that on (MONTH) 28, (YEAR) the pharmacy informed the physician of a dose reduction for Trazadone (antidepressant) and [MEDICATION NAME] (antidepressant) and the physician accepted the pharmacy recommendation. An interview with a Licensed Practical Nurse (LPN) H. on 5/20/19 at 1:47 PM revealed this was not followed up on until (MONTH) 22, 2019 when the dosages were decreased",2020-09-01
444,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,757,D,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LISCENSURE REFERENCE NUMBER 175NAC 12-006.09D Based on record review and interview : the facility failed to obtain rationale for continued use of antidepressants fo 2 residents (Resident 51 and 63) of 5 residents. The facility staff identified a census of 161. Findings are: [NAME] Record review showed the pharmacist did monthly review of current medication for Resident 63. Record review of a [MEDICATION NAME] Pharmacy Consultation(GPC) sheet revealed on 3/26/19 the pharmacist recommeded to the facility and physican that [MEDICATION NAME] 10 mg (Antidepressant medication) depression, , be reduced for Resident 63. Furthuer review of the GPC sheet dated 3/26/19 revealed the physican marked, do not accept recommendation, with out providing rationale. On 5/22/19 at 1:32PM an interview was conducted with Director of Nursing ( DON). During the interview the DON was unable to provide evidence of the rationale of continued use of the anti depressant medication. B. Record review of a Pharmacy recommendation dated 9/11/18 for Resident 51 revealed a request for a dose reduction of [MEDICATION NAME] (an antidepressant medication used to treat depression). The physician indicated to continue the same dose of the medication but no rationale for continuing the medication was documented. Interview with DON (Director of Nursing) on 05/22/19 at 02:19 PM confirmed that the physician did not give a rationale for continuing the [MEDICATION NAME] on Resident 51.",2020-09-01
445,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,761,F,0,1,N8PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].E7 Based on observation and interviews, the facility pharmacist failed to ensure that the medication labels contained the actual expiration date of the medication as opposed to the expiration date of the prescription. This had the potential to effect all residents of the facility. Findings are: Observation on [DATE] at 12:,[DATE]:30 PM of several Medication Carts revealed the following medications in cassettes with a medication label that stated EXP date, and date indicated was expired: Medication Cart A Resident # 205- Complete 50 + Vitamin (vitamin supplement), expiration date on label [DATE] Resident # 115- Tylenol Extra Strength 500mg (pain medication), expiration date on label illegible Medication Cart ,[DATE] Resident # 97-Calcium + D ,[DATE] (Calcium and Vitamin D supplement), expiration date on label [DATE] Resident # 37-[MEDICATION NAME] 40mg (medication to treat high cholesterol), expiration date on label [DATE] 400 Hall Cart- Resident # 109-Aspirin EC 81mg (medication to treat pain) -expiration date on label [DATE] Magnesium Oxide 400mg (magnesium supplement), expiration date on label [DATE] [MEDICATION NAME] C (supplement used to treat arthritis), expiration date on label [DATE] [MEDICATION NAME] (medication used to treat gout) 100mg, expiration date on label [DATE] [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION]) 75mg, expiration date on label [DATE] [MEDICATION NAME] C (supplement used to treat arthritis), expiration date on label [DATE] Interview with LPN K on [DATE] at 12:30 PM revealed that LPN assumed this was the expiration date of the medication. Interview with Pharmacist O, who provides facility medications on [DATE] at 01:30 PM revealed that the expiration dates on the cassette labels aren't accurate because they don't change them every time they refill the cassette. They go by the order date and the expiration date on the cassette is actually the expiration date of the prescription. They have to get a new prescription order every year so they put the number of the month on the plastic cover of the extra pill in the cassette to indicate the medication expiration date. Pharmacist confirmed there is no policy for this practice and that the staff would not know the expiration date by looking at the cassette if they didn't understand their process or if the cover came off the extra pill compartment on the cassette.",2020-09-01
446,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,791,D,0,1,N8PL11,LICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on record review and interview; the facility staff failed to ensure 1(Resident 139) of 1 sampled resident received dental services. The facility staff identified a census of 161. Findings are: On 5-16-2019 at 1:26 PM an interview was conducted with Resident 139. During the interview Resident 139 reported Resident 139 had not seen the dentist. Record review of Resident 139's record revealed there was not evidence the facility staff had made arrangements for Resident 139 to see Dentist. On 5-21-2019 at 8:40 AM an interview was conducted with Social Services (SS) E. During the interview SS [NAME] confirmed dental services had not been arranged for Resident 139.,2020-09-01
447,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-05-21,880,D,0,1,N8PL11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation and interview; the facility staff failed to utilized hand washing and glove techniques to prevent cross contamination during the provision of personal cares and treatment for 2( Resident 139 and 143) of 11 residents. The facility staff identified a census of 161. Findings are: [NAME] Observation on 5-20-2019 at 12:37 PM of personal care revealed Nursing Assistant (NA) H and NA I using a mechanical left transferred Resident 139 from a wheelchair into bed. Further observation revealed Resident 139 had become incontinent of urine through Resident 139's pants. NA H and NA I pulled Resident 139's pants down and off. Both NA H and NA I without changing soiled gloves touched touched Resident 139's sheets. NA H and NA I removed gloves and completed handwashing. NA H and NA I donned gloves and NA I removed the soiled brief and with the same soiled gloves assisted Resident 139 onto the right laying positions and touched clean sheets, Resident 139's blouse, hip and arms. NA H using a wipe cleansed Resident 139's buttocks area, removed the soiled gloves, applied another pair. NA H applied a barrier cream to residents 139's buttocks and without changing the soiled gloves or completing handwashing, touched Resident 139's hip, clean briefs and Resident 139's face. On 5-20-2019 at an interview was conducted with NA H. During the interview NA H confirmed soiled gloves and handwashing should have been completed and was not done. B. Observation on 5-21-2019 at 10:07 AM of wound care revealed Licensed Practical Nurse (LPN) P washed hands and donned gloves. LPN P cleansed the surface of Resident 143 tray tabled and placed wound supplies on the table. LPN P Removed socks, leg protectors and an old wound dressing from Resident 143 left lower leg. LPN P obtained a handtowel and moisten one end of the hand towel. LPN P then cleansed Resident 143's left lower leg with the wet portion of the hand towel. LPN P then turned the towel and dried Resident 143's leg. Further observations revealed the soiled part of the handtowel used to cleans Resident 143's left lower leg was laying on Resident 143's bedding. LPN P completed the dressing change and removed the soiled gloves. LPN P washed hands and donned a pair of gloves. LPN P removed Resident 143 socks, leg protector and old dressing that was wrapped around Resident 143's right leg. LPN P removed the soiled gloves and cleaned the hands and donned a pair of gloves. LPN P obtained a handtowel and wet one end. LPN P then cleansed Resident 143's right leg and then using the dry end of the handtowel, dried Resident 143's wounds on the right leg. Further observations revealed the soiled part of the handtowel used to cleans Resident 143's right lower leg was laying on Resident 143's bedding. On 5-21-2019 at 11:02 PM an interview was conducted with LPN P. During the interview LPN P confirmed the soiled handtowel were laying on Resident 143's bedding.",2020-09-01
448,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-06-06,695,D,1,0,SNXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-006.09D6 Based on interview and record review, the facility failed to ensure 1 (Resident 1) of 3 sampled residents was provided with oxygen in accordance with physician orders. The facility had a total census of 150 residents. Findings are: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. In an interview on 6/6/19 at 12:20 PM, Nurse Aide A confirmed Resident 1 had left the facility for an appointment without oxygen. Nurse Aide A reported Resident 1 was not able to use Resident 1's electric wheelchair for the transport and Resident 1's oxygen was left on Resident 1's electric wheelchair. In an interview on 6/6/19 at 12 PM, the Director of Nursing confirmed Resident 1 had been transported to a doctor's appointment without oxygen. The Director of Nursing reported a family member had met Resident 1 at the appointment and requested that facility van driver transport Resident 1 to a hospital emergency room . A review of Progress Notes for Resident 1 dated 6/4/19 revealed resident was 1 was admitted to the hospital. A review of hospital history and physical dated 6/4/19 revealed Resident 1 was admitted to the hospital with [REDACTED].",2020-09-01
449,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-06-20,580,D,1,0,URII11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview;the facility staff failed to notify the practitioner and responsible party of the development of a pressure ulcer for 1 (Resident 595) of 3 sampled residents. The facility staff identified a census of 150. Findings are: Record review of a Wound Management (WM) sheet dated 3-20-2019 revealed Resident 595 was evaluated with a pressure ulcer to the coccyx area. Record review of a WM sheet dated 3-20-2019 revealed Resident 595 was evaluated with a ulcer to the left gluteal fold. Review of Resident 595's medical record revealed there was not evidence the facility staff had notified Resident 595's practitioner or responsible party on the day when Resident 595 was evaluated with a pressure ulcer to the coccyx and ulcer to the left gluteal fold. On 6-19-2019 at 4:02 PM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview, LPN A confirmed Resident 595's practitioner and responsible party had not been notified of the development of the pressure ulcer and ulcer. When asked when should have the practitioner and responsible party been notified of the pressure ulcer and ulcer, LPN A reported the same day.",2020-09-01
450,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2019-06-20,686,D,1,0,URII11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review and interview; the facility staff failed to obtain treatment orders and failed to have a nutritional evaluation completed for the development of pressure ulcer for 1 (Resident 595) of 3 sampled residents. The facility staff identified a census of 50. Findings are: Record review of a Wound Management (WM) sheet dated 3-20-2019 revealed Resident 595 was evaluated with a pressure ulcer to the coccyx area. Record review of a WM sheet dated 3-20-2019 revealed Resident 595 was evaluated with a ulcer to the left gluteal fold. Review of Resident 595's medical record revealed there was not evidence the facility staff had requested a treatment order for Resident 595 pressure ulcers until 3-29-2019. Further review of Resident 595's medical record revealed a nutritional evaluation for pressure ulcer healing had not been completed until 4-15-2019. On 6-19-2019 at 4:02 PM an interview was conducted with the Licensed Practical Nurse (LPN) A who is the facility wound nurse. During the interview LPN A confirmed a treatment had not been obtained until 3-26-2019. When asked when should a treatment order been requested, LPN A reported the same day it was identified. On 6-20-2019 at 8:15 PM an interview was conducted with the Dietary Manager (DM). During the interview the DM reported a nutritional assessment for the pressure ulcer should be completed within a week. Record review of the facility Wound Care Protocol dated 8-2018 revealed the following information: -#2. Treatment should be determined based on the assessment. -Other Considerations: -Screen the resident for nutritional deficiencies. Ensure adequate nutrition to support healing.",2020-09-01
451,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2018-09-17,609,D,1,0,HTHZ11,"> Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report alleged allegation of potential abuse to the required State Agency within 2 hours after the allegation for 1 (Residents 13) of 3 investigations reviewed. The facility census was 160. Findings are: A record review of the Facility's Abuse, Neglect and Exploitation policy dated (MONTH) (YEAR) revealed; (H. 3.) The Administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to other officials in accordance with state law including to the state survey and certification agency. A record review of Resident 13's reported incident revealed the facility was notified of the admission to the hospital for Left femoral neck fracture on (MONTH) 13th (YEAR) at 4:30 PM, the family and physician was notified at that time. A record review of Resident 13's reported incident revealed the facility notified Adult Protective Services (APS) on (MONTH) 14th (YEAR) at 8:36 AM. An interview with Administrator revealed; that the incident was reported to the facility at 4:30 PM on the 13th of (MONTH) (YEAR). The Administrator confirmed that the incident was not called into Adult Protective Services (APS) until (MONTH) 14th (YEAR) at 8:36 AM. The Administrator agreed this injury was a significant injury requiring surgery. The Administrator then called the Director of Nursing (DON) into the room. The DON confirmed that the incident was not called in within 2 hours.",2020-09-01
452,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-10-20,242,D,0,1,JLF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on observation, record review, and interview; the facility failed to evaluate the number of baths per week for two of three residents reviewed (Residents 59 and 10), and the facility failed to follow one of three residents (Resident 169), choice for number of baths per week. The facility census was 163. Findings are: [NAME] Record review of Resident 59's face sheet dated 8/3/2016, revealed that Resident 59 was admitted to the facility on [DATE]. An interview with Resident 59 on 10/18/2016 at 10:50 AM, revealed that Resident 59 wanted three showers a week but was only receiving two. A record review of Resident 59's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9/21/2016 revealed BIMS Score (Brief Interview for Mental Status) of 14/15 (13-15: the person is intact cognitively; 9-12: the person is moderately impaired; 0-7: the person is severely impaired.) A record review of the Daily ADL Care Guide dated (MONTH) (YEAR) revealed that the Resident 59 wanted a shower but not how many times a week Resident 59 wanted the shower to occur. Interview with Registered Nurse F (RN F) on 10/20/2016 at 9:55 AM, revealed that (gender) just completed the resident's care plan meeting and stated that RN F does ask the residents about their choices quarterly and updates are needed, but this resident did not voice concerns about arise times or bathing choices. RN F further states that (gender) does not document these questions on any form just RN F's notes if there was a change. B. Record review of Resident 169's undated face sheet, revealed that Resident 169 was admitted to the facility on [DATE]. An interview with Resident 169 on 10/17/2016 at 3:26 PM revealed that Resident 169 wants 2 showers a week and currently isn't even getting once a week. A record review of Resident 169's MDS dated [DATE] revealed a BIMS score of 11/15. A record review of Resident 169's Admission Resident Assessment sheet dated 4/16/2015 revealed the following hand written in the margin: prefer shower 3x/week in AM-dated 4/17/2015. A record review of the Admission Nursing Care Plan dated 4/16/2015 revealed: shower 3x/week in AM. A record review of Resident 169's Daily ADL Care Guide dated (MONTH) (YEAR) revealed that the resident wants a shower but not how many times a week. A record review of Resident 169's CNA Charting for the month of (MONTH) (YEAR) revealed that the first week of the month there was documentation that the resident received 1 bath (3 September), weeks 2, 3 and 4 revealed there was no documentation that the Resident 169 received any baths those weeks. A record review of Resident 169's CNA Charting for the month of (MONTH) (YEAR) revealed that the first week of the month there was documentation that the resident received 1 bath (10/1/16); week 2 there was no documentation that the resident received any baths that week; week three there was documentation that the resident received 1 bath (10/19/2016). An interview with Registered Nurse A (RN A) on 10/20/2016 at 10:25 AM; revealed that choices are assessed every quarter but there was no documentation to show that. RN A stated that RN A has notes and that if there was a change RN A make a note so as to pass it on to the staff, but there was no formal form and unless there was a change to the resident's choice, that's when the change was made in the resident's chart. A record review of Resident 169's Bath Skin Report revealed that the resident received a bath on the following dates-9/3/16, 9/10/16, 9/17/16, 9/24/16, 10/8/16, 10/12/16 and 10/15/16. An interview with the ADON on 10/20/2016 at 1:35 PM confirmed that per the bathing charting reviewed, that Resident 169 was not receiving the numbers of baths requested. C. Record review of an undated Resident Face Sheet revealed Resident 10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 10-17-2016 at 11:03 AM an interview was conducted with Resident 10. During the interview, when asked how many baths a week Resident 10 would like, Resident 10 reported (gender) would like 2 baths a week and has been receiving 1 bath a week. Record review of Resident 10 medical record that included Resident 10's Comprehensive Care Plan revealed there was no evidence Resident 10's number of per week of baths/showers had been evaluated. On 10-20-2016 at 11:22 AM an interview was conducted with Registered Nurse (RN) [NAME] RN A confirmed during the interview that Resident 10's number of baths per week had not been evaluated.",2020-09-01
453,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-10-20,253,E,0,1,JLF611,"Licensure Reference Number: 175 NAC 12-006.18B3 Based on observation, record review, and interview; the facility failed to ensure ceilings, doors and walls were in good repair in Rooms 100, 309, 310, 311, 509, 510 and 603; and the facility failed to ensure bathroom ventilation vents were clean in Rooms 105 and 309. The facility has 92 resident rooms. Facility census was 163. Findings are: [NAME] During an environmental tour of the facility on 10/19/2016 at 2:18 PM with the following staff members-Facility Administrator (FA) and Maintenance Director (MD) revealed the following: Room number-100-Bathroom Ceiling stained Room number-105-Bathroom vent dusty with cobwebs present on the ceiling from the light fixture to the shower rod Room number-309-Bathroom vent dusty, bathroom door has a hole Room number-310-Ceiling above beds is cracked and peeling Room number-311-Wall damage behind recliner Room number-509-Bathroom walls and sink walls wall next to bathroom has holes Room number-510-Wall crack under the window Room number-603-Missing tile on bathroom wall An interview with the FA and MD on 10/19/2016 at 2:50 PM, confirmed all of the above items as being present during this tour and needed to be addressed.",2020-09-01
454,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-10-20,311,D,0,1,JLF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.09D Based on observations, interview, and record review; the facility failed to offer additional opportunities for grooming/hygiene activities for one resident (Resident 156) of one sampled residents. The facility had a total census of 163 residents. Findings are: Resident 156 was admitted to the facility on ,[DATE] with a [DIAGNOSES REDACTED]. Observations on 10/17/16 at 1:58 PM revealed Resident 156's hair and fingernails were not clean. Observations on 10/20/16 at 10:54 AM revealed Resident 156's hair and fingernails were not clean. In an interview on 10/20/16 at 10:54 AM, the Assistant Director of Nursing confirmed Resident 156's hair and fingernails were not clean. The Assistant Director of Nursing reported Resident 156 will often refused assistance with grooming. A review of Resident 156's care plan revealed Resident 156 required assistance from staff to meet activities of daily needs. Interventions included bathes with assistance of one with bath or shower. Resident 156 to decide a time that he would like a bath or shower. Resident 156's care plan did not reveal any interventions related to refusal of hygiene activities. A review of Bath Skin Reports revealed Resident 156 revealed the following: 9/3/16 bath/shower given 9/14/16 refused bath/shower 9/21/16 refused bath/shower 9/24/16 refused bath/shower 9/28/16 refused bath/shower 10/1/16 refused bath/shower 10/5/16 bath/shower given 10/12/16 bath/shower given 10/15/16 refused bath/shower In an interview on 10/20/16 at 2:55 PM LPN B (Licensed Practical Nurse) and LPN [NAME] reported Resident 156 is non-compliant with cares. LPN B and LPN [NAME] reported that the charge nurse is to be notified if Resident 156 refused a bath/shower and the charge nurse will attempt to convince Resident 156 to take a bath/shower. If the charge nurse is not notified until the end of the shift, the resident will not be offered a bath until the next scheduled bath day. According to LPN B and E, there was not a mechanism for a resident to be offered a bath on the next shift or day. In an interview on 10/20/16 at 2:05 PM, the Director of Nursing reported staff is encouraged to get the nursing, family, and/or social services involved if a resident refuses baths/showers.",2020-09-01
455,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-10-20,323,D,0,1,JLF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.09D7a Based on observations, interviews, and record review; the facility failed to supervise smoking related to possession of smoking materials for one (Resident 156) of one sampled residents who smoked. The facility had a total census of 163 residents. Findings include: Resident 156 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 10/17/16 at 1:58 PM revealed Resident 156 seated in facility main dining room. Resident 156 got up from table in dining room and exited the dining room to the outdoor smoking area and began smoking a cigarette. Observations on 10/17/16 at 4:26 PM revealed Resident 156 with cigarettes in his shirt pocket. On 10/19/16 at 10:15 AM revealed Resident 156 seated in main dining room. Resident 156 showed the surveyor a lighter. Resident 156 stated that Resident 156 did not have any cigarettes. Observations on 10/20/16 at 10:54 AM revealed Resident 156 had a package of cigarettes and a lighter. The Assistance Director of Nursing requested Resident 156 give the cigarettes and lighter to the Assistance Director of Nursing. Resident 156 refused to give up the cigarettes and lighter and started to get agitated. Observations at 10/20/16 at 11 AM revealed Resident 156 refused to give cigarettes and lighter to the Administrator. The Administrator accompanied Resident 156 outside to the smoking area. A review of Resident 156's Care Plan revealed a problem dated 7/28/16 that Resident 156 was a smoker and wanted to smoke independently. Approaches included the following: -All tobacco products are to be stored by the facility. -During winter months the smoking areas is off limits during meal times when the temperature outside is less than 40 degrees Fahrenheit. -The facility has the right to revoke smoking privileges if resident 156 is deemed unsafe after assessment. -Resident 156 is independent with transporting self to and from designated smoking area. -Resident 156 is limited to 5 cigarettes a shift. -Resident 156 was assessed as being able to smoke independently in facility designated area. -Resident 156's lighter and lighting products are to be stored by the facility. -Resident smoking times are from 6 AM to 8 PM. A review of Resident 156's nurse's notes revealed the following entries related to Resident 156's smoking: -7/29/16 12 AM Resident 156 requesting cigarettes excessively -7/30/16 10 PM Resident 156 requesting cigarettes and was told Resident 156 had no cigarettes available. Resident 156 stood at desk for 3.5 hours waiting for a cigarette. -10/15/16 11:30 AM Resident observed smoking in 200 hall. Cigarettes and lighter taken away from Resident 156. Another packet was found in Resident 156's room and placed at nurses' station. In an interview on 10/20/16 at 11:45 AM, LPN B (Licensed Practical Nurse) reported Resident 156's wife did not Resident 156 to smoke and did not bring in cigarettes for the resident. According to LPN B, Resident 156 did not having any cigarettes or a lighter at the nurses' station. In an interview on 10/20/16 at 1:40 PM, the Administrator reported Resident 156 had given the Administrator the package of cigarettes and lighter. The Administrator was not aware Resident 156 had been seen smoking in the building. According to the Administrator, plans were being made to move Resident 156 into the secured unit.",2020-09-01
456,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-10-20,329,D,0,1,JLF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to evaluate the need for additional medication to manage behaviors for one resident (Resident 99) of 5 residents sampled for unnecessary medications. The facility had a total census of 163 residents. Findings are: Resident 99 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. -7/28/16 [MEDICATION NAME] (an antipsychotic medication) 2.5 mg (milligrams) orally every day for aggressive behaviors -8/12/16 starting tomorrow increase [MEDICATION NAME] to 5 mg every morning for [MEDICAL CONDITION] hallucinations -8/15/16 [MEDICATION NAME] (an antipsychotic medication) 1 mg IM (Intramuscularly) now and then .5 mg every 30 minutes as need for behaviors that impair care -9/29/16 discontinue as needed [MEDICATION NAME] -10/7/16 Initiate [MEDICATION NAME] tablet 2.5 mg at bedtime and continue 5 mg every morning -10/7/16 Discontinue [MEDICATION NAME] tablets 2.5 mg orally at bed time and start [MEDICATION NAME] 5 mg orally twice a day -10/13/16 Change [MEDICATION NAME] to 10 mg orally every evening for [MEDICAL CONDITION] with behavioral disturbances -10/16/16 Initiate [MEDICATION NAME] Sprinkles (a mood stabilizer) 125 mg twice a day for behavioral and Psychological symptoms of dementia Nurse's Note dated 9/2/16 revealed Resident 99 was trying to pick up items off the floor that were not there, reaching for people that were not there, walking without walker talking to self. Resident 99 became combative with staff when assistance offered. A review of Nurse's Notes between 9/2/16 and 10/16/16 did not reveal any other documentation of behaviors by Resident 99. A review of Resident 99's Behavior Monitoring Flowsheet for (MONTH) (YEAR) revealed Resident exhibited behaviors of being irritable, antagonizing others, hollering/cursing, and throwing stuff on 9/2/16. No behaviors were documented for the remaining days of the month. A review of Resident 99's Behavior Monitoring Flowsheet for (MONTH) (YEAR) revealed no documented behaviors between 10/1/16 and 10/19/16. A review of Mental Health Clinic Note dated 10/16/16 stated staff report client with continued behavior issues this period resistant to care, irritability, anxiety, verbal yelling, verbal aggression, and nutrition issues despite recent increase of atypical anti-psychotic and anti-depressant. In an interview on 10/20/16 at 11:57 AM, the Director of Nursing confirmed that the facility documentation did not support additional behaviors for Resident 99 and Resident 99 had not been given [MEDICATION NAME] long enough to determine if it was effective before starting another medication.",2020-09-01
457,ST. JOSEPH VILLA NURSING CENTER,285078,2305 SOUTH 10TH STREET,OMAHA,NE,68108,2016-10-20,431,F,0,1,JLF611,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation and interview; the facility staff failed to ensure outdated laboratory testing supplies were not available for use in the facility. This had the potential to affect all residents in the facility. The facility staff identified a census of 163. Findings are: [NAME] Observation on 10-19-2016 at 10:20 AM with Registered Nurse (RN) C of station 2 medication storage room revealed there were 7 laboratory testing tubes with and expiration dated of 08-2016. An interview was conducted with RN C on 10-19-2016 at 10:20 AM. RN C confirmed the vials were outdated and were available for use in the facility. B. Observation on 10-19-2016 at 10:30 AM with Licensed Practical Nurse (LPN) D of station 1's medication storage room revealed there were 28 laboratory blood collection vials that were outdated and 6 culture swabs out dated on 3-2016. On 10-19-2016 at 10:30 AM, LPN D confirmed the vials and swabs were outdated and available for staff to use in the facility.",2020-09-01
458,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-01-24,759,D,1,0,6LD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on observations, record reviews, and interviews; the facility failed to administer medications according to practitioner orders or manufacturer's recommendations by administering medications after or during meal consumption for medications to be given on an empty stomach. The failure affected two sampled residents (Residents 1 and 2). The medication error rate was calculated at 9.09% (3 errors in 33 medication opportunities). Sample size was four current residents. Facility census was 77. Findings are: [NAME] Observation on 1/24/18 at 8:05 a.m. revealed MA (Medication Aide)-A was administering medications to Resident 1. Among the medications administered to the resident was [MEDICATION NAME] (an acid reducing medications). The observation revealed the [MEDICATION NAME] was administered to the resident after the resident had consumed a portion of the meal. Record review of Resident 1's chart revealed a Face Sheet printed on 1/24/18 which identified the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 1's Physician order [REDACTED]. Review of the e-Medication Administration Record [REDACTED] B. Observation on 1/24/18 at 8:10 a.m. revealed RN (Registered Nurse)-B was administering medications to Resident 2. Among the medications administered to the resident were [MEDICATION NAME] and [MEDICATION NAME]. The [MEDICATION NAME] and [MEDICATION NAME] were given to the resident among other medications. The observation revealed the [MEDICATION NAME] and the [MEDICATION NAME] were administered to Resident 2 after the resident had consumed about 2/3 of the breakfast meal. Record review of Resident 2's Face Sheet printed on 1/24/18 revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 2's Physician order [REDACTED]. In addition, [MEDICATION NAME] (generic name for [MEDICATION NAME]) was ordered for the resident on 6/1/17 with instructions to administer DAILY BEFORE BREAKFAST for GERD. The e-Medication Administration Record [REDACTED] Following observations of Medication Administration on 1/24/18 between 8:05 a.m. and 8:15 a.m., a total of 33 medications were observed with 3 medication errors ([MEDICATION NAME] given with meal to Resident 1 and [MEDICATION NAME] and [MEDICATION NAME] given with meal to Resident 2). Calculation of the medication error rate revealed a rate of 9.09% (errors divided by doses given x 100). Interview with the ADON (Assistant Director of Nursing) and the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator on 1/24/18 at 9:45 a.m. confirmed resident medications should be administered at ordered times or according to manufacturer specifications in order to obtain the maximum benefits from the medications. Source: [NAME]'s Drug Guide for Nurses, Fifteenth Edition, Copyright (YEAR). - Regarding [MEDICATION NAME] the Implementation instructions are to Administer doses before meals. - Regarding [MEDICATION NAME] the Implementation instructions are to Administer on an empty stomach 1 hr (hour) before meals .",2020-09-01
459,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-01-24,760,G,1,0,6LD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on record reviews and interviews, the facility failed to transcribe a medication order for a diuretic medication (medication to reduce swelling) for one sampled resident (Resident 4). The failure resulted in a 14 day delay in the medication being provided to the resident and resulted in the resident's continued leg swelling and development of blisters. Sample size was four current residents. Facility census was 77. Findings are: Record review of Resident 4's Face Sheet printed on 1/24/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 4's electronic medical record and chart revealed the following: - from the Departmental Notes an entry dated 12/15/17 at 4:37 p.m. revealed the resident was seen and received new orders from the physician. - A Message from Organization: (name of clinic). New Medication (a web-based communication tool with communication from the clinic to the facility) dated 12/15/17 and generated on 12/16/17 revealed the physician also started (Resident 4) on 20 mg (milligrams) of [MEDICATION NAME] PO (by mouth) daily. An Electronic Prescription via Sure Scripts form from the clinic to the pharmacy revealed an order dated 12/15/17 for Resident 4 was written for [MEDICATION NAME] 20 mg oral tab with instructions to administer 1 (one) Tablet by mouth once daily. - 12/23/17 at 3:34 p.m. from the Departmental Notes the resident was assessed with [REDACTED]. 2+ indicated indention of the skin 2-4 millimeters deep which does not rebound for 10-15 seconds when pushed inward) to BLLE (bilateral lower extremities) . - A Nursing Communication form sent to the physician on a follow up visit dated 12/29/17 revealed the resident was being seen in Follow-up and requested the physician Please look @ (at) red, raised open areas to L (left) lower leg . The physician provided a communication note from the visit which read: See web message from 12/15/17. Patient (Resident 4) should be on [MEDICATION NAME] (Generic name for [MEDICATION NAME]) 20 mg by mouth once daily. - Departmental Notes entry dated 12/29/17 at 5:30 p.m. recorded the resident had an appointment with the physician. Orders are as follows. See web message from 12.15.17. Patient (Resident 4) should be on [MEDICATION NAME] 20 mg by mouth once daily . - e-Medication Administration Record [REDACTED]. - Departmental Notes entry dated 1/18/18 at 12:12 p.m. revealed an entry by the Registered Dietitian which read: Current weight 215# (215 pounds). Admit weight was 195# in October. Dr reviewed weight of 214# with no dietary changes last month . [MEDICATION NAME] was added last month and increased this month, so we may see some weight fluctuations due to [MEDICAL CONDITION] changes . Record review of a facility Investigation Report dated 1/16/18, forwarded to the State Agency, revealed the facility investigated the delay in the order implementation for Resident 4's [MEDICATION NAME]. The investigation was initiated after Resident 4's spouse reported to the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator on 1/9/18 that Resident 4's [MEDICATION NAME] order was missed by the nursing staff when ordered on [DATE] and not started until 12/29/17. The spouse reported the resident's legs had some increased [MEDICAL CONDITION] with blisters to the lower extremities due to the resident not receiving [MEDICATION NAME]. The report acknowledged the error in getting the medication order transcribed and administering the medication to the resident. The Potential Causal factors revealed the physician sent the order over the Portal (the electronic computerized communication system between clinic and facility) and that the order had not been opened by the nurse on duty. The facility determined that once an order is opened on the portal per facility protocol, it is to be entered into the computer, if it is opened staff have no way to know it is a new order and has not been entered into the computer. The investigation Outcome revealed the order for [MEDICATION NAME] was missed on the Portal and the resident had not received (the resident's) [MEDICATION NAME] for 13 days. The report revealed It was noted by the Primary care Physician that there was increased swelling with small pinpoint blisters to lower extremities (for Resident 4) bilaterally. Primary Care Physician felt this increased swelling and blisters were caused by resident not receiving (the resident's) [MEDICATION NAME]. Interview with the ADON (Assistant Director of Nursing) and MDS Coordinator on 1/24/18 9:45 a.m. confirmed Resident 4 received a physician's orders [REDACTED]. Due to a problem with the computerized communication portal, the order was not transcribed and the medication was not started until after the physician alerted the facility to the mistake on 12/29/17. The ADON confirmed the facility investigated the issue and verified the omission of the original order resulted in the resident experiencing increased swelling and blisters.",2020-09-01
460,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,644,D,0,1,7QWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure PASRR (Pre-Admission Screening and Resident Review, a federally required assessment to determine placement and services are appropriate for residents identified with Serious Mental Illness or intellectual disabilities) assessments were updated for review to determine if a level 2 assessment was appropriate for 3 sampled residents (Residents 48, 60, and 2). Facility census was 67. Sample included 21 current residents. Findings are: [NAME] Record review of Resident 48's Face Sheet) dated 10/14/19 revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed Resident 48 was diagnosed with [REDACTED]. Record review of Resident 48's chart revealed a PASRR level 1 assessment was completed on 3/21/2019. This assessment recorded No mental health [DIAGNOSES REDACTED]. The assessment requested the facility List any antidepressants, mood stabilizers, or other mental health medications prescribed currently or other mental health medications prescribed currently or within the past six months. The assessor recorded there were No medications. The Outcome of the assessment was recorded on 3/22/19 for Dementia/MI (mental illness) Exclusion. Rationale recorded the resident's screen indicates that a PASRR disability is not present because of the following reason: A neurocognitive disorder/dementia is primary and progressed. If another behavioral health condition is also present, the neurocognitive disorder is primary and progressed. The individual would not likely benefit from disability services at this time. If changes occur or additional information suggests a primary mental illness rescreening should occur to reassess need for PASRR evaluation. Record review of a Psychiatric examination of Resident 48 dated 1/14/2020 revealed the resident was diagnosed by the psychiatrist with Subchronic undifferentiated [MEDICAL CONDITION] with acute exacerbations. The assessment indicated the resident was ordered [MEDICATION NAME] (A tranquilizing anti-psychotic medication) 0.5 milligrams twice daily for [MEDICAL CONDITION]; [MEDICATION NAME] (an anti-depressant) 15 milligrams 1/2 tablet at bedtime for appetite and depression; and [MEDICATION NAME] Sprinkles (an anti-[MEDICAL CONDITION] medication also used as a mood stabilizer) 125 milligrams one capsule twice a day at two p.m. and 8 p.m. for hypomania secondary to [MEDICAL CONDITION]. The [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The use of [MEDICATION NAME], and [MEDICATION NAME] Sprinkles was also not recorded on the level 1 PASRR assessment. There was no further PASRR assessments or referrals for level 2 evaluations in the resident's medical record. Record review of Resident 48's e-MEDICATION (Administration Record) for (MONTH) of 2020 revealed the resident continued to receive the following psychiatric medications: [REDACTED] - [MEDICATION NAME] 125 milligrams at 2 p.m. and 8 p.m. for Undifferentiated [MEDICAL CONDITION]. - [MEDICATION NAME] 15 milligrams 1/2 tablet at bed time for Depression and Appetite. - [MEDICATION NAME] 0.5 milligrams twice a day for Undifferentiated [MEDICAL CONDITION]. Interviews with the facility's SSD (Social Services Director) on 1/30/2020 at 9:44 a.m. and again at 11:16 a.m. confirmed Resident 48 received a PASRR level 1 assessment on 3/21/2020. The SSD verified the resident's [DIAGNOSES REDACTED]. The SSD verified the resident was being reviewed routinely by a psychiatrist for active [MEDICAL CONDITION] and being treated with [MEDICATION NAME], and [MEDICATION NAME] for ongoing symptoms of these mental disorders. The SSD confirmed there was no evidence the facility re-assessed the resident's PASRR to determine if a level 2 evaluation was warranted. Findings are: B. A record review of Resident #2's Facesheet printed 1/29/2020 revealed the resident was admitted on [DATE]. Review of the Diagnosis/History for Resident 2 revealed with the following [DIAGNOSES REDACTED]. The Diagnosis/History recorded [MEDICAL CONDITION] disorder, current episode depressed, mild or moderate, severe, unspecified with a recorded onset date of 7/27/2017 and [MEDICAL CONDITION] disorder, current episode depressed, mild with a recorded onset date of 11/23/2019. Review of Resident #2's care plan revealed I see Encounter Telehealth with a start date of 11/20/2019. A review of Resident #2's MDS (Minimum Data Set,(a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments, revealed the following an Annual MDS assessment was compelted on 8/1/19. The assessment revealed the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness .or a related condition. The assessment identified the resident has having medical [DIAGNOSES REDACTED]. A review of Resident #2's eMAR (electronic Medication Administration Record) for (MONTH) of 2020, revealed an order dated 3/14/2018 for Ziprasidone Hcl (an antipsychotic medication used in the treatment of [REDACTED]. A review of Resident #2's chart revealed a PASRR Level I assessment was completed on 12/5/2016. This assessment recorded No regarding whether Resident had [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION], Psychotic/Delusional Disorer, [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION]), or Paranoid Disorder. The assessments requested Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months? The assessor recorded no medications. The Outcome of the assessment was recorded on 12/5/16. The Rationale recorded the resident's screen has no indications for [DIAGNOSES REDACTED]. A negative screen is approved. Should there be an exacerbation reltaed to mental illness or a discrepancy in the reported information, a status change should be submitted to Acend for further evaluation. The [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. There was no further PASRR assessments or referrals for Level 2 evaluation in the resident's medical record. An interview on 1/30/2020 at 09:32 AM with the facility's SSD confirmed Resident #2 received a PASRR Level 1 assessment on 12/5/2016. The SSD verified the PASARR Level 1 for Resident #2 was not updated or resubmitted with a list of current [DIAGNOSES REDACTED]. C. A record review of Resident #60's Facesheet printed 1/29/2020 revealed the resident was admitted on [DATE]. A review of Resident #60's chart revealed a PASRR Level I assessment was completed on 5/13/2015. This assessment recorded No regarding whether Resident had [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION], Psychotic/Delusional Disorer, [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION]), or Paranoid Disorder. The assessments requested Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months? The assessor recorded [MEDICATION NAME] 10mg with Other listed as Diagnosis. Review of the Diagnosis/History for Resident #60 revealed the following dianosis recorded with an onset date of 5/15/2015, the resident admitted Other problems related to psychosocial circumstances. The Diagnosis/History recorded Brief [MEDICAL CONDITION] with onset date of 7/17/2018; other specified depressive episodes with onset date of 3/12/2018; delusional disorders with onset date of 6/4/2018 and resolved date of 6/14/2018. A review of the Careplan printed on 1/29/2020 for Resident #60 revealed . I have depression and other problems related to psycho-social issues. I have A-fib heat disease with a pacemaker, [MEDICAL CONDITION], spinal stenosis, [DIAGNOSES REDACTED], dementia, diabetes, a history of [MEDICAL CONDITION], brief [MEDICAL CONDITION] . It also recorded I have a [MEDICAL CONDITION], dementia, [MEDICAL CONDITION], brief [MEDICAL CONDITION] and other psychological disorders that are being treated with medication. My family and I have been educated and understand the risk and benfits of taking these medications and we know that I need them and will continue to take them. We also understand that these medications can increase the risk for falls. with start dates of 5/15/2015 and in active status. A review of Resident #60's eMAR for (MONTH) of 2020 revealed the following orders: -[MEDICATION NAME] XR (an antidepressant) 75mg capsule once capsule by mout once daily related to the [DIAGNOSES REDACTED]. -[MEDICATION NAME] XR 150mg capsule 1 tab by mouth daily for depression -[MEDICATION NAME] XR 150mg by mouth every day for depression -[MEDICATION NAME] XR 150mg by mouth every day for depression -[MEDICATION NAME] (an antipsychotic medication) 7.5mg one tablet by mouth every evening at hours of sleep for brief [MEDICAL CONDITION] The review also revealed the medication was being administered daily as ordered. The [DIAGNOSES REDACTED]. There was no further PASRR assessments or referrals for Level 2 evaluation in the resident's medical record. An interview on 1/30/2020 at 09:32 AM with the facility's SSD confirmed Resident #60 received a PASRR Level 1 assessment on 5/3/15. The SSD verified the PASARR Level 1 for Resident #60 was not updated or resubmitted with a list of current [DIAGNOSES REDACTED].",2020-09-01
461,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,657,D,0,1,7QWB11,"Licensure Reference Number 175 NAC 12-006.09C1c Based on observations, interviews, and record review, the facility failed to update the Care Plan for one sampled resident (Resident 29) to reflect the current approaches to provide a daily fluid restriction as ordered by the physician. Facility census was 67. Sample size was 21. Findings are: On 1/27/2020 at 1:56 PM during an initial interview, Resident 29 reported having a daily fluid restriction but could not specify how much fluid was allowed between meals. A full cup of water containing 500 ml (milliliters) was seen on a table by the resident's bed during the interview. On 1/28/2020 at 2:42 PM, NA (Nurse Aide)-A was passing cups of water to residents. Resident 29 was given a full cup containing 500 ml of water with ice. NA-A was asked if Resident 29 was given a limited amount of water, and NA-A replied that the resident was given a full cup routinely. On 1/29/2020 at 8:30 AM, an interview with NA-B and NA-C who were working on the hall where Resident 29's room was located revealed that water cups were refilled twice a day for all residents. Each resident's old cup would be removed and the amount of water they drank charted based on how much water was left in the cup. Then a new cup full of water was provided for all residents. NA-B and NA-C could not state the names of any residents on a fluid restriction who might to be given less water. Observation at that time showed a full cup of water in Resident 29's room. On 1/29/2020 at 3:32 PM, Resident 29 was eating potato chips and drinking soda pop in a cup. The cup contained 200 ml of liquid at that time. A full cup of water was sitting on the table as seen previously. At 3:35 PM an interview with NA-C who was passing out snacks from a cart, revealed that Resident 29 was given a 240 ml can of lemon-lime pop in a cup with their afternoon snack. NA-C verified that Resident 29 had recently been given a full cup of water but could not recall how much water this resident had consumed from the cup which was removed. At 4:44 PM, the cup which had contained pop had about 50 ml of fluid in it, and the resident reported having just about finished it. Review of the e-Medication Administration Record [REDACTED]. The Care Plan also showed record and monitor my food and fluid intake, 2000 ML FLUID RESTRICTION 480 ML AT MEALS- DIETARY 1440 ML NURSING 560 ML- 260 ML IN WATER PITCHER PER SHIFT. On 1/30/2020 at 7:46 AM, Resident 29 once again had a full cup of water in their room. On 1/30/2020 at 8:57 AM, an interview with MA (Medication Aide)-D who had signed the e-Medication Administration Record [REDACTED]. However, MA-D revealed that the actual amount of fluid consumed by the resident was monitored by the NA who picked up the water cups twice each day and was recorded in the NA charting based on the amount of water left in the cup when it was removed. MA-D explained that a full cup was given to each resident in order to ensure accurate recording of how much the residents were consuming. On 1/30/2020 at 9:05 AM, LPN (Licensed Practical Nurse)-E who was working as the Charge Nurse on the hall where Resident 29's room was located observed the full cup of water in Resident 29's room. LPN-E verified that fluid intake is charted by the NA who removes that cup of water. Review of the NA charting for the previous 24 hours by LPN-E revealed that Resident 29's total fluid intake had been about 600 cc including water and snacks served by nursing. LPN-E verified that Resident 29's fluid intake had been fairly consistent over the days which were available for review at that time. On 1/30/2020 at 11:15 AM, an interview with the facility's DON (Director of Nursing) and Dietary Manager revealed that Resident 29 was generally compliant at this time with the fluid restriction as ordered. The Dietary Manager provided a copy of Departmental Notes from 1/11/2020 made by the Dietician indicated that the resident had recently become upset about the fluid restrict and had requested to be allowed to self-limit fluids. The DON revealed that the physician had been notified of this and had declined to discontinue the fluid restriction. Another note on 1/17/2020 made by the Dietician also reflected the resident's request to self-restrict fluids and insistence on having a full pitcher of water at bedside. The note indicated the resident could identify how much water could be consumed from a full pitcher to remain compliant with the fluid restriction. The DON explained that the decision had been made to allow the resident to try this approach to see whether they would remain compliant with the fluid restriction voluntarily. However, the Care Plan had not been updated to reflect this approach.",2020-09-01
462,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,684,D,0,1,7QWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, interviews, and record review, the facility failed to identify and treat a bruise on one sampled resident (Resident 54) who was receiving an anticoagulant. Facility census was 67. Sample size was 21. Findings are: On 1/27/2020 at 5:51 PM, an observation of Resident 54 sitting in a wheelchair eating supper revealed a large bruise on the resident's left hand. On 1/29/2020 at 11:45 AM, the bruise remained visible on the left hand. While providing care for the resident, NA (Nurse Aide)-B asked the resident whether the bruise had occurred because of lab work and the resident said yes. Review of the e-Medication Administration Record [REDACTED].drugs.com/[MEDICATION NAME].html) twice a day. On 1/29/2020 at 2:33 PM, an interview with a consulting pharmacist who was in the facility revealed that no monitoring of any kind was needed with the use of [MEDICATION NAME], but they acknowledged that watching for bleeding or bruising would be a nursing concern. On 1/30/2020 at 9:14 AM, LPN (Licensed Practical Nurse)-E who was working as the Charge Nurse on 200 hall verified that bruises should be documented when seen by staff, but revealed that weekly skin checks for Resident 54 were completed on 1/22 and 1/29/2020 and show the skin was intact. LPN-E could find no charting related to the bruise on Resident 54's hand. At 9:17 AM RN (Registered Nurse)-G who was the facility's wound care nurse attempted to help LPN-E find documentation related to the bruise. RN-G revealed a lab draw was made on 1/22/2020 which had been documented in the resident's electronic health record. After checking the resident's records, bath records, and the wound care nurse's office, RN-G verified that there was no documentation to show that this bruise had been identified by staff. During an observation of Resident 54 at breakfast, RN-G verified a large ring shaped red and purple bruise on the left hand which should have been documented.",2020-09-01
463,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,689,D,1,1,7QWB11,"> Licensure Reference Number: 1[AGE] NAC 12-006.09D7a Based on record reviews and interviews, the facility failed to ensure that a gate belt was used on a transfer from wheelchair to recliner chair causing one sampled resident (Resident # 43) to have a fall. Facility census was 67 with 21 sampled residents. Findings are: Resident interview on 1/30/20 at 10:08 a.m. Resident 43 verified that staff did not use a gate belt when transferring from the wheelchair to the recliner. Resident 43 revealed that due staff not using a gate belt she fell forward hitting her face on the floor and causing a hematoma to the right side of the forehead and black eyes. Resident 43 confirmed there were no major injuries just bruising and some aches and pains. Record review progress note dated 12-25-19 at 12:37 PM 0900 The nurse called to room. Res lying in prone position on floor. The DNA(Nursing Assistant) at side. The Nursing Assistant reports I was assisting resident with transfer, Resident started to lean and I was unable to assist Resident to chair or back to wheelchair' Resident log rolled to supine position. Resident had Neurological checks completed. Noted with raised hematoma to right forehead. Ice applied to forehead. Reports pain to lower back Just from lying here and pain to right forehead. E[CONDITION](Emergency Medical System) arrives at 0910 and transports resident 43 to ER. Singed by LPN( Licensed Practical Nurse)-H. Record review Physical Therapy Progress Note dated 12/26/19 Resident has fallen with staff, Resident 43 reports new staff didn't use gait belt and brakes not locked and resident slipped and fell on to the floor on to resident's face. Resident 43 has ecchymosis/bruising eyes/face. Record review Hillcrest Nursing Home Gait Belt Use Ambulation and/or Transfer, Gate belt Policy: Gait belts are to be used on any resident who requires hands on Assistance to stand, transfer, ambulate or for residents who require help with lifting, balance or support. All nursing assistants will have their own gait belt to be used on residents who require them. Staff interview on 1/30/20 at 10:30 a.m. Director of Nursing verified Resident 43 did have a fall due to staff not utilizing a gait belt. Director of nursing verified that Resident 43 did sustain bruising to her face but no major injury. Director of Nursing confirmed that staff should use a gait belt when transferring residents who require assistance at all times. Director of Nursing confirmed that training was provided to all staff on using gait belts.",2020-09-01
464,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,761,D,0,1,7QWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.12E7 Based on observations, interviews, and record review, the facility failed to ensure that medications and supplements used by 2 residents (Residents 10 and 63) were labeled accurately based on the physician's orders [REDACTED]. Sample size was 7. Findings are: [NAME] On 1/28/2020 at 5:27 PM, observation of medication administration for Resident 10 by MA (Medication Aide)-J revealed an order on the Physician order [REDACTED]. However, the label on the box said two drops were to be placed in each eye, and MA-J administered two drops rather than one drop as ordered. LPN (Licensed Practical Nurse)-H who was the Charge Nurse supervising MA-J verified that the label was incorrect, and MA-J verified that they had administered the eye drops based on the label rather than the physician's orders [REDACTED].>On 01/29/2020 at 10:06 AM, an interview with the DON (Director of Nursing) verified that MA-J had completed a report and training related to having administered two eye drops instead of one to Resident 10. The DON also revealed that a new label has been received from pharmacy for the box containing the eye drops. B. On 1/29/2020 at 7:55 AM, observation of medication administration for Resident 63 by MA-D revealed an order on the Physician order [REDACTED]. However, the label on the card containing this medication showed Cinnamon 500 mg but did not list [MEDICATION NAME] as an ingredient of the medication. an order for [REDACTED].com/script/main/art.asp?articlekey=3254) 325 mg (milligrams). by mouth twice a day. The label did not specify EC but simply said Aspirin 325 mg. MA-D administered both of these medication to Resident 63. an order for [REDACTED]. MA-D brought this to the attention of RN (Registered Nurse)-K who was working as the Charge Nurse supervising MA-D. RN-K took the card of medication from MA-D and stated that pharmacy would have to label this medication correctly before MA-D could administer it. However, there were already several doses already missing from the card. After MA-D had finished administering the medications and supplements that were available to Resident 63, RN-K examined the labels for the resident's Cinnamon Plus [MEDICATION NAME] supplement and Aspirin EC 325 mg and verified that the labels did not match the physician's orders [REDACTED]. RN-K stated that the transportation aide would be bringing a correctly labeled card of [MEDICATION NAME] back to the facility soon, so this vitamin and mineral supplement could be administered to Resident 63 within the appropriate time frame. On 1/29/2020 at 10:45 AM, the DON placed a phone call to Farrell's Pharmacy which had provided the medications for Resident 63. The pharmacist there reported that all Aspirin 325 mg provided by their pharmacy was [MEDICATION NAME] coated and only Aspirin labeled as chewable did not contain [MEDICATION NAME] coating. However, the pharmacist acknowledged that the medication label should reflect the contents of the card accurately including whether or not the tabled was [MEDICATION NAME] coated. The pharmacist verified that the cinnamon supplement for Resident 63 did not contain [MEDICATION NAME] as was listed in the physician's orders [REDACTED]. The pharmacist revealed that they had already been contact about this by the facility and had sent a fax to the physician to verify that giving only cinnamon in one supplement and giving [MEDICATION NAME] in the multivitamin would meet the resident's needs.",2020-09-01
465,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,812,E,0,1,7QWB11,"Licensure Reference Number: 175 NAC 12-006.11E Based on Based on observations and interviews the facility failed to keep a bag of diced zucchini off the floor in the walk in freezer. This had the potential to affect only those residents who would like to eat the zucchini. Facility census was 67 with 21 current sampled residents. Findings are: Observation upon initial entry to the kitchen on 1/27/20 at 1:04 p.m. revealed a bag of frozen zucchini located on the floor at the very back of the walk in freezer. Staff interview on 1/29/20 at 1:44 p.m. Dietary Supervisor confirmed there was a bag of zucchini located on the floor at the very back of the walk in freezer located in the kitchen. Dietary Supervisor reported no food should be located or touching the ground as this would cause the food to be cross contaminated. Staff interview on 1/29/20 at 4:09 p.m. Administrator verified that there was a bag of Zucchini located on the floor of the walk in freezer and this should not have occurred and this would be addressed immediately. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 305.11(B) Food in packages and working containers may be stored less than 15 cm (6 inches ) above the floor on case lot handling equipment as specified under 4-204.122.",2020-09-01
466,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,880,D,0,1,7QWB11,"Licensure Reference Number 175 NAC 12-006.17D Based on observations, interviews, and record review, the facility failed to ensure that staff members practiced hand hygiene when changing gloves during care for one sampled resident (Resident 54) and one non-sampled resident (Resident 10). Facility census was 67. Sample size was 21. Findings are: [NAME] On 1/28/20 at 12:30 PM, observation of care for Resident 54 NA (Nurse Aide)-A revealed that NA-A performed hand hygiene using ABHR (alcohol based hand rub) before donning gloves to begin care for the resident. However, NA-A then removed their gloves and left the room to obtain additional supplies from the supply closet across the hall. Upon returning to the room, NA-A donned clean gloves without performing hand hygiene. NA-A then emptied the drainage bag for Resident 54's urinary catheter. When this was finished, NA-A placed the drainage bag into a privacy bag located on the resident's wheelchair, removed their gloves and donned clean gloves again without performing hand hygiene. NA-A then removed cleansing wipes from a large package stored in bathroom and wiped Resident 54's buttocks to clean it as the resident had had a bowel movement. NA-A then changed gloves again without performing hand hygiene and cleaned the resident's catheter using No-sting wipes. NA-A then changed gloves again without performing hand hygiene before adjusting the resident's clothing and assisting them into their wheelchair. Once the resident was seated in the wheelchair, NA-A removed their gloves and performed hand hygiene using ABHR from the dispenser located on the bathroom wall before leaving the room. Immediately following this observation, NA-A was asked when hand hygiene should be performed. NA-A replied that hand hygiene should be completed upon entering and leaving the resident's room. When asking if hand hygiene was necessary when wearing gloves, NA-A replied that hand hygiene was needed whenever gloves were put on or taken off including when changing gloves. On 1/28/2020 at 4:25 PM, observation of medication administration for Resident 10 by MA-J found that MA-J gave the resident all of their oral medications first by mixing the pills in applesauce and feeding them to the resident in several bites. MA-J then donned gloves and administered a nasal spray to the resident. However, MA-J did not perform hand hygiene before donning gloves. MA-J then removed their gloves and donned fresh gloves without performing hand hygiene. MA-J then administered eye drops to Resident 10. MA-J then removed their gloves and performed hand hygiene using ABHR before signing out the medications in the electronic record. When asked, MA-J verified that hand hygiene should be completed when changing gloves. On 1/30/2020 at 10:56 AM, an interview with the facility's DON (Director of Nursing) verified that hand hygiene should be performed any time gloves are put on and taken off including during glove changes. The DON provided a copy of the [NAME]crest Hand Washing/Hand Hygiene Policy which revealed that hand hygiene was expected at multiple times including before donning gloves, after removing gloves, and before moving from a contaminated body site to a clean body site during resident care. The DON verified that this topic had recently been reviewed during a staff meeting, so all staff should be aware of the need to perform hand hygiene with glove changes.",2020-09-01
467,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2020-01-30,909,D,0,1,7QWB11,"Licensure Reference Number: 175 NAC 12-006.12B Based on observations, record reviews and interviews the facility failed to ensure that the quarter bed rail was tight and functioning for one current sampled resident (Resident # 35). Facility Census was 67 with 21 current sampled residents. Findings are: Observation on 1/27/20 at 3:06 p.m. identified the quarter bed rail on the left side of the bed was loose to the touch in Resident 35's room of 313B. Observation on 1/29/20 at 10:57 a.m. identified the quarter bed rail on the left side of the bed was loose to the touch in Resident 35's room of 313B. Resident interview on 1/29/20 at 10:57 a.m. Resident 35 verified the quarter bed rail on the left side of the bed was loose. Staff interview on 1/29/20 at 11:30 a.m. LPN(Licensed Practical Nurse)-H identified that maintenance was in charge of handling any issues with resident beds and bed rails, as they provide the maintenance. Staff interview on 1/29/20 at 11:35 a.m. Director of Nursing confirmed that maintenance was responsible for making sure that all equipment is functioning correctly. At this time The Director of Nursing verified that Resident 35's bed rail on the left side of the bed was loose to the touch and this should be addressed immediately by maintenance. Staff interview on 1/29/20 at 1:18 p.m. MW(Maintenance Worker)-I and Director of Nursing both confirmed the quarter bed rail on the left side of the bed that belonged to Resident 35 was loose to the touch. MW-I stated this bed rail would be repaired immediately. Record review of the Physical Environment Policy and Procedure states [NAME]crest Nursing Home will conduct a regular inspections of all bed frames, mattresses, and bed rails to ensure that bed rails are compatible with the bed frame and mattress. This failed to be done in a timely manor as (MONTH) inspection had been completed but no inspection for the month of (MONTH) had been conducted as the Room Inspection form identified. Staff interview on 1/29/20 at 4:11 p.m. Administrator verified that Resident 35's bed rail on the left side of the bed was loose and this should have been identified and repaired immediately.",2020-09-01
468,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-04-03,684,D,1,0,0YN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to identify changes in condition and complete follow up assessments related to urinary tract issues to ensure care was effective for two current sampled residents (Residents 1 and 2). The facility census was 87 with four current sampled residents. Findings are: [NAME] Review of the Face Sheet, printed 4/4/18, revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care, dated 3/3/18, revealed that the resident was confused, had an indwelling urinary catheter and often had bladder infections. Review of the Departmental Notes, dated 3/27/18, revealed that an electronic message was received from the doctor's office that the resident's urine was very concentrated and that the resident needed to drink more water. Further review revealed no documentation or assessments completed to indicate that changes in the resident's urine or condition were identified before the specimen was sent to the office. Further review revealed no follow up assessments related to characteristics of the resident's urine, symptoms of dehydration or that the resident's fluid intake was increased to ensure that the care provided was effective to meet the resident's needs. B. Review of the Face Sheet, printed 4/4/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Departmental Notes, dated 3/29/18 at 5:51 PM, revealed that a clean catch urine specimen was sent to the doctor as ordered and a culture was ordered. New orders were received [MEDICATION NAME](antibiotic) two times a day for 10 days for a urinary tract infection. Further review revealed no documentation that the resident would be offered or encouraged to drink more fluids, no assessment of the resident's condition including characteristics of the resident's urine, pain or burning with urination, increased confusion or restlessness to ensure that the care provided and that the antibiotic were effective to resolve the urinary tract infection. Interview with the Director of Nursing on 4/4/18 at 3:00 PM confirmed that the nurses should identify and document changes in the resident's condition, including changes in urine characteristics or symptoms of a urinary tract infection. Further interview confirmed that follow up assessments were to be done and documented to ensure that the care interventions provided were effective to meet the resident's needs.",2020-09-01
469,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-04-03,689,D,1,0,0YN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls for one current sampled resident (Resident 1) and 2) care plan instructions were followed to ensure safe transfers for two current sampled residents (Residents 1 and 2). The facility census was 87 with four current sampled residents. Findings are: [NAME] Review of the Face Sheet, printed 4/3/18, revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care, dated 3/3/18, revealed that the resident fell quite a bit at home due to increased weakness, had a fall at home which resulted in fractured ribs and a subdural (brain) bleed, was confused, agitated at times, was hard of hearing and was at risk for falls. Interventions included that the resident required assistance of two staff with transfers, used a wheelchair for mobility, mats placed on the floor by the bed and silent alarm on the bed. Review of the Departmental Notes, dated 3/3/18 through 4/3/18, revealed the following including: - 3/8/18 at 8:00 PM - resident was found on right side on the floor, no injuries noted; - 3/10/18 at 4:40 PM - resident slid out of the wheelchair onto the floor on right side, no injuries noted. Dycem (plastic sticky pad) was placed on the seat of the wheelchair to prevent sliding out of the wheelchair; - 3/16/18 at 2:24 PM - resident found on the floor on right side with head underneath the roommate's bed, no injuries, stated was trying to get up out of the wheelchair. Follow up blood pressure readings indicated that the blood pressure was dropping, the physician was notified and the resident was sent to the emergency department for evaluation due to history of brain bleed a dew weeks ago; - 3/16/18 at 5:12 PM - report from the hospital showed that there was increased bleeding in the brain which probably caused the fall, not as a result of the fall; - 3/17/18 at 2:00 PM - spouse notified the facility that the resident was admitted to the hospital primarily for a urinary tract infection; - 3/19/18 at 4:00 PM - resident returned to the facility, agitated and looking for spouse; - 3/20/18 at 1:40 PM - resident was found sitting on wheelchair footrests next to the bed, no injuries, alarm was present but not sounding, alarm was discontinued in the wheelchair, new interventions included to assist the resident to bed when alone in the room and to pick up the floor mats by the bed when the resident was not in bed; - 3/23/18 at 8:20 AM - resident found on the floor between the bed and the wheelchair, no injuries noted; - 3/29/18 at 4:30 PM - resident found on the floor on right side between the bed and the wheelchair, no injuries noted. Interview with the DON (Director of Nursing) on 4/4/18 at 2:45 PM confirmed that the resident was considered a high risk for falls and fall interventions in place were not effective to reduce the risk for recurrent falls. Observations on 4/4/18 at 8:10 AM revealed the resident in bed, call light in place, mats on the floor on each side of the bed, sensor alarm in place. MA (Medication Aide) - A and NA (Nursing Assistant) - B wakened the resident for morning cares. MA - A and NA - B transferred the resident from the bed to the wheelchair with a gait belt (belt placed around the resident's waist and used to hold on to the resident during the transfer). Further observations at 1:45 PM revealed the resident on the bed wanting to get up. NA - B assisted the resident to the edge of the bed, applied the gait belt and transferred the resident to the wheelchair. Review of the 500 Hall Nurses Station, resident care information sheet, not dated, revealed that the resident was at risk for falls and required two staff to transfer the resident. Interview with MA - A on 4/4/18 at 7:45 AM revealed that this form was for the direct care staff to use for direction of the residents' care needs. B. Review of the Face Sheet, printed 4/4/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 4/4/18 at 8:00 AM revealed the resident seated in the wheelchair in the hallway. Further observations revealed tremors at the resident's arms and the resident repeatedly asking where do I go and what should I do. Interview with MA - A on 4/4/18 at 8:00 AM revealed that the resident required assistance of one or two with transfers depending on whether the resident was steady or not. MA - A stated that today the resident was shaky and unsteady so was transferred with two assistance from the bed to the wheelchair. MA - A stated that sometimes the resident would stand and sometimes wouldn't stand. Interview with NA - B on 4/4/18 at 9:45 AM revealed that the resident required one or two assistance with transfers depending on whether the resident would stand or not. Further interview revealed that the resident needed assistance of two this morning because the resident was so shaky. Review of the Fall Risk Assessment, dated 3/19/18, revealed that the resident was a high risk for falls. Review of the 500 Hall Nurses Station, resident care information sheet, not dated, revealed that the resident required two staff to transfer or the sit to stand mechanical lift as needed. Further review revealed that the resident was not identified as a fall risk. Interview with the DON on 4/4/18 at 2:45 PM confirmed that these residents were a high risk for falls and the staff were to follow the safe transfer instructions on the unit care worksheet. Further interview confirmed that the unit care worksheet was based on the care plan and should give specific instructions to ensure safe and consistent transfers.",2020-09-01
470,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-04-03,690,D,1,0,0YN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to: 1) Ensure facility staff followed up with assessments and urinary condition changes for one sampled resident (Resident 3) with a urinary catheter; and 2) ensured facility staff prevented catheter bags from potential cross-contamination during transfers for two sampled residents (Residents 3 and 1). Sample size was three current residents with urinary catheters. Facility census was 87. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.09D3 Record review of Resident 3's Face Sheet printed on 4/3/18 revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed the resident had medical [DIAGNOSES REDACTED]. Record review of a facility Investigation Report dated 3/29/18 describing an incident involving Resident 3 falling on 3/20/18. In the section entitled Describe the incident the investigation recorded the resident was noted on the floor by the wheelchair on 3/20/18 at 9:23 p.m. Further review of the description recorded: . Resident having dark, foul urine in catheter bag and had several days reported to nurse for confusion and hallucinations, so on 3/21/2018 nurse obtained an order for [REDACTED]. Record review of Resident 3's Departmental Notes between 3/6/18 through 4/3/18 printed on 4/3/18 revealed the following entries: - 3/9/18 through 3/11/18 entries revealed the resident was treated for [REDACTED]. - Between 3/11/18 through 3/20/18 there were no entries describing the resident's urinary status. - 3/20/18 at 9:23 p.m. the resident was discovered on the floor. Nothing charged about the resident's urinary status or condition. - 3/21/18 at 9:44 a.m. the entry read: Urine collected at this time via foley cath (catheter) port. Urine dark yellow, cloudy and malodorous (foul smelling). Coolected per orders for: Recent falls, increased confusion and cloudy urine. Sample sent to (clinic). - Between 3/21/18 and 3/27/18 there were no assessments of the resident's urinary condition or any vital sign readings to determine if the resident had an elevated temperature associated with the abnormal urinary symptoms recorded on 3/21/18. - 3/27/18 at 3:42 p.m. a note recorded that at 10:15 p.m. on 3/26/18 the resident had been found on the floor. The note continued stating: . will observe. and see how (the resident) is doing in the morning . if needed can make clinic appointment, also told of waiting UA (urinalysis) status . Nothing was recorded in this entry about the condition of the resident's urine. - Between 3/27/18 and 4/3/18 there were no other entries recording anything regarding the UA results or the resident's urinary status or vital signs. On 4/3/18 during interview with the facility DON (Director of Nursing) at 10:45 a.m., a request was made as to the UA results for REsident 3 from a sample sent to the clinic on 3/21/18. Following the request, the ADON (Assistant Director of Nursing) returned with a UA results form obtained through the facility's portal (electronic system for communication between the facility and physician) dated 4/3/18 at 11:11 a.m. The form revealed abnormal UA results for positive [MEDICATION NAME], trace blood, UA [NAME] blood cells present, UA red blood sells present, and Moderate UA Bacteria. An additional portal note dated 4/3/18 at 12:52 p.m. identified the physician chose not to treat the finding with antibiotic therapy. Interview with the DON and ADON on 4/3/18 at 2:55 p.m. confirmed that the facility noted abnormal urinary symptoms and confusion on 3/21/18 precipitating receiving an order for [REDACTED]. B. Licensure Reference Number: 175 NAC 12-006.09D3 (1) Observation of Resident 3's morning transfer from the bed to the motorized wheelchair was conducted on 4/3/18 beginning at 7:30 a.m. and concluding at 8:00 a.m. During the observation, NA (Nurse Aide)-C and NA-D were assisting Resident 3 with a mechanical lift transfer. The resident was placed in a sling and lifted with the mechanical lift. NA-D removed the resident's catheter bag from a cover bag and it was placed directly on the floor in front of the resident's wheelchair and remained in direct contact with the floor while the resident was lifted in the sling and positioned in the motorized wheelchair. Once the resident acknowledged comfort with the positioning, NA-C picked the urinary catheter drainage bag off the floor and placed it in a covered bag attached to the resident's wheelchair. C. Review of the Face Sheet revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care, dated 3/3/18, revealed that the resident had increased confusion, had an indwelling urinary catheter and often had bladder infections. Observations on 4/4/18 at 7:45 AM, 8:10 AM and at 1:45 PM revealed the resident resting on the bed with the uncovered urinary catheter drainage bag placed directly on the floor on the floor mat next to the bed. Observations on 4/4/18 at 8:10 AM revealed MA (Medication Aide) - A and NA (Nursing Assistant) - B assisted the resident with morning cares. Further observations revealed NA - B emptied the urinary drainage bag without cleaning the drainage spout with an alcohol wipe before and after the urine was drained into the collection container. Interview with the Director of Nursing on 4/4/18 at 3:00 PM confirmed that urinary catheter drainage bags were not to be placed on the floor and that the drainage bags were to be cleaned with an alcohol wipe before and after the urine was drained into the collection container to reduce the risk of cross contamination and infection.",2020-09-01
471,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-04-03,692,D,1,0,0YN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D9 Based on observations, record reviews and interviews; the facility failed to ensure that fluid intake was monitored and evaluated to ensure hydration needs were met for two current sampled residents (Residents 1 and 2) identified at risk for dehydration and with a history of or current urinary tract infections. The facility census was 87 with four current sampled residents. Findings are: [NAME] Review of the Face Sheet, printed 4/4/18, revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care, dated 3/3/18, revealed that the resident had increased confusion, had an indwelling urinary catheter and often had bladder infections. Interventions included remind to eat and drink enough. Observations on 4/4/18 at 8:10 AM revealed MA (Medication Aide) - A and NA (Nursing Assistant) - B assisted the resident with morning cares. Further observations revealed the resident's mouth and lips appeared dry, no oral cares were done before breakfast and no water or fluids were offered with morning cares. The urine in the urinary catheter drainage bag was dark amber. Observations on 4/4/18 at 8:40 AM revealed the resident seated in the dining room for breakfast with food and fluids not consumed. Further observations revealed no staff in the area to encourage or assist the resident to eat or drink. Interview on 4/4/18 at 9:45 AM with NA - B revealed that the resident took bites of food and about 160 cc. (cubic centimeters) of fluids at breakfast. Observations on 4/4/18 at 1:45 PM revealed the resident yelling out and wanting to get out of bed. Further observations revealed NA - B assisted the resident into the wheelchair, offered the resident a glass of iced tea and the resident responded that would be good. NA - B assisted the resident to the lounge area for an activity but did not give the resident a glass of iced tea. Review of the Nutrition Evaluation, dated 3/3/18, revealed that the resident required 1920 cc. of fluids daily to maintain hydration. Review of the Departmental Notes, dated 3/27/18, revealed that an electronic message was received at 11:34 AM that the resident's urine was very concentrated and the resident needed to drink more water. Further review revealed that the resident was to be offered 120 cc of water between meals. Review of the I (intake) and O (output) Roster, dated 3/3/18 - 4/3/18, revealed that the resident's fluid intake and output were documented each shift but the daily amount was not totaled. Review of the Meals and Snacks Roster, dated 3/3/18 - 4/3/18, revealed that the amount of fluids consumed at meals was documented but the daily amount was not totaled. B. Review of the Face Sheet, printed 4/4/18, revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nutritional Evaluation, dated 3/19/18, revealed that the resident required 1980 cc. of fluid to maintain hydration. Review of the I and O (Calculated) Roster, dated 3/19/18 through 4/3/18, revealed that the resident's fluid intake was documented every shift but the daily amount was not totaled. Review of the Meals and Snacks Roster, dated 3/19/18 through 4/3/18, revealed that the residents fluid intake was documented but the daily amount was not totaled. Review of the Departmental Notes, dated 3/29/18 at 5:51 PM, revealed that a clean catch urine specimen was sent to the doctor as ordered and a culture was ordered. New orders were received [MEDICATION NAME](antibiotic) two times a day for 10 days for a urinary tract infection. Further review revealed no documentation that the resident would be offered or encouraged to drink more fluids. Interview with the DON (Director of Nursing) on 4/4/18 at 3:00 PM confirmed that the staff did not calculate the residents' total fluid intake daily to evaluate their actual intake and ensure that their hydration needs were met. Further interview confirmed that the residents were at risk for dehydration due to confusion, dependence on staff and urinary tract infections. The DON confirmed that the resident's needed encouragement and assistance to take fluids throughout the day with cares, snacks and meals.",2020-09-01
472,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2019-05-07,600,E,1,0,VED411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on record reviews and interview, the facility failed to have interventions in place to manage behaviors and prevent episodes of resident to resident abuse involving three residents (Residents 1, 4 and 6) who reside in the SCU (Special Care Unit). The facility census was 80 with 10 residents currently residing in the SCU. Findings are: Review of Resident 1's Departmental Notes revealed that on 3/21/19 the resident was hollering out during activities and Resident 6 raised hand and open handed slapped the resident across the left cheek. Further review revealed that on 4/26/19 at 1:09 PM, Resident 4 smacked the resident in the face. Review of the Care Plan, printed 5/7/19, revealed that the resident frequently hollered out and interventions included keep other residents away at last five feet so they don't hit at me, if I am disturbing others redirect me, when I holler too loudly for others remind me to quiet down by saying Shhh or offer me other things like drinks, snacks, [MEDICATION NAME] oils or anything calming. Interview with the Director of Nursing on 5/7/19 at 9:30 AM confirmed that interventions in place were not always effective to manage the resident's disruptive behaviors and reduce the risk for resident to resident altercations. Review of the facility policy Freedom From Abuse, Neglect and Exploitation, dated (MONTH) (YEAR), revealed the following including: Purpose: The purpose of this policy is to ensure resident safety by promoting an environment which is free from abuse, neglect and exploitation. Policy: All residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents .",2020-09-01
473,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2019-05-07,744,E,1,0,VED411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.009D5 Based on observations, record review and interviews; the facility failed to manage ongoing adverse behaviors for one current sampled resident (Resident 1) to promote a comfortable environment for residents who reside in the SCU (Special Care Unit). The facility census was 80 with 10 residents in the SCU. Findings are: Observations on 5/6/19 at 4:30 PM revealed Resident 1 seated in the lounge area of the secured SCU with five other residents. The resident was yelling out repeatedly and could be heard on the units adjacent to the SCU. Further observations revealed the DON (Director of Nursing) sitting with the resident trying to calm the resident. Observations on 5/7/19 at 8:30 AM revealed the resident screaming and yelling in room with the door closed. The screaming and yelling could be heard on the units adjacent to the SCU. Further observations revealed MA (Medication Aide) - B and MA- C transferred the resident from one wheelchair to another wheelchair and the resident continued to scream. Interview with MA - B on 5/7/19 at 8:30 AM revealed that this behavior was not uncommon. MA - B stated that some days were better than others and interventions don't always help control the resident's yelling and screaming. Review of the Departmental Notes revealed the following including: - 2/11/19 at 7:24 PM The resident was anxious most of the day, very agitated for 2-3 hours at a time and did not have positive response to interventions, very angry at times, threw food and drinks on the floor and was very loud verbally; - 2/20/19 at 3:50 AM The resident had been hollering and screaming for the past two hours; - 2/25/19 at 3:41 PM The resident had a difficult day, cried out, growling and yelling very loudly most of the day, did not respond positively to any interventions and other residents expressed negatively towards the resident; - 2/26/19 at 12:30 AM The resident screamed loudly; - 3/9/19 at 7:49 PM The night shift reported that the resident was up for most of the night until around 4:00 AM, very anxious and was yelling loudly. Today resident was making constant yelling noise, combative with cares and other residents observed being agitated with the resident, multiple interventions were not effective, the resident had been yelling constantly most of the day; - 3/14/19 at 9:44 PM The staff reported that the resident had screamed and hollered out frequently today, entered another resident's room and knocked several things over; - 3/23/19 Resident hollered out from 6:30 PM until 8:30 PM; - 4/9/19 Resident hollered out from 7:30 PM to 1:26 AM; - 4/14/19 at 3:23 AM The resident was awake and hollering out, interventions ineffective; - 4/25/19 at 1:10 PM The resident yelled and screamed continuously in the unit living room this afternoon; - 5/1/19 at 5:54 PM The resident screamed and yelled this afternoon and interventions were not effective; - 5/4/19 at 5:15 AM The resident hollered out from 4:00 AM to 4:30 AM, screamed in the afternoon and hollered for about an hour at 10:00 PM; - 5/6/10 at 6:00 AM The resident hollered loudly. Review of the Care Plan, printed 5/7/19, revealed that the resident had a [DIAGNOSES REDACTED]. Approaches included observe for yelling, pushing people or staff, running away and throwing self on the floor screaming, wandering and violent behavior, keep other residents at least five feet away so they don't hit the resident, approach in a clam and reassuring manner, one to one interactions, soothing music, hand massage when anxious or hollering, offer snacks, redirect if disturbing others, wheelchair rises around the facility, remind to be quiet or offer drinks, snacks, [MEDICATION NAME] oils when hollering loudly and medications as ordered. Interview with the DON on 5/7/19 at 9:30 AM revealed that the resident had ongoing behavior cycles due to diagnoses. Further interview confirmed that interventions were not always effective to manage behaviors and to promote a comfortable environment for the other residents who reside in the SCU.",2020-09-01
474,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-06-01,314,D,1,0,FBYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility failed to follow interventions to promote healing of a pressure ulcer for Resident 3. This affected 1 of 4 sampled residents. The facility identified a census of 80 at the time of survey. Findings are: Review of Resident 3's Significant Change in Status Assessment MDS (minimum data set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/20/2016 revealed that Resident 3 was admitted to the facility on [DATE] and that Resident 3 required extensive assistance of 2 staff for bed mobility. Resident 3 was dependent upon staff for transfers and was at risk for developing pressure ulcers. Review of Resident 3's quarterly MDS dated [DATE] revealed Resident 3 had a Stage 2 pressure ulcer with date of origin 1/28/2017 that was not present at admit/reentry. Review of Resident 3's Visual Body Map dated 6/1/2017 revealed Resident 3 had a pressure ulcer to the coccyx (tailbone). Review of Resident 3's Care Plan dated 8/1/2016 revealed Resident 3 was at risk for altered skin integrity and staff were to encourage frequent turning. Also Resident 3 had a coccyx wound that required treatment. Review of Resident 3's TAR (Treatment Administration Record) for (MONTH) (YEAR) revealed that Resident 3 was to receive [MEDICATION NAME] (a protein nutritional supplement to promote healing of pressure ulcers and prevent weight loss) 2 ounces TID (three times a day) between meals. There was no documentation that the protein supplement was administered to Resident 3 at 10:00 AM and 3:00 PM on 5/4, 5/10, 5/15, 5/17, 5/24, 5/25, and 5/29. There was also no documentation the supplement was administered at 3:00 PM on 5/11, 5/16, 5/22, and 5/23 and at 8:00 PM on 5/25. Observation of Resident 3 on 6/1/2017 revealed Resident 3 was observed sitting in the wheelchair on the following: -9:56 AM; -11:00 AM; -12:05 PM; -12:30 PM; -1:40 PM; and -2:02 PM; -3:00 PM. Observation of Resident 3 on 6/1/2017 at 3:25 PM revealed that Resident 3 was assisted with cares and to lie down in bed. Resident 3 was observed to have a Stage 2 pressure ulcer to the coccyx. Resident 3 had not been observed to be repositioned from 9:56 AM to 3:25 PM or approximately 5 1/2 hours without being repositioned. Interview with the ADON (Assistant Director of Nursing) on 6/1/2017 at 5:07 PM revealed that a resident with a pressure ulcer should be repositioned every 2 hours. The ADON confirmed that Resident 3's protein nutritional supplement should have been documented. Interview with the FSS (Food Service Supervisor) on 6/1/2017 at 5:30 PM revealed it was the expectation that the facility staff document protein nutritional supplements as ordered.",2020-09-01
475,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-08-16,677,D,1,0,1UV211,"> Licensure Reference Number 175 NAC 12-006.09D1c Based on record review and interview, the facility failed to provide prompt responses to calls for assistance. Census: 97 residents. Sample size: 4 residents. Findings are: On 8/15/18 at 10:00 AM a review of the call light system report for unit 300 (19 residents) for the dates 7/26/18, 7/27/18, and 7/28/18, revealed a total of 144 call lights over 20 minutes, of which, 35 call lights were on for over 40 minutes, 21 call lights were on for over 60 minutes, 14 call lights were on for over 100 minutes, and 2 call lights were on for over 365 minutes (registered as system administrator). On 8/15/18 at 12:00 PM a review of facility complaints/grievances revealed 4 grievances were filed regarding call lights not being answered in a timely manner: 1) on 8/6/18 by Resident #1; 2) on 8/6/18 by Resident #7; 3) on 8/6/18 by Resident #1, and 4) on 5/31/18 by Resident #8. On 8/15/18 at 11:20 AM an interview with Resident #6 confirmed long wait times for call lights to be answered. Sometimes it takes 20 to 30 minutes before someone comes. On 8/15/18 at 3:00 PM an interview with the ADON confirmed that call lights were not being answered promptly and in a timely manner for the residents needs. On 8/15/18 at 3:00 PM an interview with the administrator confirmed that call lights were not being answered promptly and in a timely manner for the residents needs.",2020-09-01
476,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-08-16,684,D,1,0,1UV211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D3 Based on record review and interview, the facility failed to provide care and treatment for [REDACTED].#1). Census: 97 residents. Sample size: 4 residents. Findings are: On 8/14/18 at 09:30 AM a review of the call light system report over a random 3 day period for Resident #1 revealed call light wait times of: 7/26/18 at 10:25 AM: 44 minutes 25 seconds; 7/26/18 at 2:37 PM: 39 minutes 48 seconds; 7/26/18 at 5:59 PM: 20 minutes 9 seconds; 7/26/18 at 6:40 PM: bathroom call light: 30 minutes 9 seconds; 7/26/18 at 6:45 PM: 24 minutes 55 seconds; 7/27/18 at 10:17 AM: 25 minutes 10 seconds; 7/27/18 at 8:33 PM: 26 minutes 36 seconds; 7/27/18 at 10:14 PM: 42 minutes 38 seconds; 7/28/18 at 1:10 PM: 30 minutes 42 seconds; 7/28/18 at 4:41 PM: bathroom call light: 30 minutes 38 seconds; On 8/15/18 at 12:00 PM a review of facility complaints/grievances revealed 4 grievances were filed regarding call lights not being answered in a timely manner: 1) on 8/6/18 by Resident #1; 2) on 8/6/18 by Resident #7; 3) on 8/6/18 by Resident #1, and 4) on 5/31/18 by Resident #8. On 8/14/18 at 10:00 AM a review of the care plan for Resident #1 revealed Resident #1 requires assistance with toileting and is care planned for toileting assist to bathroom upon rising, before and after meals, at HS (hours of sleep) and PRN (as needed). On 8/15/18 at 11:20 AM an interview with Resident #6 confirmed long wait times for call lights to be answered. Sometimes it takes 20 to 30 minutes before someone comes. On 8/15/18 at 3:00 PM an interview with the ADON confirmed that call lights were not being answered promptly in order to promote healthy bowel elimination for residents. On 8/15/18 at 3:00 PM an interview with the administrator confirmed that call lights were not being answered promptly and in a timely manner for the residents needs and in order to promote healthy bowel elimination.",2020-09-01
477,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-08-16,839,D,1,0,1UV211,"> Licensure Reference Number 175 NAC 12-006.04A1 Based on record review and interview, the facility failed to ensure staff had the required credentials prior to their assuming job responsibilities for 1 nursing staff out of 5 employees sampled. Findings are: On 8/13/18 at 2:00 PM a review of employment files revealed that NA-A (nurse assistant-A) had been hired from by the facility to work as a N[NAME] NA-A applied to transfer a Kansas NA certification to Nebraska. It revealed that NA-A took the comprehensive evaluation written and clinical exam on 3/5/18, passed the written portion of the exam and failed the clinical portion twice. It revealed that NA-A took the comprehensive evaluation clinical portion of the exam again on 3/19/18 and passed. The review of the employee filed NA-A also revealed that NA-A was on the nursing schedule and the unit/hall assignment schedule to be working in a NA capacity on the night shift (6:00 PM to 6:00 AM) beginning 4/1/18. The review revealed that NA-A worked 13 shifts and was scheduled 14 shifts (4/1, 4/5, 4/6, 4/9, 4/10, 4/12, 4/13, 4/14 (on the schedule but crossed off), 4/15, 4/16, 4/17, 4/18, 4/19 & 4/20) prior to being active on the NE Registry for NA's. NA-A didn't become active on the NE Registry for NA's until 4/23/18. On 8/13/18 at 3:25 PM an interview with the ADON confirmed that NA-A was scheduled and working prior to being active on the Nebraska registry for NA's. On 8/13/18 at 4:30 PM an interview with the Administrator confirmed that NA-A was scheduled and working prior to being active on the NE registry for NA's.",2020-09-01
478,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,157,D,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on interviews and record reviews, the facility failed to notify family members for one sampled resident's (Resident 86) change in condition and transfer to the hospital when events occurred. Sample included 25 current residents. Facility census was 81. Findings are: Record review of Resident 86's Face Sheet printed on 10/4/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Interview with Resident 86's family members on 10/3/17 at 3:54 p.m. revealed Resident 86 experienced a change of condition after being admitted to the facility. The family described the resident suffering a stroke requiring a stay in the hospital. When asked if the facility notified the family members promptly when the event occurred the family members stated no and described that the resident began experiencing symptoms around 10 a.m. and was transferred to the hospital in the afternoon around 2 p.m. and none of the family were notified of the symptoms or the hospital transfer until 3 p.m. Record review of Resident 86's electronic health record revealed an entry in the Departmental Notes dated 9/11/17 at 6:57 p.m. The note recorded that at 11 a.m. the Resident noted to have trouble talking in complete sentences. Able to answer questions as they were being asked but had trouble ending the sentence. No signs of facial droop, able to move all extremities, hand grip equal bilateral (both hands). The note went on to further describe at 2:00 p.m. Resident sent to ER as speech showed no signs of improvement. UA (urine collection for analysis) obtained and sent to clinic. There was no documentation from the electronic health record to indicate attempts were made, or family was notified of the resident's change in condition of symptoms, UA, or transfer to the emergency room . A document from Resident 86's clinic dated 9/11/17 at 12:59 p.m. recorded the resident was seen for a urine collection for weakness, confusion, and lethargy (sluggishness). The impression of the resident recorded on the document was : Acute ischemic stroke on CT (diagnostic scan) of the head. Will admit for stroke work-up. Interview with the facility DON (Director of Nursing) on 9/11/17 at 10:15 a.m. confirmed Resident 86 had a history of [REDACTED]. The DON confirmed the resident began experiencing symptoms at 11:00 a.m. and was sent to the emergency room at 2:00 p.m. The DON verified there was no documentation in the resident's medical record or evidence the family was made aware of the resident's changes or the transfer to the hospital.",2020-09-01
479,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,164,D,0,1,T01F11,"Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interview, the facility failed to ensure that privacy was provided during the administration of injections for two current sampled residents (Residents 35 and 51). The facility census was 81 with five residents sampled for observations of medication administration. Findings are: [NAME] Observations on 10/5/17 at 7:30 AM revealed Resident 35 resting in bed. RN (Registered Nurse) - A administered an insulin injection without utilizing the privacy curtain or closing the door. Further observations revealed residents and staff members walking in the hallway by the resident's room. B. Observations on 10/5/17 at 8:15 AM revealed Resident 51 seated in the wheelchair in the lobby area with several other residents waiting for an exercise class. RN - B administered the resident's insulin injection in the lobby area in view of the other residents and staff members. Interview with the Director of Nursing on 10/11/17 at 8:25 AM confirmed that the nurses were to utilize the privacy curtains or close the door to provide privacy during injections in the resident's rooms. Further interview confirmed that the nurses were not to administer injections in public areas to promote privacy for the residents.",2020-09-01
480,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,226,D,1,1,T01F11,"> Licensure Reference Number: 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to forward incident investigations to the state agency within the five working days for 2 sampled residents (Residents 21 and 83). Sample size was 25 residents. Facility census was 81. Findings are: Record review of [NAME]crest Nursing Homes investigation reports from the last 6 months revealed that there was an incident involving Resident (21) on (MONTH) 7, (YEAR) that the facility reported to Adult Protective Services and the facility did not turn in a investigation report until (MONTH) 15, (YEAR). The report was one day late. Interview with the Assistant Director of Nursing on 10/11/2017 confirmed that the incident ocurred on (MONTH) 7, (YEAR) and a report was sent on 6/15/2017 and the report was sent one day late. Record review of [NAME]crest Nursing Homes investigation reports from the last 6 months revealed that there was an incident involving Resident (83) that the facility reported to Adult Protective Services on (MONTH) 28, (YEAR) and a report had not been sent in to the state agency regarding this incident. Interview with the Assistant Director of Nursing on 10/11/2017 confirmed that the incident was called in on (MONTH) 28, (YEAR) and a report was not sent.",2020-09-01
481,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,246,D,0,1,T01F11,"Licensure Reference Number 175 NAC 12-006.18B1 Based on observations and interviews, the facility failed to ensure that call lights were within reach for two current sampled residents (Residents 31 and 21). The facility census was 81 with 25 current sampled residents. Findings are: [NAME] Observations on 10/4/17 at 9:30 AM revealed Resident 31 seated in the recliner in room. Further observation revealed the call light positioned on the bed out of reach for the resident. Interview on 10/4/17 at 9:30 AM with the resident revealed that I might need that call light. Interview on 10/4/17 at 9:30 AM with MA (Medication Aide) - [NAME] confirmed that the resident was supposed to have the call light within reach to call for assistance with transfers. B. Observations on 10/5/17 at 7:15 AM revealed Resident 21 in bed and trying to get up. The resident was calling out I can't find the call light, I need the call light and I have to go to the bathroom. Further observation revealed the call light on the recliner out of the resident's reach. Interview with NA (Nursing Assistant) - F on 10/5/17 at 7:20 AM confirmed that the resident should have the call light within reach to call for assistance. Interview with the Director of Nursing on 10/11/17 at 9:40 AM confirmed that the residents were to have their call lights within reach to call for assistance.",2020-09-01
482,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,253,E,0,1,T01F11,"Licensure Reference Number: 175 NAC 12-006.18B Based on observations and interviews, the facility failed to repair damaged walls in resident rooms and bathroom door frames. Rooms affected were rooms 202, 205, 206, 212, and 422. Sample size was 35 resident rooms and facility census was 81. Findings are: Observations conducted of resident rooms on (MONTH) 3, (YEAR) and (MONTH) 4, (YEAR) revealed the following: -Room 202 had chipped up paint in bedroom walls and marred up paint on door frame outside of bathroom door. -Room 205 had marred up paint on door frame outside of bathroom door. -Room 206 had marred up paint on door frame outside of bathroom door. -Room 212 had marred up paint on door frame outside of bathroom door and damage to wall in bathroom down by floor molding. -Room 422 had marred up paint on door frame outside of bathroom door. Interview and inspection of resident rooms with the Maintenance Man on 10/10/2017 2:53 PM confirmed the damage to these rooms.",2020-09-01
483,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,276,D,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record reviews and interview, the facility failed to complete and submit to the State Agency Quarterly MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments within the required 92 day time frame for one non-sampled resident (Resident 106). Sampled residents included 25 current residents. Facility census was 81. Findings are: During a reconciliation of current residents with the list of residents' MDS assessments uploaded to the State Agency on 10/3/17 at 12:23 p.m., it was discovered Resident 106 was listed in a facility census list identifying residents residing in the facility on 10/3/17. Comparison of the list and the uploaded MDS assessments revealed Resident 106 had not had any MDS's uploaded into the system since an Admission assessment on 3/8/17. Interview with the facility Business Office Manager on 10/3/17 at 12:33 p.m. confirmed Resident 106 was a current resident residing in the facility and verified the resident was admitted to the facility on [DATE] and had not been discharged for any reasons since being admitted . Record review of Resident 106's MDS assessments revealed the resident had an Entry Tracking Record MDS uploaded identifying the resident was admitted to the facility on [DATE]. An Admission MDS assessment was completed and submitted on 3/8/17. Further review of MDS records revealed no MDS assessments were completed or submitted to the State Agency between 3/8/17 and 10/3/17. Interview with MDS Coordinators, RN (Registered Nurse)-A and RN-B on 10/5/17 at 11:04 a.m. verified Resident 106 had not had any MDS assessments completed or submitted to the State Agency between 3/8/17 and 10/3/17. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (An instructional manual describing requirements for completing and submitting MDS assessments) Version 1.14 (MONTH) (YEAR), Regarding Quarterly Assessments the manual instructs the facility that after admission assessments were completed the facility was required to be completed at least every 92 days following the previous assessment of any type.",2020-09-01
484,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,279,E,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1b Based on record reviews and interviews, the facility failed to develop care plans to address 1) PASRR 2 (Preadmission Screening and Resident Review) status for one current sampled resident (Resident 73), 2) behaviors for one current sampled resident (Resident 56), 3) risk for abnormal bleeding for one current sampled resident (Resident 1) on a routine anticoagulant medication and 4) risk for dehydration for one current sampled resident (Resident 8) on multiple diuretic medications. The facility census was 81 with 25 current sampled residents. Findings are: [NAME] Review of Resident 73's PASRR Summary of Findings, dated 12/23/14, revealed that the resident met the criteria for mental illness and nursing home admission and care. Review of the Care Plan, dated 9/1/17, revealed no care plan to address the resident's PASRR 2 status and interventions to meet the resident's specialized needs. Interview with the Social Services Director on 10/11/17 at 10:15 AM confirmed that a care plan should have been developed to address the resident's PASRR 2 status. B. Review of Resident 56's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized for care plan development), dated 8/4/17, revealed that the resident had episodes of physically abusive behaviors directed towards others. Review of the Care Plan, dated 7/7/17, revealed no care plan to address the resident's behaviors. Interview with RN (Registered Nurse) - G, MDS Coordinator, confirmed that a care plan should have been developed to address the resident's behaviors. D. Record review of Resident 1's Face Sheet document printed on 10/4/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 1's e-Medication Administration Record [REDACTED]. The medication was originally ordered on [DATE] and administered to the resident every evening. Record review of Resident 1's Care Plan revised in (MONTH) of (YEAR) revealed there were no problems, risks, goals, or interventions developed on the care plan related to Resident 1's propensity for blood clotting or use of an anticoagulant (Xarelto) medication which increases risks for bleeding and bruising. Source: [NAME]'s Drug Guide for Nurses Fifteenth Edition (YEAR). With regard to potential side effects for Xarelto list a high risk for bleeding among residents taking the medication. E. Record review of Resident 8's Face Sheet document printed on 10/4/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 8's e-Medication Administration Record [REDACTED] - [MEDICATION NAME] (a diuretic medication to remove fluid to reduce [MEDICAL CONDITION] associated with heart failure). The medication was originally ordered on [DATE] and was administered to the resident every 72 hours. - [MEDICATION NAME] (a diuretic medication to remove fluid to reduce [MEDICAL CONDITION] associated with heart failure). The medication was originally ordered on [DATE] and administered to the resident daily. Record review of Resident 8's Care plan revised in (MONTH) of (YEAR) revealed there were no problems, risks, goals, or interventions developed on the care plan to address the resident's propensity for [MEDICAL CONDITION] and the use of duplicate diuretic medications which increase the risk for dehydration. Source: [NAME]'s Drug Guide for Nurses Fifteenth Edition (YEAR). Regarding [MEDICATION NAME] and [MEDICATION NAME], the adverse reactions and side effects for these medications identify high risks for dehydration, and imbalances of electrolytes (ionized salts in blood tissue essential for health balance). Interview with the DON (Director of Nursing) on 10/11/17 at 10:10 a.m. confirmed that Resident 1 received daily doses of Xarelto and the resident's care plan had not been developed to identify the potential risk associated with routine use of the medication. Further interview with the DON verified Resident 8 received daily doses of [MEDICATION NAME] and an additional diuretic dose of [MEDICATION NAME] every 72 hours. The DON verified the resident's care plan had not been developed to identify the potential risks for dehydration associated with the duplicative use of diuretics.",2020-09-01
485,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,282,D,1,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006. 09C Based on record reviews, interviews, and observation, the facility failed to implement the interventions developed on the care plan for safe mechanical lift transfers for one sampled resident (Resident 14). Sample size included 25 current residents. Facility census was 81. Findings are: Record review of Resident 14's Face Sheet printed on 10/4/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 14's Care plan initiated on 2/13/17 revealed updated entries which read: - An entry for the problem of Risk for falls recorded an updated entry of: Requires full lift/standing machine and documented near miss fall- resident in lift getting ready for bed. Lift got off center and tipped sideways . - An entry for the problem Resident Preferences recorded on 7/29/17 instructed the staff to use: 3 assist with full lift for transfers. - An undated entry under a problem for Self Care Deficit provided instructions regarding: Transfer Full lift c (with) 3 assist for safety. Interview with Resident 14 on 10/4/17 at 1:38 p.m. revealed the resident was admitted to the facility in (MONTH) of (YEAR). The resident described the need for a mechanical lift to transfer from bed to wheelchair due to his limited mobility and size. The resident described an incident in (MONTH) of (YEAR) where the mechanical lift transfer tipped during the transfer. Since that time, the resident stated they (facility staff) were supposed to have three persons in the room during the transfer. The resident described how the facility had not always followed this plan as often there were only two staff present during mechanical lift transfers. Interviews with facility staff revealed the following: - NA (Nurse Aide)-I on 10/10/17 at 5:20 p.m. NA-I described working at facility since (MONTH) of (YEAR) on the day shift from 6 a.m. to 6 p.m. NA-I was familiar with Resident 14's care. NA-I described the staff transferred the resident with a mechanical sling lift and stated two staff persons perform the transfer. - NA-J on 10/10/17 at 6:15 p.m. NA-K stated being a short-shift nurse aide working from 6 p.m. to 10 p.m. NA-J was familiar with Resident 14's care. NA-J stated the resident was being transferred from wheelchair to bed with the use of a mechanical sling lift and stated two persons perform the transfer. - NA- K on 10/11/17 at 7:00 a.m. NA-K stated working the day shift from 6 a.m. to 6 p.m. NA-K was familiar with Resident 14's care. NA-K stated the resident was being transferred from wheelchair to bed with the use of a mechanical sling lift and stated two persons perform the transfer. - MA (Medication Aide)-L on 10/11/17 at 7:00 a.m. MA-L was familiar with Resident 14's care. MA-L stated working the day shift from 6 a.m. to 6 p.m. MA-L stated Resident 14's care. NA-K stated the resident was transferred from wheelchair to bed with the use of a mechanical sling lift and stated two persons perform the transfer. Observation of Resident 14's mechanical lift transfer on 10/11/17 beginning at 6:30 a.m. revealed NA-K and MA-L assisted the resident with the transfer from bed to chair without the assistance of a third staff member. Interview with the DON (Director of Nursing) on 10/11/17 at 10:15 a.m. confirmed Resident 14's care plan was updated following a near miss fall during a mechanical lift transfer in (MONTH) of (YEAR). The DON confirmed the care plan directed the staff to have three staff assisting the resident with the mechanical lift transfers.",2020-09-01
486,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,309,D,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) assessments were completed for one current sampled resident (Resident 74) with complaints of severe pain and 2) vital signs were obtained and assessed with [REDACTED]. The facility census was 81 with 25 current sampled residents. Findings are: [NAME] Observations on 10/4/17 at 11:20 AM revealed Resident 74 seated in the recliner wearing a neck brace. Interview with the resident on 10/4/17 at 11:20 AM revealed that the resident had a neck pain due to a fractured neck and received some relief from the pain medications. Review of the e- Medication form, dated (MONTH) (YEAR), revealed that the resident complained of pain, rated 8 on 10/2/17 and 10/3/17 and 10 on 10/2/17 and 10/4/17. The pain scale of 1 - 10 with 8 - 10 indicated severe pain. Review of the Administration Record revealed no assessments of the resident's severe pain to include location and precipitating factors. Further review revealed follow up documentation that the Medication was effective. Interview with the Director of Nursing on 10/11/17 at 9:20 AM confirmed that assessments, including location, type of pain, and potential causal factors should be completed. Further interview confirmed that more specific and objective follow up should be done to ensure that the resident's pain management needs were met. B. Record review of Resident 86's Face Sheet printed on 10/4/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 86's electronic health record revealed an entry in the Departmental Notes dated 9/11/17 at 6:57 p.m. The note recorded that at 11 a.m. the Resident noted to have trouble talking in complete sentences. Able to answer questions as they were being asked but had trouble ending the sentence. No signs of facial droop, able to move all extremities, hand grip equal bilateral (both hands). The note went on to further describe at 2:00 p.m. Resident sent to ER as speech showed no signs of improvement. UA (urine collection for analysis) obtained and sent to clinic. There was no documentation from the electronic health record of the resident's vital signs at the time of the initial presentation of the symptoms, following the identification of symptoms, or at the time the resident was transferred to the emergency room for evaluation. Record review of a Community Hospital progress note for Resident 86 on 9/12/17 revealed the medical practitioner's note recorded the resident came to the emergency roiagnom on [DATE] due to difficulty expressing self. A C-T (brain scan) registered positive for acute ischemic insult (stroke). Interview with the DON (Director of Nursing) on 10/11/17 at 9:55 a.m. confirmed Resident 86 began experiencing symptoms of speech difficulties on 9/11/17 at 11:00 a.m. and was transferred to the emergency room at 2:00 p.m. on the same day. The DON confirmed there were no entries or evidence in the resident's medical record that staff attempted to or obtained resident vital signs during the change of condition.",2020-09-01
487,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,323,E,1,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) fall interventions were in place to reduce the risk for falls for two current sampled residents (Residents 48 and 31), 2) oxygen concentrators were turned off while not in use to reduce the risk of accidental fires for four current sampled residents (Residents 83, 65, 5 and 48), 3) potentially hazardous chemicals were secured to reduce the risk of accidental exposure and injuries for eight current residents identified as confused and wandering (Residents 44, 49, 53, 62, 26, 100, 90 and 107) and 4) grab bars were tightly secured on beds for five sampled residents (Residents 64, 14, 86, 38 and 52). The facility census was 81 with 35 sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D7 [NAME] Review of the Face Sheet, printed 10/4/17, revealed that Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, printed 10/4/17, revealed that the resident had impaired physical mobility related to weakness and interventions included ambulation with a walker and staff assistance. Further review revealed that the resident was at risk for injuries due to history of falls and interventions included remind resident to ask for help when getting up. On 6/13/17, staff education do not leave alone in the bathroom was added to the care plan. Further review revealed that the resident was legally blind, had difficulty hearing and had dementia with episodes of disorientation. Review of the Departmental Notes revealed the following including: - 6/13/17 Resident noted sitting on the floor in the bathroom in front of the toilet at 7:40 AM. Resident complained of bottom hurting and no injuries noted; - 6/15/17 at 9:41 AM Care team met to discuss the resident's fall. The resident was left unattended in the room and staff education was provided not to leave the resident unattended in the bathroom. Interview with the DON (Director of Nursing) on 10/11/17 at 8:45 AM confirmed that the resident was at risk for falls and needed assistance with ambulation. Further interview confirmed that the resident should not have been left unattended in the bathroom to reduce the risk for falls. B. Review of the Face Sheet, printed 10/4/17, revealed that Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 9/7/17, revealed that the resident was at risk for falls related to new admission, mental status, recent fall and history of falls. Interventions included encourage the resident to ask for assistance, bed alarm, chair alarm and place call light within reach. Further review revealed a problem of self care deficit due to confusion and weakness and interventions included assist of one with walker and gait belt (applied around the resident's waist for staff to assist the resident to transfer and ambulate) for ambulation and assist of one to the bathroom. Review of the Departmental Notes revealed the following including: - 9/8/17 at 4:39 AM Resident was up and to the bathroom at 4:30 AM, did not use the call light for assistance. The resident was reeducated on the importance of using the call light and the need for assistance to prevent falls; - 9/11/17 at 9:43 AM Care team met to discuss 9/9/17 at 9:00 AM resident stated (gender) was getting out of bed to go to the bathroom and when (gender) legs gave out and (gender) sat on the floor. No injury noted at this time, alert and confused . Alarm sounded.; - 9/15/17 at 2:23 AM Resident was noted on the floor at 6:45 PM. Resident received a skin tear on left posterior hand. No other injuries or pain noted; 10:02 AM Care team met to discuss fall that occurred on 9/14/17 at 6:45 PM. The resident was noted on the floor in the bathroom. Staff and family educated to ensure that alarms are in place. Observations on 10/4/17 at 9:30 AM revealed the resident seated in the recliner in room. Further observation revealed the call light positioned on the bed out of reach for the resident. Observations on 10/5/17 at 6:45 AM revealed the resident standing in the bathroom with no staff present for assistance. Interview with the DON (Director of Nursing) on 10/11/17 at 8:45 AM confirmed that the resident was at risk for falls and fall interventions were not consistently in place to reduce the risk of falls and injuries. Licensure Reference Number 175 NAC 12-006.09D7a C. Observations on 10/3/17 at 12:30 PM, during the initial tour of the facility, revealed the oxygen concentrators on in Room 200 (Resident 83), Room 418 (Resident 65) and Room 401 (Resident 5). Further observations revealed that the residents were not in their rooms. Observations on 10/11/17 at 7:00 AM revealed the oxygen concentrator on in Room 410 (Resident 48) and the resident was not in the room. Interview with the Administrator on 10/11/17 at 7:45 AM confirmed that the oxygen concentrators were to be turned off while not in use to reduce the risk of accidental fires. Licensure Reference Number 175 NAC 12-006.18E4 D. Observations on 10/3/17 at 12:30 PM, during the initial tour of the facility, revealed the following including: - 200 wing utility room door unlocked with a container of Hydrogen Peroxide Cleaner Disinfectant Wipes on the counter; - 300 wing utility room door unlocked with a container of Clorox Bleach wipes on the counter; - 300 wing treatment cart by the nurses station with a container of Sani-Cloth Plus Germicidal wipes on the top of the cart; - Special Care Unit bathing room door unlocked with Virex 11 256 Disinfectant spray container and MARC 120 Cherry Blossom Air Freshener spray container in an unlocked cupboard. Interview on 10/3/17 at 12:30 PM with RN (Registered Nurse) - G confirmed that the chemicals were to be kept locked up to reduce the risk of accidental exposure and injuries for the residents. RN - G identified Resident 53 (100 wing), Resident 62 (200 wing), Residents 44 and 49 (400 wing) and Residents 26, 100, 90 and 107 (Special Care Unit) as being confused and wandered in the facility and at risk for accidental exposure and injuries. References Safety Data Sheets/Toxicological Information: Hydrogen Peroxide Cleaner Disinfectant Wipes - Inhalation - may cause irritation of the respiratory tract; - Eye contact - may cause slight irritation; - Skin contact - may cause slight skin irritation; - Ingestion - may cause irritation to mucous membranes, gastrointestinal irritation, nausea, vomiting and diarrhea. Sani-Cloth Plus Germicidal Disposable Cloth - Eye contact - mildly irritating to eyes on test data; - Exposed individuals may experience eye tearing, redness and discomfort. Virex 11 256 One-Step Disinfectant Cleaner and Deodorant - Skin contact - corrosive, causes severe burns, blisters redness and pain which may be delayed; - Eye contact - corrosive, serious eye damage, pain, burning sensation, redness watering, blurred vision or loss of vision; - Ingestion - causes burns, serious damage to mouth, throat and stomach, harmful if swallowed - vomiting, nausea; - Inhalation - may cause irritation and corrosive effects to nose, throat and respiratory tract, coughing and difficulty breathing. MARC 120 Cherry Blossom Air Freshener - Eyes - direct contact may irritate eyes; - Skin - prolonged or repeated contact can irritate or dry skin. E. Licensure Reference Number: 175 NAC 12-006.18B3 Observations conducted on 10/3/2017 and 10/4/2017 of resident rooms revealed the following: -[RM #]2A Repositioning rail on both sides of the bed were loose. -[RM #]4B Repositioning rail on both sides of the bed were loose. -[RM #]5A Repositioning rail on both sides of the bed were loose. -Room 311A Repositioning rail on both sides of the bed were loose. -Room 422A Repositioning rail on both sides of the bed were loose. Interview and inspection of resident rooms with the Maintenance Man on 10/10/2017 2:53 PM confirmed that the repositioning rails to the beds were loose and needed tightening to the bed frame.",2020-09-01
488,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,329,D,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that the heart rate was monitored for one current sampled resident (Resident 74) on a routine heart medication (used to slow and strengthen the heart rate) to ensure the therapeutic benefits of the medication. The facility census was 81 with five residents sampled for observations of medication administration. Findings are: Observations on 10/5/17 at 7:30 AM revealed MA (Medication Aide) - C administered routine morning medications for Resident 74, including [MEDICATION NAME] (medication to slow and strengthen the heart rate). Further observations revealed no heart rate obtained before administration of the medication. Review of the eMedication record, dated (MONTH) (YEAR), revealed an order, dated 9/18/17, for [MEDICATION NAME] five days a week for [MEDICAL CONDITION](fast heart rate). Further review revealed no recorded heart rates. Interview on 10/5/17 at 7:30 AM with MA - C confirmed that the resident's heart rate was not obtained before administering the medication. Interview with the Director of Nursing on 10/11/17 at 9:20 AM confirmed that the nurses should obtain and record the resident's heart rate before administering [MEDICATION NAME] to ensure the therapeutic benefits of the medication for the resident. Reference: [NAME]'s Drug Guide for Nurses, Fifteenth Edition. (YEAR) [MEDICATION NAME] Nursing Implications and Assessment. Monitor apical pulse for one full minute before administration, withhold dose and notify the health care professional if pulse rate is less than 60 beats per minute in an adult and any significant change in rate, rhythm or quality of pulse.",2020-09-01
489,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,332,D,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10D Based on observations, record reviews and interviews; the facility failed to ensure that medications were administered as ordered and medication error rate was not 5% or greater. The medication error rate was 8% with medication errors for two sampled residents (Residents 74 and 51). The facility census was 81 with five residents sampled for observations of medication administration. Findings are: [NAME] Observations on 10/5/17 at 7:30 AM revealed MA (Medication Aide) - C administered routine morning medications for Resident 74 including [MEDICATION NAME] for Gastro-[MEDICAL CONDITION] Reflux Disease. Further observations revealed that MA - C administered the medications for the resident in the dining room at the same time that the resident received a breakfast tray and began eating. Review of the eMedication form, dated (MONTH) (YEAR), revealed an order, dated 9/18/17 for [MEDICATION NAME] every morning. Interview on 10/5/17 at 7:30 AM with MA - C confirmed that the medication was to be administered before breakfast. B. Observations on 10/5/17 at 8:15 AM revealed RN (Registered Nurse) - B administered [MEDICATION NAME] (insulin) for Resident 51. Review of the eNurse Administration Record, dated (MONTH) (YEAR), revealed an order, dated 1/2/15, for [MEDICATION NAME] at 7:00 AM. Interview with the Director of Nursing on 10/11/17 at 8:20 AM confirmed that the nurses were to administer medications at the prescribed times to ensure the therapeutic benefits of the medications. The DON confirmed that the [MEDICATION NAME] was to be administered at least one hour before meals and the [MEDICATION NAME] was not administered within the required time frame. Review of the facility policy and procedure Administering Medications, revised (MONTH) 2007, revealed the following including: Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation - . 3. Medications must be administered in accordance with the orders, including any required time frame .8. Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified.",2020-09-01
490,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,425,E,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews; the facility failed to ensure that 1) prescription labels were compared to the medication orders at least three times before administration for five sampled residents (Residents 74, 35, 51, 24 and 30) to reduce the risk for errors and 2) routine medications were available for administration as ordered for two current sampled residents (Residents 74 and 1). The facility census was 81 with 25 current sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.10A3 175 NAC 12-006.10A2 [NAME] Observations on 10/5/17 at 7:30 AM revealed MA (Medication Aide) - C prepared morning medications for Resident 74. Further observations revealed that MA - C removed the medication cards from the medication cart, compared the prescription labels with the medication orders two times, poured the medications and placed the medication cards back into the medication cart. MA - C administered the medications and returned to the medication cart to sign off the medications administered. Observations on 10/5/17 at 7:30 AM revealed RN (Registered Nurse) - A obtained a blood sugar reading for Resident 35 from a Medication Aide at the medication cart and stated would give the resident insulin. RN - A obtained a box of insulin vials from the medication room, picked up a box with Novolog insulin, did not read the prescription label, drew up 10 units and placed the vial back into the insulin box without looking at the prescription label. RN - A administered the Novolog and returned to a computer to sign off the medication administered. Observations on 10/5/17 at 8:15 AM revealed RN - B obtained a syringe with the medication already drawn up from a basket of insulin vials in the medication room and administered the injection for Resident 51. RN - B continued with other tasks without returning to a computer to sign the medication off as administered. Observations on 10/10/17 at 5:00 PM revealed MA - R prepared medications for Resident 24. MA - R removed the medications from the medication cart, compared the prescription label one time with the current orders, poured the medications and returned them to the medication cart. MA - R administered the medications and then returned to the medication cart to sign off the medications administered. Observations on 10/10/17 at 5:15 PM revealed LPN (Licensed Practical Nurse) - D prepared to administer medications for Resident 30. LPN - C removed the medication cards from the medication cart, compared the prescription labels with the current orders one time, poured the medications and returned them to the medication cart. LPN - C administered the medications and returned to the medication cart to sign off the medications administered. Interview with the Director of Nursing on 10/11/17 at 8:25 AM confirmed that the nurses were to compare the prescription label with the current orders at least three times before administering medications per facility policy and procedures to reduce the risk for errors. Further interview confirmed that medications were not to be prepared in advance to administer later to reduce the risk for errors. Review of the facility policy Administering Medications, revised (MONTH) 2007, revealed the following including: Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method of administration before giving the medication. 8. Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed times. Licensure Reference Number 175 NAC 12-006.12 B. Review of Resident 74's Administrative Record, dated (MONTH) (YEAR), revealed that on 10/3/17 at 8:23 AM, the resident's routine dose of Lutein was not available. Further review revealed that on 10/4/17 at 8:00 AM, the routine dose of Atorvastatin was not available. Interview with the Director of Nursing on 10/11/17 at 8:25 AM confirmed that the routine medications were to be available from the pharmacy and administered as ordered to ensure that the resident's needs were met. C. Record review of Resident 1's Face Sheet document printed on 10/4/17 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 1's e-Medication Administration Record [REDACTED]. The medication was originally ordered on [DATE] and administered to the resident every evening. Further review of the document revealed doses scheduled on 9/2/17 and 9/5/17 were recorded as N (symbol for not given or administered). Record review of Resident 1's electronic medical record revealed in the Departmental Notes an entry on 9/5/17 at 6:49 p.m. recorded the resident's Xarelto was not administered due to not available reorder from pharmacy. There was no entry in the medical record documenting why the Xarelto dose on 9/2/17 was not administered. Interview with the DON (Director of Nursing) on 10/11/17 at 10:00 a.m. verified Resident 1 was ordered to receive Xarelto every evening and from the e-Medication Administration Record [REDACTED]. The DON verified the dose on 9/5/17 was not administered due to the medication being unavailable from the pharmacy as documented in the Departmental Notes. The DON confirmed there was no documentation as to why the resident had not received the Xarelto dose on 9/2/17.",2020-09-01
491,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,431,D,0,1,T01F11,"Licensure Reference Number 175 NAC 12-006.12E7 Based on observations, record reviews and interview; the facility failed to ensure that the prescription label matched the current orders to reduce the risk for medication errors for one sampled resident (Resident 35). The facility census was 81 with five residents sampled for observations of medication administration. Findings are: Observations on 10/5/17 at 7:30 AM revealed RN (Registered Nurse) - A prepared to administer the morning dose of Novolog insulin for Resident 35. RN - A administered 10 units of Novolog insulin. Review of the e-Nurse, medication administration form, revealed an order, dated 8/4/17, for Novolog 10 units three times a day before meals. Review of the prescription label revealed orders for 15 - 25 units before meals per sliding scale orders. Interview with the Director of Nursing on 10/5/17 at 10:10 AM confirmed that the prescription label did not match the current orders and needed to be changed to reduce the risk for errors.",2020-09-01
492,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,441,E,0,1,T01F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to: 1) ensure Contact Isolation procedures were implemented during dressing changes for one sampled resident (Resident 30); 2) ensure dressings were not cross-contaminated during dressing changes for one sampled resident (Resident 30); 3) ensure urinary catheter bags were kept from direct contact with the floor for one sampled resident (Resident 14); and 4) ensure hand hygiene was implemented per facility policies and current standards for 3 sampled residents (Residents 30, 35, and 51). Sample size included 25 current residents. Facility census was 81. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.17A (4) On 10/5/17 beginning at 6:40 a.m. an observation was conducted for Resident 30's wound care. During the observation, a sign was present on the entry to the room directing visitors to report to the nurse's station. The wound care and dressing changes for Resident 30 were performed by RN (Registered Nurse)-A and RN-B. Observations during the procedure revealed the pressure ulcers on the left outer malleolus (bony prominance on the outer ankle), right inner malleolus (bony prominence on the inner ankel) and heel. These wounds were observed to have saturated through the previous dressings with yellow, red, and brownish drainage present. The procedures were observed from 6:40 a.m. concluding at 7:25 a.m. During the observation staff were observed applying and removing disposable gloves, but no other protective equipment was utilized by the staff. Interview with RN-B on 10/5/17 at 9:10 a.m., the staff member was asked if Resident 30's wounds were infected and RN-B replied only being a part-time staff and that this was the first time RN-B worked as a charge nurse on the wing. RN-B stated being unaware of any infections to Resident 30's wounds. Interview with RN-A on 10/5/17 at 10:55 a.m. revealed RN-A was the charge nurse on another wing and was called to help RN-B with the wound care. RN-A stated having knowledge of Resident 30 being on an antibiotic but was not certain where or what type of infection the resident had contracted. Record review of an undated facility policy entitled Contact Preacautions and a policy dated 2003 for Contact Precautions revealed the following directions for staff: - Wear gowns before entering the resident's room. - A gown should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent or wound drainage is not contained by a dressing. Interviews with RN-O, the facility Infection Control Practitioner on 10/11/17 at 10:15 a.m. revealed Resident 30 was diagnosed with [REDACTED]. After explaining the observation of RN-A and RN-B providing wound care without protective equipment other than dispoable gloves on 10/5/17, RN-O stated the facility staff should wear gowns when performing this wound care and that gowns were available in a drawered cabinet outside of the resident's room. Observation with RN-O on 10/11/17 at 10:15 a.m. revealed a cabinet with drawers was positioned in the hall across from the resident's room and there were disposable gowns in the bottom drawer of the cabinet. B. Licensure Reference Number: 175 NAC 12-006.17 On 10/5/17 beginning at 6:40 a.m. an observation was conducted for Resident 30's wound care. The wound care and dressing changes for Resident 30 were performed by RN (Registered Nurse)-A and RN-B. Observations during the procedure revealed RN-A and RN-B were cleansing, treating, and dressing pressure ulcers to the resident's left buttock, left outer malleolus, right inner malleolus and heel. During the procedures, RN-A and RN-B were oberved cross contaminating clean surfaces of the dressing as follows: - RN-B removed the resident's dressing to the left buttock and changed gloves. RN-B cleansed the wound and disposed of gloves. RN-B applied another set of disposable gloves and opened a 4x4 (four inch by four inch guaze) dressing with gloved hands and removed the dressing. RN-B then placed the dressing on the bedside table, touching both top and bottom surfaces of the dressing, on top of the outer (potentially contaminated) portion of the 4x4 paper container. RN-B then placed the 4x4 guaze on a blue pad and saturated the guaze with normal saline. After changing gloves, RN-B picked up the saturated dressing again touching both top and bottom surfaces and placed the dressing on the resident's pressure ulcer. RN-B then opened an ABD (thick padded dressing) package with the gloved hands that placed the dressing and covered the wound. - RN-A removed dressing from Resident 30's left outer malleolus wound and disposed the saturated dressing in a plastic bag. RN-A removed gloves and applied a new pair and opened a container of a Calcium Alginate Dressing (treatment to dry wounds) with gloved hands and removed the Calcium Alginate dressing touching both top and bottom surfaces with the gloved hands. RN-A then took a pair of scissors and cut the dressing to the size of the wound holding on to the top and bottom of the dressing. RN-A than applied the Calcium Alginate to the open pressure wound. - RN-A removed dressing from Resident 30's right inner malleolus wound and disposed the saturated dressings in a plastic bag. RN-A removed gloves and applied a new pair and opened a container of a Calcium Alginate Dressing (treatment to dry wounds) with gloved hands and removed the Calcium Alginate dressing touching both top and bottom surfaces with the gloved hands. RN-A then took a pair of scissors and cut the dressing to the size of the wound holding on to the top and bottom of the dressing. RN-A than applied the Calcium Alginate to the open pressure wound. - RN-A removed dressing from Resident 30's right inner heal and disposed the saturated dressing in a plastic bag. RN-A removed gloves and applied a new pair and opened a container of a Calcium Alginate Dressing (treatment to dry wounds) with gloved hands and removed the Calcium Alginate dressing touching both top and bottom surfaces with the gloved hands. RN-A then took a pair of scissors and cut the dressing to the size of the wound holding on to the top and bottom of the dressing. RN-A than applied the Calcium Alginate to the open pressure wound. revealed these wounds had saturated the previous dressings with yellow, red, and brownish drainage. The procedures were observed from 6:40 a.m. concluding at 7:25 a.m. During the observation staff were observed applying and removing disposable gloves, but no other protective equipment was utilized by the staff. Record review of facility policy for Dressings, Dry/Clean revised in (MONTH) of 2009, the policy instructs staff on the methods to change and apply dressings to wounds. The Steps in the Procedure included the following instructions: - When removing soiled dressings, staff were instructed to Pull glove over dressing and discard into plastic or biohazard bag. - Wash and dry hands thoroughly (after removing and discarding soiled dressings). - Open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface (of the dressing and before applying gloves) - Using clean technique, open other products (i.e., prescribed dressing, dry, clean guaze. - Cleanse the wound. Use a syringe to irrigate the wound, if ordered. If using guaze, use a clean guaze for each cleansing stroke. - Apply ordered dressing and secure with tape. Interview with RN-O, the facility Infection Control Practitioner on 10/11/17 at 10:15 a.m revealed the facility staff were expected to follow facility policies for dressing changes. RN-O confirmed that opening and handling dressings used for cleansing a wound or for ordered treatment should be done when setting up for a dressing change prior to applying gloves and that surfaces of the dressings that were placed directly on the wounds should not be touched by staff as this could cause cross-contamination into wounds. C. Observations of Resident 14 revealed the following: - 10/5/17 at 10:40 a.m. the resident was up in a motorized chair being assisted with NA (Nurse Aide)-P and NA-Q for morning cares. During the observation, the resident's catheter (urinary device placed in the bladder to drain urine) tubing and bag was positioned on the floor in front of the wheelchair for a period of five minutes before the bag was picked up and placed in a container attached to the resident's motorized chair. - 10/11/17 at 7:25 a.m. the resident was observed being assisted with a mechanical lift transfer from the bed to the chair by staff members NA-K and MA (Medication Aide)-L. During the transfer, MA-L removed the resident's catheter bag from a container attached to the bed and placed it on the sling of the lift. The resident was then transferred into the wheelchair and NA-K removed the catheter bag and placed the bag directly on the floor in front of the resident's wheelchair while NA-K and MA-L removed the sling and positioned the resident in the motorized chair. At 7:28 a.m. NA-K then placed the catheter bag into the container on the resident's motorized chair. Interview with RN-O, the facility Infection Control Practitioner on 10/11/17 at 10:15 a.m confirmed catheter bags and tubing were not to come into contact with the floor as this could increase the potential for cross-contamination. RN-O stated facility procedures for mechanical lift transfers for catheterized residents was for one staff member to hold the bag to prevent the bag falling to the floor during the procedure and that the bag should not be attached to a lift sling as this may cross-contaminate the bag as well. D. Licensure Reference Number: 175 NAC 12-006.17D On 10/5/17 beginning at 6:40 a.m. an observation was conducted for Resident 30's wound care. The wound care and dressing changes for Resident 30 were performed by RN-A and RN-B. Observations during the procedure revealed the following related to disposable gloves and hand hygiene: -RN-A and RN-B assisting the resident in removing and disposing soiled dressings for pressure sores on the resident's left buttock, left outer malleolus, right inner malleolus and the right inner heel. Both RN-A and RN-B applied disposable gloves prior to removal of these dressings and disposed of the dressings in a plastic bag container and removed and disposed of the disposable gloves. Both RN-A and RN-B were observed donning clean disposable gloves after removal, without performing any hand hygiene between changes. - RN-B cleansed Resident 30's left buttock wound with a wound cleanser. Removed and disposed gloves without performing hand hygine. RN-B applied clean gloves and applied a wet to dry dressing to Resident 30's left buttock wound. Removed and disposed gloves without performing hand hygiene. RN-B then applied clean gloves and placed an ABD dressing over the wound and taped it down. Removed and disposed gloves without performing hand hygiene. - RN-A applied clean gloves and cleansed Resident 30s left outer malleolus wound with wound cleanser. Removed gloves and disposed them without performing hand hygiene. RN-A then put on clean gloves, opened a paper container of Calcium Alginate, cut the Calcium Alginate dressing to size of the wound, placed the Calcium Alginate dressing over the wound, placed a pink foam dressing over the wound, taped the wound, removed and disposed gloves without performing hand hygiene. - RN-A applied clean gloves and cleansed Resident 30s right inner malleolus wound with wound cleanser. Removed gloves and disposed them without performing hand hygiene. RN-A then put on clean gloves, opened a paper container of Calcium Alginate, cut the Calcium Alginate dressing to size of the wound, placed the Calcium Alginate dressing over the wound, placed a pink foam dressing over the wound, taped the wound, removed and disposed gloves without performing hand hygiene. - RN-A applied clean gloves and cleansed Resident 30s right inner heel wound with wound cleanser. Removed gloves and disposed them without performing hand hygiene. RN-A then put on clean gloves, opened a paper container of Calcium Alginate, cut the Calcium Alginate dressing to size of the wound, placed the Calcium Alginate dressing over the wound, placed a pink foam dressing over the wound and removed and disposed of the gloves. After the wounds were all dressed and covered, RN-A and RN-B went into the resident's bathroom and handwashed in the sink. Record review of the facility policy entitled: Handwashing/Hand Hygiene reivsed (MONTH) 2009 revealed instructions that: Employees must wash their hands for 20 seconds using antimocrobial or non-antimocrobrial soap and water under the following conditions . After removing gloves . The policy goes on to say that In most situations, the preferred method of hand hygiene is with an alcohol based hand rub containg 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations . After handling used dressings . After removing gloves . Interview with RN-O, the facility Infection Control Practitioner on 10/11/17 at 10:15 a.m confirmed that facility staff were expected to follow policies and procedures related to hand washing and hand hygiene. RN-O verified that when staff are using disposable gloves for tasks that when removing the gloves following a task, hand hygiene should be performed after removal and before applying clean gloves. E. Observations on 10/5/17 at 7:45 AM revealed RN - A donned disposable gloves and administered an insulin injection for Resident 35. RN - removed gloves, did not wash hands, and donned another pair of gloves to examine the resident's eye. F. Observations on 10/5/17 at 8:15 AM revealed RN - A prepared to administer an injection for Resident 51. RN - A did not wash hands, donned disposable gloves and administered the injection. Interview with the Director of Nursing on 10/11/17 at 8:25 AM confirmed that the nurses were to wash their hands before and after the use of disposable gloves to reduce the risk of cross contamination.",2020-09-01
493,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,463,D,0,1,T01F11,"Licensure Reference Number 175 NAC 12-006.04G Based on observations and interviews, the facility failed to ensure that call lights were functioning for three current sampled residents (Residents 48, 10 and 21). The facility census was 81 with 35 residents sampled for room observations. Findings are [NAME] Observations of Resident 48's bathroom on 10/4/17 at 9:45 AM revealed that the call light was not functioning. Interview with LPN (Licensed Practical Nurse) - S on 10/4/17 at 9:45 AM confirmed that the bathroom call light was not functioning. Interview with the Maintenance Director on 10/4/17 at 10:00 AM confirmed that the call light needed to be fixed. B. Observations of Resident 10's room on 10/4/17 at 9:50 AM revealed that the bedside call light was not functioning. Interview with LPN - S on 10/4/17 at 9:50 AM confirmed that the call light was not functioning and needed to be reset. C. Observations of Resident 21's room on 10/4/17 at 10:20 AM revealed that the bedside call light was not functioning. Interview with RN (Registered Nurse) - H on 10/4/17 at 10:20 AM confirmed that the bedside call light was not functioning and needed to be reset. Interview with the Director of Nursing on 10/11/17 at 9:40 AM confirmed that the residents' call lights needed to be functioning to ensure that they had access to the staff and that their needs were met.",2020-09-01
494,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,498,E,1,1,T01F11,"> Licensure Reference Number: 175 NAC 12-006.04 Based on record reviews, observation, and interviews, the facility failed to ensure facility direct care staff operating mechanical lifts demonstrated proficiency in safely performing the task per facility policies for four of four sampled employees. This failure could potentially result in unsafe transfers for 22 current residents (Residents 30, 29, 14, 97, 36, 40, 4, 9, 38, 54, 60, 1, 68, 8, 28, 44, 33, 52, 27, 2, 45, and 15) identified as being transferred with mechanical lifts. Facility census was 81. Findings are: Record review of a facility Investigation Report completed and forwarded to the State Agency on 8/7/17 revealed on 7/28/17 at 9:00 p.m. Resident 14 was being transferred in the full body lift and the lift tipped forward when the resident was in the lift over the bed. The resident experienced pain after the incident but x-rays revealed no fracture or dislocation. The resident reported to the DON (Director of Nursing) that the lift was the wrong angle, the lift went down on (the resident) The investigation identified NA's (Nurse Aides) M and N were assisting the resident during the transfer. The investigation went on to further record NA-M and NA-N were educated on 7/28/17 by a charge nurse on the lift policy and proper use of transfer and to stay with new staff during orientation process as NA-N was new and maybe did not know not to extend the lift hydrolic (sic) so high with a heavier resident. Observation of Resident 14's mechanical lift transfer on 10/11/17 beginning at 6:30 a.m. revealed NA-K and MA-L assisted the resident with the transfer from bed to chair without the assistance of a third staff member as directed on the resident's care plan. Record review of Resident 14's Care plan initiated on 2/13/17 revealed updated entries which read: - An entry for the problem of Risk for falls recorded an updated entry of: Requires full lift/standing machine and documented near miss fall- resident in lift getting ready for bed. Lift got off center and tipped sideways . - An entry for the problem Resident Preferences recorded on 7/29/17 instructed the staff to use: 3 assist with full lift for transfers. - An undated entry under a problem for Self Care Deficit provided instructions regarding: Transfer Full lift c (with) 3 assist for safety. Interviews with NA-K and MA-L following the resident's transfer on 10/11/17 at 7 a.m. revealed that NA-K was hired by the facility in (MONTH) of (YEAR) and MA-L was hired by the facility in (MONTH) of (YEAR). Both employees described going through an orientation at the facility. When questioned how they received training on using mechanical lifts both stated they watched videos. When questioned if the staff members were required to demonstrate proficiency in the use of facility mechanical lifts they both responded they hadn't. When questioned if when being a new employee providing direct care they were paired with experienced staff members, both stated not always, often they worked in pairs with another new employee. Interview with the facility (URC) Utilization and Review Coordinator on 10/11/17 at 10:15 a.m. The URC described the newly hired employee process for education on use of mechanical lifts. The URC stated the employees are given videos to watch, and then they do hands on demonstrations with the URC of proficiency to ensure the new employees are competent in using the devices. The URC provided a copy of the New Hire Orientation document used by the facility which included items for body mechanics and safety and described each new employee received a New Hire Information document describing facility resident transfers policies. The URC verified there was no documentation or evidence to confirm new employees demonstrated the safe use of mechanical lifts and to ensure staff understood facility transfer policies. The URC stated that there is a one hour video training noted on orientation forms entitled Relias Training Orientation. Record reviews of four sampled employee orientation records revealed the following: - NA- M's New Hire Orientation form revealed the staff member was hired on 5/3/17. The orientation form revealed the staff member recorded and signed on 5/3/17 as having received or completed a Relias Training Orientation which included a 1 hour video training on Safe Use of Mechanical lifts There was no documentation NA-M received training or competency demonstrations on the use of mechanical lifts. - NA- N's New Hire Orientation form revealed the staff member was hired on 7/24/17. The orientation form revealed the staff member recorded and signed on 5/3/17 as having received or completed a Relias Training Orientation which included a 1 hour video training on Safe Use of Mechanical lifts There was no documentation NA-M received training or competency demonstrations on the use of mechanical lifts. - NA- K's New Hire Orientation form revealed the staff member was hired on 8/11/17. The orientation form revealed the staff member recorded and signed on 5/3/17 as having received or completed a Relias Training Orientation which included a 1 hour video training on Safe Use of Mechanical lifts recorded as having been done on 8/14/17. There was no documentation NA-M received training or competency demonstrations on the use of mechanical lifts. - NA- M's New Hire Orientation form revealed the staff member was hired on 5/3/17. The orientation form revealed the staff member recorded and signed on 5/3/17 as having received or completed a Relias Training Orientation which included a 1 hour video training on Safe Use of Mechanical lifts There was no documentation NA-M received training or competency demonstrations on the use of mechanical lifts. - MA-L's New Hire Orientation form revealed the staff member was hired on 3/27/17. The orientation form revealed the staff member recorded and signed on 5/3/17 as having received or completed a Relias Training Orientation which included a 1 hour video training on Safe Use of Mechanical lifts There was no documentation NA-M received training or competency demonstrations on the use of mechanical lifts. Second interview with the URC on 10/11/17 at 11:15 a.m. confirmed that the four sampled employee files (NA-M; NA-N; NA-K, and MA-L) had not included any verification that these employees received any hands-on education and demonstrated competency in the use of mechanical lifts.",2020-09-01
495,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2017-10-11,520,E,0,1,T01F11,"Licensure Reference Number 175 NAC 12-006.07C Based on observations, interviews, and record reviews; the facility's QA (Quality Assurance) Committee QA failed to identify, develop and implement plans of action to correct deficient practice relevant to resident care and services. The facility failed to implement effective plans of action to maintain correction for 2 previously cited areas of deficient practice identified. Census was 81. Findings Are: The facility was found to be deficient in multiple areas of regulatory compliance for cited tags at: F157- failure to notify family for resident change of condition. F164- failure to provide privacy during cares. F226- failure to complete and send investigative reports per required time frames. F246- Provision of call lights within resident reach. F253- physical environment condition of rooms. F279- failure to develop resident care plans for identified problems/concerns. F282- Following care plan interventions for mechanical lift instructions. F309- failure to monitor blood pressures and providing pain assessments for residents with active symptoms. F323- failure to implement fall interventions for residents at high risk for falling and ensuring oxygen concentrators were not left on when unattended. F425- failure to ensure medications were available for residents when ordered and following standards of practice for medication administration. F431- failure to ensure medication labels matched physician orders. after the standard survey completed on 10/11/2017. F441- failure to ensure isolation policies were followed, ensuring that handwashing/gloving procedures were followed. F498- failure to ensure facility staff were competency tested and deemed proficient at mechanical lift use. The facility failed to maintain correction for the regulations identified as repeat deficiencies: F332 Free of medication error rates of 5% or more and F425 Pharmaceutical Services medications provided as ordered Interview with the Assistant Director of Nursing on 10/11/2017 11:27 AM confirmed that the facility Quality Assurance Committee has difficulty identifying issues and maintaining correction on past deficiencies due to the change over in the Leadership of the Committee.",2020-09-01
496,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,622,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a (7) Based on record reviews and interviews, the facility failed to record the circumstances leading to resident hospital discharges for two sampled residents (Residents 12 and 28). Facility census was 89. Sample size was 23 current residents. Findings are: [NAME] Record review of Resident 12's Face Sheet printed on 11/27/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 12's MDS (Minimum Data Set, a federally mandated tool utilized for facility tracking data) records revealed: Resident 12 was discharged from the facility to a hospital on [DATE] and returned to the facility from the hospital on [DATE]. Record review of Resident 12's Departmental Notes revealed the following entries: 9/25/18 at 5:34 a.m. the resident was started on [MEDICATION NAME] (medication used for bowel infection associated with diarrhea and [MEDICAL CONDITION] (inflamed bowel)). 9/25/18 at 10:34 a.m. a bath weight was taken. 9/25/18 at 11:30 a.m. the entry recorded the resident's stool culture was negative. Continued with yellow stools, diarrhea, nausea/vomiting and headaches. Will try a celiac (Gluten Free/Dairy Free) diet. Spoke with resident and dietary director and left message with family. 9/25/18 at 12:14 p.m. the entry recorded speaking with family member about diet trial. Res to have an appointment with a [MEDICATION NAME] on 10/8/18 and resident's spouse will meet resident at appointment. No further entries were recorded until 9/29/18 at 4:32 p.m. this entry recorded the resident returned from the hospital at 12:00 noon. There were no entries on 9/26/18 describing the circumstances, discussions with family or physician regarding sending the resident to the hospital. There were no entries describing the condition of the resident precipitating a hospitalization on [DATE]. B. Record review of Resident 28's Face Sheet printed on 11/27/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 28's MDS tracking assessments revealed Resident 28 was transferred from the facility to a hospital on [DATE] and returned from the hospital, back to the facility on [DATE]. Record review of Resident 28's Departmental Notes revealed the following entries: 10/18/18 at 6:30 p.m. the note recorded the resident was seen by a physician in-house today. no new orders. The note went on to record the resident was attempting to exit the building and grabbing on to other resident's wheelchairs. 10/19/18 at 1:31 p.m. the entry recorded the resident was experiencing behaviors, bumping wheelchair into others, difficult to redirect, entering areas (other resident rooms, behind nurses' station, and exit doors). 10/19/18 at 1:37 p.m. the entry recorded the resident vomited after breakfast and temperature rose to 100.4 degrees by 11 p.m. Clear liquids were ordered for lunch. A Nurse Practitioner evaluated the resident and diagnosed gastroenteritis and ordered lab work and to push fluids. The family member was notified. There were no further entry regarding the resident until 10/23/18 at 6:40 p.m. recording the resident was readmitted to the facility from the hospital at 11:45 a.m. There were no entries on 10/19/18 describing the circumstances, discussions with family or physician regarding sending the resident to the hospital. There were no entries describing the condition of the resident precipitating a hospitalization on [DATE]. Interviews with the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) on 11/29/18 at 7:58 a.m. confirmed Resident 12 was admitted to the hospital on [DATE] and Resident 28 was admitted to the hospital on [DATE] and the staff had not documented in the medical records for these residents regarding the circumstances, family/physician discussions, or condition of the residents precipitating their hospitalization s.",2020-09-01
497,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,623,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 - NAC .05 Based on record reviews and interviews, the facility failed to provide notice in writing for two sampled residents (Resident #66 and Resident #79) or their personal representatives, and the State Ombudsman regarding discharge to the hospital. Facility census was 89. Sample included 23 current residents. Findings are: [NAME] Record review of Resident #66 Face Sheet printed on 11/27/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident #66 MDS (Minimum Data Set, a federally mandated comprehensive assessment and tracking tool) revealed the resident was discharged to an Acute hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #66 electronic medical record and chart revealed no documentation regarding discharge to an acute hospital. The resident or resident's representative was not notified in writing regarding the hospital discharge. There was no documentation in the resident's medical record the State Ombudsman was notified in writing of Resident #66's discharge to the hospital. Record review of Resident #66 Progress Note revealed an entry on 7/13/18 at 7:43 p.m. resident to emergency room due to behaviors and stating staff wanted to kill Resident #66 and Resident #66 wanted to kill staff. Resident #66 was admitted to the Hospital. Record review of Resident #66 Progress Note revealed an entry on 7/17/18 at 8:37 p.m. Resident #66 readmitted to facility, transported back by facility van. Hospital stay [DIAGNOSES REDACTED]. Staff interview on 11/28/18 at 2:35 p.m. with the SSD (Social Services Director) revealed that no letters documenting the notification of the resident or the resident's representative had been sent. SSD also verified the State Ombudsman was not notified in writing of Resident #66's discharge to the hospital. B. Record review of Resident #79 Face Sheet printed on 11/27/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident #79's MDS (Minimum Data Set, a federally mandated comprehensive assessment and tracking tool) revealed the resident was discharged to an Acute hospital on [DATE] and Returned to the facility on [DATE]. Record review of Resident #79's electronic medical record and chart revealed no documentation of the discharge to an acute hospital. The resident or resident's representative was not notified in writing regarding the hospital discharge. There was no record the State Ombudsman was notified in writing of Resident #79's discharge to the hospital. Record review of Resident 79's Progress Note revealed no entry of the date of discharge to the hospital, but progress note dated on 10-9-18 discussed the resident being NPO (Nothing Through Mouth) after midnight and morning before the surgery. Progress note dated 10-17-18 Resident 79 returns from the hospital after ostomy placement in RLQ (Right Lower Quadrant). Resident ostomy site upon assessment clean dry and intact. Staff interview on 11/28/18 at 3:17 p.m. SSD ( Social Services Director) revealed that no letters notifying the resident or the resident's representative had been sent. SSD also verified the State Ombudsman was not notified in writing of Resident #79's discharge to the hospital. Staff interview on 11/28/18 at 2:42 p.m. DON and Administrator verified the facility had failed to provide notice in writing to Resident #66 and Resident # 79 and the resident's representatives of discharge to the hospital. It was also verified by the DON and Administrator the State Ombudsman was not notified in writing of Resident #66 and Resident #79's discharge to the hospital.",2020-09-01
498,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,625,E,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide the resident or resident representative written notice of the facility's bed-hold policy following transfers to the hospital for 7 current residents (Residents 12, 28, 38, 42, 66, 79, and 81). Facility census was 89. Sample size was 23 current residents. Findings are: [NAME] Record review of Resident 12's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 12's tracking MDS (Minimum Data Set, a federally mandated tracking tool) records revealed Resident 12 was discharged to a hospital on [DATE] and readmitted to the facility, from the hospital on [DATE]. Record review of Resident 12's medical record revealed no documentation of a written facility bed-hold policy provided to the resident or the resident representative during the hospital stay from 9/26/18 to 9/29/18. B. Record review of Resident 12's Face Sheet revealed the resident was admitted to the facility on [DATE] . Record review of Resident 28's tracking MDS records revealed the resident was discharged to a hospital on [DATE] and readmitted to the facility from the hospital on [DATE]. Record review of Resident 28's medical record revealed no evidence of a written facility bed-hold policy being provided to the resident or resident representative during the hospital stay from 10/19/18 to 10/23/18. C. Record review of Resident 38's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 38's tracking MDS (Minimum Data Set, a federally mandated tracking tool) records revealed the resident was discharged to a hospital on [DATE] and readmitted to the facility from the hospital on [DATE]. Further review of the records revealed the resident was again discharged from the facility to a hospital on [DATE] and readmitted to the facility from the hospital on [DATE]. Record review of Resident 38's medical record revealed no documentation of a written facility bed-hold policy being provided to the resident or the resident representative during the hospital stays from 7/18/18 to 7/22/18 and again on 10/14/18 to 10/17/18. D. Record review of Resident 42's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 42's tracking MDS records revealed the resident was discharged to a hospital on [DATE] and readmitted to the facility from the hospital on [DATE]. Record review of Resident 42's medical record revealed no documentation of a written facility bed-hold policy being provided to the resident or the resident representative during the hospital stay from 9/5/18 to 9/9/18. Interview with the facility SSD (Social Service Director) verified there was no documentation in the medical records that Residents 12, 28, 38, and 42 had received written notice of the facility's bed-hold policy during transfers and admissions for hospital stays. E. Record review of Resident #66's Face Sheet printed on 11/27/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident #66's tracking MDS (Minimum Data Set, a federally mandated tracking tool)records revealed the resident was discharged to a hospital on [DATE] and readmitted to the facility from the hospital on [DATE]. Record review of Resident # 66's medical record revealed no documentation of a written facility bed-hold policy being provided to the resident or the resident representative during the hospital stay from 9/26/18 to 9/29/18 F. Record review of Resident #79's Face Sheet printed on 11/27/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident #79's MDS (Minimum Data Set, a federally mandated tracking tool) records revealed the resident was discharged to a hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #79's medical record revealed no documentation of a written facility bed-hold policy being provided to the resident or the resident representative during the hospital stay from 10/10/18 to 10/16.18 Staff interview on 11/28/18 at 3:17 p.m. with the facility SSD (Social Services Director) verified there was no documentation in the medical records that Resident's 66 and 79 had received written notice of the facility's bed-hold policy during transfers and admissions for hospital stays. Example G During an interview with Resident # 71 on 11/27/18 at 1:45 PM, the resident revealed a recent hospitalization for internal bleeding . An interview on 11/28/18 at 4:20 PM with RN (Registered Nurse)-B revealed that this resident was transferred to the local emergency room based on the resident's request to be seen by a doctor on 9/29/18. RN-B verified that the decision to admit the resident to the hospital was made in the emergency room , and the facility was made aware of that decision the evening of 9/29/18. Record review of the resident's Face Sheet printed 11/27/18 showed [DIAGNOSES REDACTED]. The Face Sheet also showed a hospital stay at Great Plains Regional from 9/29/18 through 10/4/18 Further review revealed Transition Orders and Information for the Continuation of Patient Care which showed that Resident 71 was admitted to Great Plains hospital on [DATE] and was discharged on [DATE]. Record review did not reveal any notification of the bed hold procedure in Resident 71's record. An interview with the Social Worker for the facility on 11/29/18 at 10:00 AM verified that no bed hold agreement had been provided to this resident. An interview with the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) on 11/29/18 at 10:10 AM verified that if the Social Worker could not find a copy of the bed hold notice it had not been done as the Social Worker was responsible to maintain these records.",2020-09-01
499,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,656,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews, and interviews; the facility failed to develop a comprehensive care plan for 2 sampled residents (Resident #77 and Resident #71). The facility census 89 residents. Sample size 23 residents. Findings are: [NAME] On 11/28/18 at 01:40 PM an observation of RN-B and LPN-L performing wound care revealed: a pressure ulcer to the coccyx and an open area to the R hip of Resident#77. On 11/28/18 at 03:42 PM a review of the face sheet for Resident #77 revealed a [DIAGNOSES REDACTED]. On 11/28/18 at 03:42 PM a review of the care plan for Resident #77 revealed I have a sacral decubitis ulcer stage 3, see TAR (Treatment Administration Record) for tx (treatment) d/c (discontinue) 11/26/18; I have a sacral decubitis ulcer, unstageable - please see MAR (Medication Administration Record) for dressing change orders 11/26/18; and wound nurse will perform my skin assessment weekly. The record review revealed the care plan for Resident #77 was not developed specifically related to skin condition, wound care, or interventions, and had no related measurable goals. On 11/28/18 at 3:42 PM a review of the Skin Inspection Report for Resident #77 revealed the resident was admitted on [DATE] with an existing skin concern. The report also revealed a new skin concern on 10/15/18. On 11/28/18 at 3:42 PM a review of the Wound Assessment Report revealed wound assessments performed and documented for Resident #77. On 11/28/18 at 02:45 PM an interview with the Director or Nursing (DON) and LPN-I, the Assistant Director of Nursing (ADON) confirmed a comprehensive care plan was not developed for Resident #77 specifically related to skin condition, wound care, or interventions, and had no related measurable goals. On 11/28/18 at 04:30 PM an interview with RN-B confirmed a comprehensive care plan was not developed for Resident #77 specifically related to skin condition, wound care, or interventions, and had no related measurable goals. On 11/28/18 at 04:45 PM an interview with MA-A confirmed a comprehensive care plan was not developed for Resident #77 specifically related to skin condition, wound care, or intervention, and had no related measurable goals. On 11/28/18 at 05:00 PM an interview with the Administrator confirmed a comprehensive care plan was not developed for Resident #77 specifically related to skin condition, wound care, or interventions and had no related measurable goals. Example B In an interview on 11/26/18 at 6:21 PM, Resident 71 revealed [MEDICAL TREATMENT] (the process of removing excess water, solutes, and toxins from the blood of people whose kidneys can no longer perform these functions effectively) was performed at a local [MEDICAL TREATMENT] facility on Monday, Wednesday, and Friday afternoons. A fistula (a surgical joining of an artery and vein to create an access point for [MEDICAL TREATMENT]) was observed in the resident's left upper arm. On 11/28/18 at 11:00 AM an interview with MA (Medication Aide)-A and NA (Nurse Aide)-H revealed these two direct care staff members were able to state which days Resident 71 went to [MEDICAL TREATMENT] and resident was on a fluid restriction. However, both MA-A and NA-H were unclear about how much fluid should be provided to the resident in the room or with medications. NA-H stated that the resident could have 4 ounces of fluid at a time while MA-A stated that the fluid limit was 1500 cc daily but could not say how much could be given each shift by nursing. Both of these staff members MA-A and NA-H stated that they did not know where the resident's [MEDICAL TREATMENT] fistula was located so that the other arm would be used when checking the resident's blood pressure. Record review of Resident 71's Face Sheet printed 11/27/18 showed [DIAGNOSES REDACTED]. The Care Plan for this resident did not include kidney disease or [MEDICAL TREATMENT] as specific problems. However, under a problem related to diet there were interventions including: on a 1500 cc fluid restriction and go to [MEDICAL TREATMENT] 3 times a week. The goal listed for this problem was to get enough nutrition for wound to heal. Approaches did include monitoring of the fistual every shift but did not say where the fistula was located. Other approaches were related to diet and diabetes. There were no dates documented to indicate when the problem began and no target dates or measurable goals included in this portion of the care plan. Also on the Care Plan under Smart Chart Scheduled Care Task was an approach: the resident could have 240 ml per shift in room with a 1200 ml fluid restrictions. An interview with LPN (Licensed Practical Nurse)-I who served as the facility's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used to develop resident care plans) coordinator on 11/28/18 at 11:30 AM verified that the Care Plan was not developed to address this resident's kidney disease and [MEDICAL TREATMENT] related care. On 11/29/18 at 10:10 AM in interview, the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) verified that the care plan for this resident was not developed to be comprehensive with specific measurable objectives and timeframe's related to kidney disease and [MEDICAL TREATMENT] care. The DON acknowledged multiple concerns which should be addressed on the care plan including but not limited to the location of the fistula and the need to monitor the site for bleeding, days on which [MEDICAL TREATMENT] is performed, and accurate information related to fluid restriction.",2020-09-01
500,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,695,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, interviews, and record review, the facility failed to provide oxygen therapy as required for one sampled resident (Resident 72). Facility census was 89. Sample size was 23. Findings are: On 11/26/18 at 5:15 PM Resident 72 was observed in the dining room sitting in a wheelchair and wearing a nasal cannula (a device used to provide supplemental oxygen directly to the nose) which was connected to a portable oxygen tank. However, the pressure gauge on the regulator (a device used to control and measure the amount of oxygen being administered from a portable oxygen system) was in the red which indicated that the tank needed to be replaced as it no longer contained enough oxygen for the resident. Observation on 11/27/18 at 9:00 AM revealed resident sitting in a wheelchair in the dining room using a portable oxygen tank. The gauge on the regulator on the tank was in the red and indicated that the tank needed to be replaced. On 11/27/18 at 9:35 AM, the resident was observed at an exercise activity, and the gauge remained in the red area showing the tank needed to be replaced. On 11/28/18 at 8:40 AM an interview with MA (Medication Aide)-A revealed that portable oxygen tanks should be checked by the MA when residents come to the dining room for meals to verify that there is enough oxygen available for the resident while using the portable tank. MA-A revealed that there was no system in place to check when portable oxygen tanks were changed. Observation on 11/29/18 at 8:10 AM found the resident in the dining room using a portable oxygen tank with the gauge on the regulator in the red indicating that the tank needed to be replaced. On 11/29/18 at 8:20 AM an interview with the DON (Director of Nursing) verified that the gauge on Resident 72's portable oxygen tank was in the red indicating that the tank needed to be replaced because it did not contain sufficient oxygen to meet the resident's needs. An interview on 11/29/18 at 10:10 AM with the DON and the ADON (Assistant Director of Nursing) verified that Resident 72 was not receiving oxygen as ordered due to portable oxygen tanks not being replaced when necessary. Record review revealed that Resident 72's Face Sheet printed 11/27/18 showed [DIAGNOSES REDACTED]. Review of the e-Medication (Administration Record) for (MONTH) (YEAR) showed an order to check the portable oxygen tank and replace if empty or if not write down amount left in tank for dayshift nurse at hs (hour of sleep) daily.",2020-09-01
501,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,812,F,0,1,0WID11,"Licensure Reference Number 175 NAC 12-006.11E Based on observations and interviews; the facility failed to practice effective hand hygiene and failed to prevent cross contamination during meal service. This failure had the potential to affect all residents who consumed food and meals from the dining room. Facility census was 89. [NAME] Findings are: Dining observation on 11/27/18: At 11:56 AM, RN-B presented to the kitchen service window with a tray to be prepared for Resident #29. RN-B performed hand hygiene prior to serving lunch meal to Resident #29. At 11:59 AM, MA-A presented to the kitchen service window with a tray to be prepared for Resident #78 and Resident #46. No hand hygiene was performed prior to serving lunch meal to Resident #78 and Resident #46. At 12:05 PM, RN-C presented to the kitchen service window with a tray to be prepared for Resident #81. RN-C performed no hand hygiene prior to serving the lunch meal to Resident #81. At 12:07 PM, RN- B presented to the kitchen service window with a tray to be prepared for Resident #79. While waiting for the tray to be completed, RN-B was observed to have hands in and out of own pockets and no hand hygiene was performed prior to serving the lunch meal to Resident #79. At 12:09 PM, NA-D presented to the kitchen service window with a tray to be prepared for Resident #63. No hand hygiene was performed prior to serving the lunch meal to Resident #63. At 12:11 PM, RT-E presented to the kitchen service window with a tray to be prepared for Resident #31 and Resident #11. No hand hygiene was performed prior to serving the lunch meal to Resident #31 and Resident #11. At 12:14 PM, RT-F presented to the kitchen service window with a tray to be prepared for Resident #65 and Resident #64. No hand hygiene was performed prior to serving the lunch meal to Resident #65 and Resident #64. 11/27/18 03:00 PM Interview with the Certified Dietary Manager confirmed hand hygiene was not performed by staff during service of lunch meal to residents in the main dining room. 11/27/18 05:15 PM Interview with the Director of Nursing confirmed hand hygiene was not performed by staff during service of lunch meal to residents in the main dining room. 11/28/18 04:23 PM Interview with the Administrator confirmed hand hygiene was not performed by staff during service of lunch meal to residents in the main dining room. B. Findings are: Special Care Unit Kitchen observations on 11/26/18: At 05:35 PM CNA-J performed appropriate hand washing technique and entered the SCU (special care unit) kitchen. No gloves worn. Drinks were poured. Reuben sandwiches temped at 164 degrees. CNA-J removed the thermometer from the Reuben sandwiches, wiped the thermometer with a table napkin, and use the thermometer to temp the french fries. The french fries temped at 168 degrees. CNA-J removed the thermometer from the french fries and wiped it with the same table napkin used to wipe it after temping the Reuben sandwiches, and then temped the vegetables with the same thermometer. When asked if that procedure was the proper procedure for cleaning the thermometer between separate food items, CNA-J replied, Well, it's not what I normally use but I don't have any of the wipes. CNA-J removed plates from a drawer and placed them on the countertop, placed wrapped silverware onto the countertop, then placed trays onto the counter top. CNA-J placed two resident tickets on a tray, portioned food items onto the plates, placed plates on the serving tray along with the wrapped silverware and drinks. MA-K served the plates to the residents at the table. CNA-J, placed service tickets for Resident #80 and Resident #33, portioned foods onto plates. MA-K presented service window and requested ketchup. CNA-J stopped portioning foods onto plates, went to the refrigerator, pulled out BBQ sauce, returned it to the shelf of refrigerator, then retrieved the ketchup, handed it to MA-K, returned to portioning food/drink for Resident #80 and Resident #33, without performing hand hygiene. CNA-J left the kitchen and served Resident #80 and Resident #33. CNA-J returned to the kitchen and began portioning the food for Resident #7. MA-K served Resident #7. CNA-J went to the refrigerator and removed a bag of grapes, rinsed the grapes off in water, removed a bowl full of grapes from the vine for Resident #17. CNA-J placed the bowl of grapes and half a sandwich on a plate to be served to Resident #17. MA-K served the tray to Resident #17. CNA-J performed proper handwashing technique prior to beginning service of the lunch meal. No further hand hygiene was performed throughout the entirety of the meal service. 11/27/18 03:00 PM Interview with the Dietary Manager confirms cross contamination, lack of hand hygiene, and not sanitizing thermometer between foods when temping. 11/27/18 05:15 PM Interview with the Director of Nursing confirmed cross contamination, lack of hand hygiene, and not sanitizing thermometer between foods when temping. 11/28/18 04:23 PM Interview with the Administrator confirmed cross contamination, lack of hand hygiene, and not sanitizing thermometer between feeds when temping.",2020-09-01
502,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,880,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17B Based on observations, interviews, and record review, the facility failed to store oxygen tubing and nebulizer (a drug delivery system used to administer medication in the form of a mist inhaled into the lungs) tubing and face mask to prevent possible cross contamination for one sampled resident (Resident # 72). Facility census was 89. Sample size was 23. Findings are: prevent possible cross contamination. Record Review revealed that Resident 72's Face Sheet printed on 11/27/18 showed [DIAGNOSES REDACTED]. The e-Medication (Administration Record) for (MONTH) (YEAR) showed an order for [REDACTED]. Observation on 11/26/18 at 2:40 PM revealed Resident 72 resting in bed and wearing a nasal cannula (a device used to provide supplemental oxygen directly to the nose) which was not connected to any tubing. Oxygen tubing was connected to an oxygen concentrator (a device, which concentrates oxygen from the ambient air to provide increased oxygen concentrations for inhalation) on one end, but the end which should have been connected to the resident's nasal cannula was lying on the floor next to the concentrator. At the same time, a nebulizer machine with tubing and a face mask attached to it was sitting in a chair next to the concentrator. Another observation on 11/26/18 at 3:40 PM showed no changes in the location of the resident's oxygen tubing and nebulizer with its tubing and face mask. Observation on 11/27/18 at 9:00 AM revealed the resident's oxygen tubing with the nasal cannula attached lying on top of the oxygen concentrator and not covered or contained in any way. The nebulizer with its tubing and face mask attached was sitting in the chair next to the concentrator with a blanket resting on top of it. Another observation on 11/27/18 at 1:10 PM showed the oxygen tubing with the nasal cannula attached stored on top of the concentrator uncovered and the nebulizer with its tubing and face mask attached sitting in the chair. Observation on 11/28/18 at 8:50 AM showed the resident's oxygen tubing and nasal cannula on top of the concentrator and not covered in any way, and the nebulizer machine with its tubing and face mask in the chair with a pressure relieving boot resting on top of it. An interview on 11/28/18 at 9:30 AM with RN (Registered Nurse)-G who served as the facility infection control co-coordinator, verified Resident 72's oxygen tubing and nebulizer supplies were not being stored correctly to prevent possible cross contamination. RN-G stated nebulizer tubing and face mask should be rinsed after each use and stored in the plastic storage box labeled for this purpose which was empty and found sitting on top of the TV cabinet, and the nebulizer equipment remained in the chair. RN-G also verified that the oxygen tubing and nasal cannula should be stored in the mesh bag attached to the back of the oxygen concentrator when not in use by the resident. An interview on 11/29/18 at 10:10 AM with the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) verified that oxygen tubing should be stored in the mesh bag when not in use and that nebulizer tubing and face mask should be rinsed after use and then stored in a closed container to prevent possible cross contamination.",2020-09-01
503,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,921,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.18A Based on observations and interviews, the facility failed to ensure the ceiling was free from chipping and falling paint and texture in one Resident's (Resident 15) room [ROOM NUMBER]B. Facility census was 89. Sample size was 23 current residents. Findings are: Observation on 11/27/18 at 11:05 a.m. in Resident 15's room [ROOM NUMBER]B had chipping paint and plaster on the ceiling, next to the curtain divider. Observation on 11/29/18 at 8:23 a.m. in Resident 15's room [ROOM NUMBER]B had chipping paint and plaster on the ceiling, next to the curtain divider Resident interview on 11/29/18 at 8:23 a.m. Resident 15 revealed the chipping paint and plaster in the room had been that way for sometime now. Staff interview on 11/29/18 at 9:26 a.m. Maintenance Supervisor and DON verified the paint and plaster was chipping in Resident 15's room [ROOM NUMBER]B.",2020-09-01
504,HILLCREST NURSING HOME,285080,"P O BOX 1087, 309 WEST 7TH STREET",MCCOOK,NE,69001,2018-11-29,923,D,0,1,0WID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-007.04D Based on observations and interviews, the facility failed to provide a working ventilation system to prevent the concentration of odors for 3 sampled resident rooms (Resident 38 in room [ROOM NUMBER] A, Resident 82 in room [ROOM NUMBER] B and Resident 12 in room [ROOM NUMBER] A). Facility census was 89. Sample Size was 23 current residents. Finding are: [NAME] Observation on 11/27/18 at 9:26 a.m. Resident 38's bathroom vent in room [ROOM NUMBER] A in was not operational as a one ply tissue test was completed and it did not pull the tissue up. Observation on 11/29/18 at 9:26 a.m. Resident 38's bathroom vent in room [ROOM NUMBER] A in was not operational as a one ply tissue test was completed and it did not pull the tissue up. Staff interview on 11/29/18 at 9:28 a.m. Maintenance Supervisor and DON verified that the vent in Resident 38's bathroom in room [ROOM NUMBER] A was not operational. B. Observation on 11/27/18 at 9:26 a.m. Resident 82's bathroom vent in room [ROOM NUMBER] B in was not operational as a one ply tissue test was completed and it did not pull the tissue up. Observation on 11/29/18 at 9:26 a.m. Resident 82's bathroom vent in room [ROOM NUMBER] B in was not operational as a one ply tissue test was completed and it did not pull the tissue up. Staff interview on 11/29/18 at 9:28 a.m. Maintenance Supervisor and DON verified that the vent in Resident 82's bathroom in room [ROOM NUMBER] B was not operational. C. Observation on 11/27/18 at 12:12 p.m. Resident 12's bathroom vent in room [ROOM NUMBER] A in was not operational as a one ply tissue test was completed and it did not pull the tissue up. Observation on 11/29/18 at 9:27 a.m. Resident 12's bathroom vent in room [ROOM NUMBER] A in was not operational as a one ply tissue test was completed and it did not pull the tissue up. Staff interview on 11/29/18 at 9:28 a.m. Maintenance Supervisor and DON verified that the vent in Resident 12's bathroom in room [ROOM NUMBER] A was not operational.",2020-09-01
505,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,550,E,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to knock and request permission to enter Resident 66's room and exposed Resident 68 and left their door open during a medical procedure. This affected 2 of 2 sampled residents. The facility identified a census of 16 at the time of survey. Findings are: A. Review of Resident 66's Care Plan revealed an admission date of [DATE]. Observation of Resident 66 on 12/31/19 at 1:45 PM revealed they were sitting in their recliner in their room talking with visitors. NA-H (Nurse Aide) walked into 66's room and did not knock or request permission to enter. NA-H walked in and said I have to chart and went to the computer in the corner of the room and started working with it. B. Review of Resident 68's initial MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/20/2019 revealed an admission date of [DATE]. Observation of Resident 68 on 1/02/20 at 10:32 AM revealed RN-F (Registered Nurse) administered an injection into Resident 68's belly after pulling up their shirt and exposing their belly. Resident 68's door was open. Resident 68 was lying in the bed and was visible to the hall and potential passersby. Review of the facility policy Patient Rights and Responsibilities dated 2/2019 revealed the following: It is the policy (facility) to honor patient rights and support patients in meeting their responsibility. Patient rights and responsibilities are defined according to the following goals: Dignity and respect; privacy and confidentiality. Interview with RN-B on 1/06/20 at 12:54 PM revealed the privacy curtain should have been pulled or the door closed while RN-F was administering the injection to Resident 68. Staff were to take residents to a private place when doing medical procedures and that would apply in the room as well. It was RN-B's expectation that staff knock and request permission to enter a resident's room and wait for a response before entering.",2020-09-01
506,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,584,E,0,1,5VOC11,"LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.18 Based on observation, interview, and record review; the facility staff failed to maintain a clean environment by failing to clean the light fixtures, exhaust fan covers and a feeding tube pole. This affected 3 of 3 sampled residents (Residents 67, 14 and 11). The facility identified a census of 16 at the time of survey. Findings are: A. Observation of Resident 67's room on 12/31/19 at 3:09 PM revealed there were dead insects in the light fixture in the bathroom. Observation of Resident 67's room on 1/06/20 at 12:16 PM with the HS (Housekeeping Supervisor) confirmed there were dead insects in the light fixture in the bathroom. B. Observation of Resident 14's room on 12/31/19 at 3:07 PM revealed there were dead insects in the light fixture in the bathroom and the bathroom exhaust cover was soiled with gray debris. Observation of Resident 14's room on 1/06/20 at 12:18 PM with the HS confirmed there were dead insects in the light fixture covers and the bathroom exhaust cover had gray debris on it. Interview with the HS on 1/06/20 at 12:18 PM revealed housekeeping staff was supposed to be cleaning the bathroom exhaust fan covers. The HS revealed it was their expectation that the exhaust fan covers were cleaned. Interview with the HS on 01/06/20 at 2:10 PM revealed the facility staff were supposed to notify maintenance when the lights needed to be cleaned. Review of the facility policy How to Clean a discharged Patient Room revealed the following: High dust with microfiber sleeve high duster in room and rest room: vents Review of the undated facility policy Daily Patient Room Cleaning revealed the following: no direction for cleaning vents. C. Observation of Resident 11's room on 12/31/19 at 10:32 AM revealed there was cream colored spillage on the base of the pole that held a feeding tube pump. Observation of Resident 11's feeding tube pump pole with the DON (Director of Nursing) on 01/06/20 at 02:43 PM revealed it had cream colored spillage on it. Interview with the DON at this time revealed it was their expectation that it would be cleaned. The DON revealed the facility staff were supposed to clean the poles on Sundays and when they were soiled. Review of the facility policy Cleaning and Disinfection of Environment and Equipment dated 3/2019 revealed the following: To ensure appropriate techniques, products, and cleaning schedules are used to reduce the potential for disease transmission and provide the most effective means of maintaining a clean, healing, and professional environment. Patient rooms are cleaned daily, at discharge, and as needed in between.",2020-09-01
507,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,636,D,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 1[AGE]NAC 12-006.09B(7) Based on observation, interview, and record review the facility failed to ensure that the required Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) documented the resident use of Continuous Positive Airway Pressure ([MEDICAL CONDITION]) (a machine pump that forces air through a face mask into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing for patients with obstructive sleep apnea) for 1 resident (Resident 9) of 1 resident reviewed. The facility census was 16. Findings are: Record review of the Registration/Admission Form for Resident 9 revealed that the resident admitted to the facility on [DATE]. Record review of the Transfer Order for Resident 9 dated 10/25/19 revealed that Resident 9 had a physician's order for [MEDICAL CONDITION] use during sleep. Record review of the After Visit Summary (patient information and instructions provided to a patient by a health care provider) dated [DATE] for Resident 9 revealed a [DIAGNOSES REDACTED]. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway). Observation on 1/2/20 at 2:02 PM revealed that Resident 9 was in the bed in the resident's room with the resident's eyes closed. Resident 9 had a [MEDICAL CONDITION] mask on with the [MEDICAL CONDITION] pump running. Record review of the MDS assessment dated [DATE] for Resident 9 revealed that documentation of the resident [MEDICAL CONDITION] use was omitted from section O0100G ([MEDICAL CONDITION] use) of the MDS. Record review of the facility policy titled Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Policy and Procedure dated 4/2019 revealed Procedure Step 1. The facility must make a comprehensive assessment of the resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by C[CONDITION] (Centers for Medicare and Medicaid Services). Step 5. The interdisciplinary team members, completing any items on the MDS, will access the RAI User's Manual for guidance to ensure coding accuracy. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 9 had a physician's order for [MEDICAL CONDITION] use and that the [MEDICAL CONDITION] use was not identified and documented on the resident MDS assessment. LPN-A confirmed that the resident [MEDICAL CONDITION] use should have been identified and documented in section O0100G of the MDS.",2020-09-01
508,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,638,D,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09B2 Based on record review and interview, the facility failed to ensure the completion an MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) every 3 months on one resident (Resident 3) out of one resident sampled. The facility census was 16 at the time of the survey. Findings are: Record review of Resident 3's quarterly MDS dated [DATE] for the ARD (Assessment Reference Date). There was no assessment in progress at the time of survey entrance. The required time frame between ARDs was to be 92 days or less. Interview on 1/02/20 at 3:10 PM with LPN-A (Licensed Practical Nurse) revealed that the last MDS Quarterly assessment had a dated of 9/20/19 for Resident 3 and the next MDS should have been completed before 12/31/19. The MDS was not scheduled to be completed until [DATE] which is outside the required ARD of 92 days or less. Review of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Policy and Procedure policy revealed in accordance with Federal Regulation, Title 42 4[AGE].20-Resident assessment. This facility will conduct initially and periodically an accurate, standardized reproducible assessment of each resident's current functional, psychosocial, clinical and mental status. Procedure: for #3 states: A facility must assess a resident using the quarterly review instrument specified by the State and approved by C[CONDITION] not less frequently then every 92 days.",2020-09-01
509,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,640,D,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and transmit a discharge MDS assessment (Minimum Data Set, a federally required assessment tool for tracking) for one sampled resident (Resident 2) discharged from the facility. This affected 1 of 16 residents. The facility identified a census of 16 at the time of survey. Findings are: Review of Resident 2's Patient Abstract with a run date of 1/6/2019 revealed an entry date of 7/11/19 and a discharge date of [DATE] to an acute care hospital. Review of Resident 2's MDS assessments revealed no documentation a discharge tracking record was completed. Interview with LPN-A (Licensed Practical Nurse) on 01/06/20 at 10:31 AM confirmed a discharge assessment should have been completed for Resident 2 and it was not completed. Interview with RN-B (Registered Nurse) on 01/06/20 at 1:05 PM confirmed the discharge assessment should have been completed. Review of the facility policy Resident Assessment Instrument Minimum Data Set (MDS) Policy and Procedure revealed the following: This facility will conduct initially and periodically an accurate, standardized reproducible assessment of each resident's current functional, psychosocial, clinical and mental status. The interdisciplinary team members, completing any items on the MDS, will access the RAI 3.0 User's Manual, Chapter 3, for guidance to ensure coding accuracy.",2020-09-01
510,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,641,E,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09B Based on observation, interview and record review; the facility staff failed to code MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) assessments to reflect the resident condition at the time of the assessment. This affected 3 of 16 residents whose MDS assessments were reviewed during the survey process (Resident 14, Resident 68, and Resident 217). The facility identified a census of 16 at the time of survey. Findings are: A. Observation of Resident 14 on 01/02/20 at 2:09 PM revealed they had a black area on the back of the left heel. Review of Resident 14's SCSA (Significant Change in Status) MDS dated [DATE] revealed no documentation of the area on Resident 14's left heel. Review of the MDS manual revealed the following: Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined. Review of Resident 14's Wound Care Clinic visit dated 12/6/2019 revealed documentation Resident 14 had a deep tissue injury to the left heel. Review of Resident 14's Orders and Progress Record dated 12/20/2019 revealed Resident 14 had a DTI (Deep Tissue Injury) to the left heel. Review of Resident 14's Orders and Progress Record Wound Care Note dated [DATE] revealed the following: Area to left heel has an approx. 5x5 cm (centimeter) DTI. Review of Resident 14's Wound Assessments and Treatments dated 1/5/20 revealed the area to the left heel was marked as 1.5 cm x 1.5 cm. Interview with LPN-A (Licensed Practical Nurse) on 1/06/20 at 10:12 AM confirmed they did not mark the DTI on Resident 14's heel on the SCSA MDS and they should have as it was present at the time of the assessment. B. Interview with Resident 68 on 12/31/19 at 2:43 PM revealed they had an infection in their leg that had occurred sometime after surgery and they had been receiving antibiotics. Review of Resident 68's Admission MDS dated [DATE] revealed an admission date of [DATE]. Antibiotics were received 7 days of the 7 day look back period. There was no active [DIAGNOSES REDACTED]. Interview with LPN-A on 1/02/20 at 3:35 PM confirmed they did not mark an infection on the MDS. Review of Resident 68's Orders and Progress Record dated 1[DATE]19 revealed an order for [REDACTED]. C. Review of Resident 217's Admission MDS dated [DATE] revealed an admission date of [DATE]. Antipsychotic medication was received 7 days of the 7 day look back period. Fractures and other multiple trauma was marked as the primary medical condition. No other active [DIAGNOSES REDACTED]. Review of Resident 217's Medication Reconciliation Tool dated 1/2/20 revealed the following medications: [REDACTED]. Interview with LPN-A on 1/02/20 at 3:28 PM confirmed there was not an active [DIAGNOSES REDACTED]. Interview with LPN-A on 1/02/20 at 3:54 PM confirmed they had omitted Resident 14's pressure ulcer and Resident 16's infection from the MDS assessments. Interview with RN-B on 1/06/20 at 12:54 PM revealed if the conditions were present at the time of the assessments, they should have been coded on the MDS assessments. Review of the facility policy Resident Assessment Instrument Minimum Data Set (MDS) Policy and Procedure revealed the following: This facility will conduct initially and periodically an accurate, standardized reproducible assessment of each resident's current functional, psychosocial, clinical and mental status. The interdisciplinary team members, completing any items on the MDS, will access the RAI 3.0 User's Manual, Chapter 3, for guidance to ensure coding accuracy.",2020-09-01
511,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,655,E,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09C1a Based on interview and record review, the facility failed to put interventions for bleeding risk on the baseline care plan for Resident 6 and failed to provide a written summary of the baseline care plan to the resident or resident representative prior to the initial care plan meeting for Residents 14, 67, and 8. This affected 4 of 14 sampled residents whose baseline care plans were reviewed during the survey process. The facility identified a census of 16 at the time of survey. Findings are: A. Interview with Resident 6 on 01/02/20 at 10:22 AM revealed they received a blood thinner. Review of Resident 6's baseline care plan dated 12/30/2019 revealed an admission date of [DATE]. There was no documentation of interventions to monitor for bleeding risk due to the use of a blood thinner. Review of Resident 6's Medication Reconciliation Report dated 1/2/20 revealed the following: [MED] (a blood thinner) 20 mg (milligram) administered every day. Review of the Nursing2018 Drug Handbook revealed the following nursing considerations for [MED]: Monitor patient carefully for bleeding which can occur at any site during therapy. Watch for signs and symptoms of blood loss. Search for a bleeding site if an unexplained fall in hematocrit (the ratio of the volume of red blood cells to the total volume of blood) or BP (blood pressure) occurs. Life-threatening adverse reactions listed: GI (gastrointestinal) hemorrhage, bleeding events (including hemorrhage). Interview with RN-B (Registered Nurse) on 1/06/20 at 12:54 PM confirmed there were no interventions regarding bleeding risk on Resident 6's baseline care plan. Interview with NA-E (Nurse Aide) on 1/06/20 at 1:41 PM revealed they got the information they needed to care for the residents from the care plan. B. Interview with Resident 14 on 12/31/19 at 11:21 AM revealed they did not recall receiving a written summary of their baseline care plan prior to their initial care plan meeting. Review of Resident 14's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/10/2019 revealed an admission date of [DATE]. Resident 14 had a BI[CONDITION] (Brief Interview for Mental Status) score of 14 which indicated Resident 14 was cognitively intact. Review of Resident 14's Care Plan dated 12/3/2019 revealed no documentation a written summary of the baseline care plan was given to Resident 14 or their resident representative. Review of Resident 14's Interdisciplinary Care Plan sheet dated 12/16/2019 revealed the resident signed attendance at the initial care plan conference. There was no documentation that Resident 14 received a written summary of their baseline care plan or that it was reviewed with them prior to the initial care plan conference date. C. Interview with Resident 67 on 12/31/19 at 10:52 AM revealed they didn't recall receiving a written summary of their baseline care plan. Review of Resident 67's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 67 had a BI[CONDITION] score of 14, which indicated Resident 67 was cognitively intact. Review of Resident 67's baseline care plan dated 12/5/2019 revealed no documentation a written summary was given to the resident or resident representative or that it was reviewed with them prior to the initial care plan conference. Review of Resident 67's Interdisciplinary Care Plan sheet dated 1[DATE]19 revealed the resident and family signed attendance at the initial care conference. There was no documentation a written summary of the baseline care plan had been given the Resident 67 or their personal representative prior to the initial care conference on 1[DATE]19. Interview with RN-B on 01/02/20 at 2:01 PM confirmed the facility staff were not giving the resident and/or resident representative a written summary of the baseline care plan. Review of the undated untitled facility policy regarding care planning revealed no documentation the resident/personal representative would be given a written summary of the baseline care plan and that it would be reviewed with them. D. Review of the Care Plan for Resident 8 with an initiation date 4/29/19 revealed no signatures of the resident representative and the other signatures were of the nursing staff. Review of the [DIAGNOSES REDACTED]. Review of the Progress Notes for Resident 8 revealed no documentation that the resident or the resident representative was given a summary of the baseline care plan. Interview on 1/06/20 at 8:40 AM with RN-B (Clinical Manager) revealed there was no written summary of the baseline care plan given to the residents or resident representatives.",2020-09-01
512,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,657,E,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 1[AGE]NAC 12-006.09C1c Based on record review, observation, 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 anticoagulant (a blood thinner medication used to prevent the formation of blood clots) use for 2 residents (Residents 1 and 9) of 2 residents reviewed, and the facility failed to ensure that the resident care plan was updated to include care for resident Continuous Positive Airway Pressure ([MEDICAL CONDITION]) (a machine pump that forces air through a face mask into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing for patients with obstructive sleep apnea) use for 1 resident (Resident 9) of 1 resident reviewed. The facility census was 16. Findings are: A. Record review of the Registration/Admission Form for Resident 9 revealed that the resident admitted to the facility on [DATE]. Record review of the scheduled MEDICATION ORDERS FOR [REDACTED]. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment dated [DATE] for Resident 9 revealed in section N0410 that Resident 9 had received an anticoagulant each day. Record review of the care plan for Resident 9 revealed that it contained no care plan interventions for the resident use of an anticoagulant. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 9 had a physician's orders [REDACTED]. LPN-A confirmed that the care plan for Resident 9 did not contain a care plan for the resident use of an anticoagulant. LPN-A confirmed that care plan interventions for anticoagulant use should have been on the resident's care plan. B. Record review of the Registration/Admission Form for Resident 1 revealed that the resident admitted to the facility on [DATE]. Record review of the Transfer Order for Resident 1 dated 1[DATE] revealed that Resident 1 had a physician's orders [REDACTED]. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment dated [DATE] for Resident 1 revealed in section N0410 that Resident 1 had received an anticoagulant. Record review of the care plan for Resident 1 revealed that it contained no care plan interventions for the resident use of an anticoagulant. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 1 had a physician's orders [REDACTED]. LPN-A confirmed that the care plan for Resident 1 did not contain a care plan for the resident use of an anticoagulant. LPN-A confirmed that care plan interventions for anticoagulant use should have been on the resident's care plan. C. Record review of the Registration/Admission Form for Resident 9 revealed that the resident admitted to the facility on [DATE]. Record review of the Transfer Order for Resident 9 dated 10/25/19 revealed that Resident 9 had a physician's orders [REDACTED]. Record review of the After Visit Summary (patient information and instructions provided to a patient by a health care provider) dated [DATE] for Resident 9 revealed a [DIAGNOSES REDACTED]. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway). Observation on 1/2/20 at 2:02 PM revealed that Resident 9 was in the bed in the resident's room with the resident's eyes closed. Resident 9 had a [MEDICAL CONDITION] mask on with the [MEDICAL CONDITION] pump running. Record review of the care plan for Resident 9 revealed that it contained no care plan for the resident use of the [MEDICAL CONDITION]. Interview on 1/6/20 at 12:37 PM with Licensed Practical Nurse A (LPN-A) confirmed that Resident 9 had a physician's orders [REDACTED]. LPN-A confirmed that the care plan should have contained a care plan for the resident's [MEDICAL CONDITION] use.",2020-09-01
513,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,658,D,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.10 Based on observation, interview, and record review; the facility staff failed to follow professional standards for the administration of subcutaneous (applied under the skin) [MEDICATION NAME] (a blood thinner) to Resident 68. This affected 1 of 1 sampled residents. The facility identified a census of 16 at the time of survey. Findings are: Observation of RN-F (Registered Nurse) on 1/02/20 at 10:32 AM revealed they administered [MEDICATION NAME] 5000 units per ML (milliliter) 1 ML into Resident 68's left abdomen at a 45 degree angle. RN-F then rubbed back and forth over the site 3 times with an alcohol wipe after injecting. Review of the undated facility policy Skills: Medication Administration: Subcutaneous Injection revealed the following: Special Considerations for [MEDICATION NAME] Administration: when [MEDICATION NAME] is administered subcutaneously, it should be injected at a 90-degree angle and administered slowly. Apply gentle pressure to the site. If [MEDICATION NAME] was given, hold the alcohol swab or gauze until clotting occurs. Do not massage the site. Massaging can damage the underlying tissue. Review of the Nursing 2018 Drug Handbook revealed the following nursing considerations for [MEDICATION NAME]: Don't massage injection site; watch for signs of bleeding there. Inject deep into subcutaneous fat. Interview with RN-B on 01/06/20 at 12:54 PM confirmed the standard for the [MEDICATION NAME] injection administration was to administer it at 90 degree angle so the medication went deep into the subcutaneous fat and the site should not have been massaged after injection.",2020-09-01
514,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,756,D,0,1,5VOC11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.12B(5) Based on interview and record review; the facility staff failed to complete a monthly medication review for Resident 14. This affected 1 of 5 sampled residents. The facility identified a census of 16 at the time of survey. Findings are: Review of Resident 14's SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/10/2019 revealed an admission date of [DATE]. Review of the facility documentation of the monthly pharmacy review titled Monthly Counseling Summary dated 12/26/2019 revealed no documentation Resident 14's pharmacy review was completed in December. Other residents were listed but Resident 14's name was not listed. Interview with RN-B (Registered Nurse) on 01/06/20 at 12:54 PM confirmed there was no documentation Resident 14's pharmacy review was completed in December. RN-B confirmed Resident 14 was in the facility on 12/26/2019 so the pharmacy review should have been completed. RN-B revealed all residents have an initial reconciliation of their medications then once a month thereafter. Review of the facility policy Skilled Nursing Pharmacist Drug Therapy Consulting Summary dated 10/2018 revealed the following: The consultant pharmacist will complete a monthly review of all skilled residents with a length of stay greater than 30 days. All skilled residents will have medications reviewed by a pharmacist upon admission.,2020-09-01
515,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,758,D,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D Based on interview and record review, the facility failed to complete a baseline AI[CONDITION] (Abnormal Involuntary Movement Scale-a screening tool used to monitor for the adverse side effects of movement disorders from antipsychotic medication use) assessment and failed to ensure there was a [DIAGNOSES REDACTED]. This affected 1 of 5 sampled residents. The facility identified a census of 16 at the time of survey. Findings are: Review of Resident 217's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 12/29/2019 revealed an admission date of [DATE]. Antipsychotic medication was received 7 days of the 7 day look back period. Fractures and other multiple trauma was marked as the primary medical condition. No other active diagnoses were listed. Interview with LPN-A (Licensed Practical Nurse) on 01/02/20 at 3:28 confirmed there was no [DIAGNOSES REDACTED]. Review of Resident 217's Patient Abstract which lists the diagnoses with a run date of 1/2/20 revealed there was no [DIAGNOSES REDACTED]. Anxiety was the only diagnosis listed that indicated a psychological condition. Review of Resident 217's Medication Reconciliation Tool dated 1/2/20 revealed the following medications: [REDACTED]. Review of Resident 217's Dismissal Order/Transfer Order dated [DATE] revealed no [DIAGNOSES REDACTED]. Review of Resident 217's chart revealed no documentation an AI[CONDITION] assessment had been completed for Resident 217. Interview with LPN-A on 1/06/20 at 10:06 AM confirmed no AI[CONDITION] assessment had been completed for Resident 217. Interview with RN-B (Registered Nurse) on 1/06/20 at 02:12 PM confirmed they could not find a [DIAGNOSES REDACTED]. Review of the facility policy Skilled Nursing Pharmacist Drug Therapy Consulting Summary dated 10/2018 revealed the following: The consultant pharmacist will complete a monthly review of all skilled residents with a length of stay greater than 30 days. All skilled residents will have medications reviewed by a pharmacist upon admission. Antipsychotic drugs should not be used if one or more of the following is/are the only indication: wandering, poor self-care, restlessness, impaired memory, anxiety. Charts will be evaluated for appropriate use of antipsychotic drug use. Charts will be evaluated for absence of adequate documented supporting [DIAGNOSES REDACTED]. Review of the manufacturer's Indications for Use for [MEDICATION NAME] revealed the following: treatment of [REDACTED]. The following Warning was listed: Tardive Dyskinesia A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs. Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to rely upon prevalence estimates to predict, at the inception of antipsychotic treatment, which patients are likely to develop the syndrome.",2020-09-01
516,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,812,E,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to store food off of the floor. This affected 2 of 2 residents who received nutritional supplements (Residents 14 and 217) and 2 of 2 residents who received tube feeding formula (Residents 8 and 17). The facility identified a census of 16 at the time of survey. Findings are: Observation of the facility kitchen on 12/31/19 at 9:20 AM revealed there were 4 boxes of [MEDICATION NAME] 1.5 cal (a formula used for residents requiring tube feeding) and 5 boxes of Ensure [MEDICATION NAME] (an oral liquid dietary supplement) sitting on the floor. Interview with DA-I (Dietary Aide) at this time confirmed the supplements were for the facility residents. Interview with the DON (Director of Nursing) on 01/06/20 at 10:53 AM revealed the supplements were not supposed to be stored on the floor. Review of the facility policy Food Supply and Storage dated 3/2018 revealed the following: Store dry and staple items at least 18 inches above the floor. Received a list from RN-B on 1/06/20 at 5:00 PM of the residents receiving [MEDICATION NAME]: Resident 8 and Resident 11. Resident 14 and Resident 217 received the Ensure.",2020-09-01
517,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,867,F,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.07 Based on record review and interview, the facility's Quality Assurance Committee (QA) failed to develop and implement plans of actions to correct issues of deficient practice relevant to resident care and services and the facility failed to implement effective plans of action to maintain correction for 4 previously cited areas of deficient practice identified (F638, F655, F812, and F8[AGE]). This had the potential to affect all residents that reside in the facility. The facility census was 16 at the time of the survey. Findings are: Record review of the Statement of Deficiencies for the annual survey completed on 9/27/2018 revealed repeat citations at F638 Quarterly Assessments, F655 Baseline Care Plan, F812 Food Procurement/store/prepare/serve-Sanitary, and F8[AGE] Infection prevention & Control. The facility was found to be deficient in the area of Federal regulatory compliance after the tasks of the annual standard survey were completed 01/06/2020. The facility failed to maintain corrections for the regulation identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings. -F550 Resident Rights/Exercise of Rights-Dignity -F5[AGE] Safe/Clean/Comfortable/Homelike Environment -F636 Comprehensive Assessments & Timing -F640 Encoding/Transmitting Resident Assessment -F641 Accuracy of Assessments -F657 Care Plan Timing and Revision -F658 Services Provided Meet Professional Standards -F[AGE]6 Drug Regimen Review -F[AGE]8 Free from Unnecessary [MEDICAL CONDITION] Meds/PRN use -F[AGE]7 QA Interview on 1/06/2020 at 4:11 PM with RN-B ( Clinical Manager/QA Coordinator) revealed the QA committee meets at least quarterly and more often if needed. Also currently working on falls, Urinary Tract Infections's, Pressure ulcers, [MEDICAL CONDITION] ([MEDICAL CONDITIONS] results from disruption of normal healthy bacteria in the colon, often from antibiotics) infections and CAUTI's (Catheter Associate Urinary Tract Infections). There was a unit based council that will monitor and identify issues and report back to the committee.",2020-09-01
518,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2020-01-06,880,F,0,1,5VOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.17A Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during resident dining, failed to wear a mask per facility policy to prevent the potential spread of infection to the facility residents, and failed to perform hand hygiene, change gloves, and perform wound care to prevent potential cross contamination for Resident 14 and Resident 9. This had the potential to affect all of the facility residents. The facility identified a census of 16 at the time of survey. Findings are: A. Observation of the facility dining room on 12/31/19 at 12:13 PM revealed NA-C (Nurse Aide) did a 2 second hand scrub with hand sanitizer and got a tray out of the food cart and gave it to Resident 7. NA-C then then put on gloves and set up Resident 7's tray of food by handling the plate, glasses, and silverware. NA-C had the same gloves on and took Resident 12 a tray of food. NA-C then took a phone from another staff member and put it into their pocket. NA-C then continued to set up Resident 12's tray of food without changing gloves. NA-C then took the gloves off, performed a 3 second hand scrub with hand sanitizer then took food to Resident 216 and set up their tray of food. NA-C then did a 2 second hand scrub with hand sanitizer, put gloves on and set up Resident 216's tray of food. Resident 7, Resident 12, and Resident 216 were all observed feeding themselves and handling the items NA-C had handled. Observation of the facility dining room on 12/31/19 at 12:18 PM revealed NA-E did a 1 1/2 second hand scrub with hand sanitizer and opened the thermal cart and took a tray out and took it to Resident 217. NA-E removed the cover from Resident 217's food, drinks and touched the glass, the containers of food and a cookie that was wrapped in plastic wrap. Resident 217 then proceeded to touch the items with their hands that NA-E had handled. Observation of NA-E passing room trays on 12/31/19 at 12:21 PM revealed the following: NA-E performed a 3 second hand scrub with hand sanitizer then took Resident 9 a tray of food and handled the items on the tray by removing the food cover, plate, and glasses to remove the plastic wrap covering them. NA-E then did a 3 second hand scrub and took a tray to Resident 218 who was in contact isolation. NA-E donned gown, gloves, and mask and took the tray in to Resident 218. NA-E then washed their hands for 5 seconds after removing the gown and gloves. NA-E then left the room and went to the dining room galley and got 2 cans of soda out of the cupboard and then opened the refrigerator in the galley. On 12/31/19 at 12:28 PM NA-E then took a Styrofoam cup and a can of soda to Resident 9. NA-E then went and got an ice bag out of the staff room and took it to resident 9, opened the can of soda and poured ice into a glass out of the bag it was in and poured the soda into the Styrofoam cup. Resident 9 then drank out of the cup. Interview with RN-B (Registered Nurse) on 12/31/19 at 12:48 PM revealed Resident 218 was in contact isolation as a precaution as they were waiting for a report to determine if Resident 218 had [DIAGNOSES REDACTED]icile ([MEDICAL CONDITION] (klos-TRID-e-um dif-uh-SEEL), also known as Clostridioides difficile and often referred to as [DIAGNOSES REDACTED]icile or [DIAGNOSES REDACTED], is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from [DIAGNOSES REDACTED]icile most commonly affects older adults in hospitals or in long-term care facilities and typically occurs after use of antibiotic medications). At 1:02 PM, RN-B reported they were able to lift the contact isolation for Resident 218. Review of the undated Mandatory Education Log revealed the following: Infection control policy outlined and reviewed. This is to include types of isolation and PPE related to each type. Proper signage directions related to isolation. Accurate donning and doffing of PPE (Personal Protective Equipment) including sequencing of procedure, use of hand sanitizer prior to gloving, and hand washing guidelines. Clinical skills video in Mosby education module to be viewed regarding proper PPE and application. Hand hygiene audit forms are introduced and explained for compliance and monitoring process. Outline disciplinary action for failure to follow proper infection control guidelines. Review of the facility policy Hand Hygiene dated 11/2012 revealed the following: In the Food and Nutrition Department, all employees associated with the handling of food will wash hands. Hands are to be washed with soap and water at the following times: before handling food or clean utensils/dishes/equipment, putting on gloves; between handling raw and cooked foods; after touching hair, skin, beard, or clothing; handling soiled silverware; removing gloves; any other activity that may contaminate the hands. While on the nursing units, alcohol-based hand sanitizer/gel is used to decontaminate hands when there is no visible soiling of the hands (food or other materials). Procedure: Wet hands with warm water, and apply disinfectant soap, lathering up to mid-arm. Work lather into hands for 20 seconds, including areas under fingernails, between fingers, and on the inside and outside of hands. Rinse thoroughly under warm running water, allowing the water to flow from the arm, down to the fingertips. Review of the undated facility policy Hand Hygiene revealed the following: Hand hygiene is not optional. Hand Antisepsis Using and Instant Alcohol Waterless Antiseptic Rub: Dispense the recommended amount of product per the manufacturer's instructions for use into the palm of one hand. Rub the hands together, covering all surfaces of the hands and fingers with antiseptic rub. Rube the hands together until the alcohol is dray. Allow the hands to completely dry before donning gloves. Perform hand hygiene with an instant alcohol waterless antiseptic rub, from start to dry, for 20 to 30 seconds. Do not use an alcohol waterless antiseptic rub for hand hygiene when spore-producing pathogens are suspected or confirmed. Interview with RN-B on 01/06/20 at 12:54 PM revealed if staff were going between residents or handling food or touched that food it would be considered contaminated gloves before they go to the next resident so hand hygiene was expected. The expectation for hand sanitizer is to scrub for 20-30 seconds. We always tell the staff to say the pledge of [MEDICATION NAME] when they wash their hands; The whole process should take at least 1 or 2 minutes by the time they go through the washing, scrubbing nails, rinsing and drying. B. Interview with Resident 14 on 12/31/19 at 11:25 AM revealed they had a sore on their bottom the facility staff were treating. Observation of RN-F on 01/02/20 at 2:09 PM revealed RN-F assisted Resident 14 to stand and get into bed. Resident 14 was wearing a non-skid sock on the right foot and an orthotic boot on the left foot. RN-F removed the boot from Resident 14's left foot. RN-F then donned gloves and lifted up Resident 14's left leg. There was a dark black area on the back of Resident 14's left heel about the size of a quarter. RN-F then put a pillow under Resident 14's left leg to prop up their foot. RN-F then opened the room door with the same gloved hands and went out of the room and brought back in some washcloths and [MEDICATION NAME] swabs. RN-F laid the washcloths on the arm of Resident 14's wheelchair which was parked in front of the sink and put the [MEDICATION NAME] swabs on the bedding at the foot of the bed. RN-F turned the faucet on and wet some washcloths and put soap on one of the wash cloths from the soap dispenser by the sink. RN-F then turned the faucet off by the handle with the same gloved hands. RN-F then handled Resident 14's heel and washed the heel with one of the washcloths. RN-F then put the washcloth into the sink. RN-F then dried the area on the heel with another washcloth; opened one of the [MEDICATION NAME] swabs and washed the area from the outside to the inside toward the center of the wound. RN-F then removed the right glove and put another one on and did not change the left glove or perform any hand hygiene before putting their hand into the box of gloves and using the left gloved hand to put the new right glove on. RN-F then picked up an [MEDICAL CONDITION] wear and put it on Resident 14's left leg handling and touching their foot and leg. RN-F then put the boot back on to Resident 14's left lower leg and foot; RN-F touched the boot which Resident 14 had stood on to transfer into bed with the gloved hands. RN-F then put an [MEDICAL CONDITION] wear and the same non-skid sock onto Resident 14's right leg/foot which was soiled from standing on it to transfer. At 2:21 PM RN-F said they were now going to do wound care on Resident 14's bottom as they had an open area on their bottom. RN-F was still wearing the same gloves. RN-F picked up a stethoscope that was laying on Resident 14's love seat and put it around RN-F's neck. RN-F then helped Resident 14 roll to their right side in bed. RN-F lowered Resident 14's pants then covered Resident 14 with a blanket as there was a knock at the door. RN-F had asked them to wait while they covered Resident 14 with a blanket. RN-F then said come in and no one came in so RN-F went to the door and opened it with the same gloved hands. No one was there so RN-F closed the door and went to the sink. RN-F took the dirty washcloth out of the sink and laid it on the edge of the sink. RN-F touched the faucet with the same gloved hands and turned the water on. RN-F then touched the open area on Resident 14's left buttock while RN-F examined it. The area was open on the left buttock. RN-F then went to the sink and wet a washcloth by handling the faucet and put soap on it from the dispenser by the sink. RN-F washed the wound with the washcloth from outside to inside toward the wound and up and down over the wound. RN-F then washed an area on Resident 14's tailbone with the same washcloth. RN-F then put that washcloth onto the edge of the sink; RN-F then grabbed the last washcloth from the arm of Resident 14's wheelchair and dried the wound areas with it. RN-F was still wearing the same pair of gloves. RN-F then picked up a tube of ointment from Resident 14's bed and put ointment on the open area on Resident 14's buttock using the same gloved hands then put ointment on Resident 14's tailbone. At 2:30 PM RN-F pulled up Resident 14's brief and pants; RN-F still had the gloves on. RN-F touched Resident 14's belly and shirt then grabbed Resident 14's right hand with the same gloved hands. RN-F then put the gloved hands on Resident 14's back and helped them sit up. RN- F picked up a gait belt and put it around Resident 14's waist and helped them stand and get into the wheelchair. RN-F put the foot pedal for Resident 14's left leg on the wheelchair. At 2:36 PM RN-F removed the gloves and handled Resident 14's water pitcher and gave Resident 14 a Styrofoam cup which Resident 14 started to drink from. RN-F picked up the other [MEDICATION NAME] swab off the bed they had not used and put it in their pocket. RN-F then went to the computer in Resident 14's room and touched the mouse and the keyboard and charted. RN-F did not do any hand hygiene after they had removed the gloves. Interview with the DON (Director of Nursing) on 1/02/20 at 3:00 PM revealed gloves were to be changed when they are soiled and hand hygiene should be done after gloves are removed. Wound care was to be completed from the center of the wound moving outward. Review of the undated facility policy Skills Pressure Injury: Treatment revealed the following: Gather the necessary equipment and supplies. Perform hand hygiene and don gloves. Cleanse the pressure injury and surrounding skin with a 0.9% [MED] chloride solution or wound cleanser. Apply skin barrier/protectant to peri-wound skin, as needed, or apply prescribed medication ointment to the wound using cotton-tipped applicators or gauze. Measure the pressure injury dimensions. Discard supplies, remove PPE, and perform hand hygiene. Document the procedure in the patient's record. C. Observation on 12/31/19 at 11:57 AM revealed NA-C (Nurse Aide) washing NA-C's hands for 45 seconds using soap and water. NA-C then took a glass of water to Resident 14 and touched the middle of the glass . NA-C then used hand sanitizer for 2 seconds quickly touching the bottom and top of both hands. NA-C then applied a pair of blue gloves and entered the kitchenette to make a root beer float for Resident 14. NA-C touched the door handle of the refrigerator with the gloved hands which contaminated them. NA-C then took a can of root beer from the refrigerator and touching the handle of the freezer (further contaminating NA-C's hands) removed the ice cream. On the way from the kitchenette NA-C grabbed a Styrofoam cup. NA-C obtained a plastic spoon and began placing the ice cream into the Styrofoam cup. There was ice cream dripping down the outside of the ice cream container and NA-C used NA-C's contaminated gloved finger to wipe off the ice cream and placed the ice cream covered finger inside the Styrofoam cup. NA-C then scrapped the ice cream from the finger by drawing it along the inside of the cup. NA-C also used the spoon for stirring the ice cream mixture to scrape ice cream off the side of the container. NA-C removed the gloves and reapplied new gloves without doing hand hygiene. NA-C then added root beer to the ice cream in the cup. NA-C then opened a straw and used the outside of the glove, which had touched the can of root beer, into the cup. NA-C touched the drinking end of the straw and handed the cup to Resident 14. NA-C had washed NA-C's hand one time during the meal service and used hand sanitizer the rest of the meal time. Interview on 12/31/19 at 1:09 PM with RN-B (Clinical Manager) revealed NA-C was the Activity Coordinator and a NA and had received all of the competency checks from hand hygiene to peri care. Also staff are to wash hands between changing gloves or use hand sanitizer. The hand sanitizer was to cover all areas of the hands, between the fingers and under the nails. The hand sanitizer was too dry before touching anything. D. Observation on 1/02/20 at 3:19 PM of NA-D (Nurse Aide) revealed NA-D sitting in dining room documenting on the computer with the isolation mask NA-D had on under her nose and not over the nose. There were residents seated slight to the right and behind NA-D. Interview on 1/02/20 at 3:41 PM with NA-D revealed NA-D was wearing the mask was because NA-D opted to not receive the influenza vaccine and NA-D was wearing the mask due to it being the peak flu season and it protects the residents. Interview on 1/02/20 at 3:30 PM with the DON (Director of Nursing) revealed that staff who do not receive influenza vaccine were to wear a mask until the flu season was over. This was per facility policy. Review of the infection control and prevention policy revealed a comprehensive Influenza and Pneumococcal Vaccine Policy that states the purpose was to protect the health and well-being of all employees, physicians, volunteers, students, faculty, patients, families, and the community at large. Scope and definitions were defined. Also included is the vaccination of health care workers. It states on page 3 of the policy #2 Employee Requirement: B. If an employee does not receive the vaccination, they must sign a declination form and a mask must be worn until it is announced flu season has officially ended. E. When the prevalence of influenza disease rises to the threshold designated by the local CHI Health ministry, masking will be instituted for all non-vaccinated employees and non-employed health care providers working in a CHI Health facility. 1. Masks must cover the mouth and nose. 2. Masking occurs in all areas of the facility, unless the employee is eating/drinking in approved areas, i.e., break room, cafeteria, etc. 3. Masks are provided by the employer. E. Record review of the facility skills titled Hand Hygiene (hand washing) dated June 2019 revealed the section titled Hand Antisepsis (using an antiseptic to eliminate germs that cause disease) using an Instant Alcohol Waterless Antiseptic Rub (the same as ABHR) Step 1. Dispense the recommended amount of product per the manufacturer's instructions for use into the palm of one hand. Step 2. Rub the hands together, covering all surfaces of the hands and fingers with antiseptic rub. Step 3. Rub the hands together until the alcohol is dry. Allow the hands to completely dry before donning gloves. Perform hand hygiene with an instant alcohol waterless antiseptic rub, from start to dry, for 20 to 30 seconds. Record review of the facility skills titled Hand Hygiene dated June 2019 revealed the section titled Hand Washing Using Plain or Antimicrobial Soap and Water Step 2. Turn on the water. Step 5. Wet the hands and wrists thoroughly under the running water. Keep the hands and forearms lower than the elbows during washing. Step 6. Apply the recommended amount of plain or antimicrobial soap to the hands according to the manufacturer's instructions for use. Step 7. Lather thoroughly. Step 8. Apply friction and perform washing for at least 15 seconds or for the length of time stated in the manufacturer's instructions for use for the product used. Interlace the fingers and rub the palms and back of the hands together using a circular motion for at least five cycles. Keep the fingertips down to facilitate the removal of microorganisms. Observations of wound care on 1/6/20 at 2:13 PM for Resident 9 in the resident's room revealed that Licensed Practical Nurse A (LPN-A) applied alcohol based hand rub (ABHR) to the hands and rubbed the hands for 14 seconds and then put on disposable gloves. Registered Nurse B (RN-B) entered the room and turned on the water at the sink with the right hand and wet the right hand. RN-B then applied soap to the dry left hand and performed scrubbing with soap for 12 seconds before rinsing the hands. RN-B put on a pair of disposable gloves. LPN-A removed the disposable gloves and performed hand washing with ABHR rubbing the hands for 5 seconds and then put on disposable gloves and set a clean linen on the foot of the resident's bed. LPN-A placed the wound care supplies on top of the clean linen. LPN-A removed the gloves and performed 7 seconds of rubbing with ABHR and then put on new gloves. RN-B removed the dressing from the resident's right knee wound. The wound on top of the right knee contained meaty reddish pink tissue with a hole on the top edge of the wound. RN-B removed the gloves and applied ABHR and rubbed the hands for 16 seconds and then put on disposable gloves. LPN-A removed the gloves and rubbed the hands for 4 seconds with ABHR and then put on disposable gloves. RN-B obtained a 4X4 gauze and went to the sink and wet the gauze with tap water. RN-B scrubbed the wound with the 4X4 gauze and discarded the gauze into the trash. RN-B used a new dry gauze to pat the wound dry. RN-B removed the gloves and performed 20 seconds of rubbing with ABHR and then put on new disposable gloves. LPN-A removed the gloves and performed 4 seconds of rubbing with ABHR and then put on new disposable gloves. RN-B inserted a swab stick into the hole at the top of the wound and measured the depth of the hole at 4.2 centimeters. RN-B measured the width across the wound at 4.4 centimeters and the length up and down of the wound at 5.0 centimeters. LPN-A wrote the measurements on the whiteboard on the wall in the resident's room. LPN-A removed the gloves and rubbed the hands with ABHR for 5 seconds and then put on new disposable gloves. RN-B inserted a piece of white foam into the hole at the top of the wound using a swab stick. RN-B then opened some clear adhesive dressings and adhered the clear dressings around the edges of the wound. LPN-A then trimmed a piece of black foam for the wound. RN-B applied the piece of black foam on top of the wound. LPN-A cut a piece of clear adhesive cover to place over the black foam on the wound and RN-B placed the adhesive cover over the black foam on the wound. LPN-A cut a small hole in the cover on top of the black foam. RN-B applied the suction tubing on the top of the hole over the black foam. LPN-A connected the wound vac (a type of therapy machine that provides vacuum assisted closure of a wound to help a wound heal) to the suction tubing from the wound. LPN-A turned on the wound vac. The dressing on Resident 9's right knee drew tight to the resident's skin. RN-B then removed the disposable gloves and rubbed the hands for 17 seconds with ABHR and then put on new disposable gloves. RN-B assisted the resident in putting a shoe on the right foot. LPN-A gathered the trash into the trash bag and then removed the gloves. LPN-A performed hand rubbing for 3 seconds with ABHR and then put on new disposable gloves. RN-B and LPN-A placed a soft brace on the right leg of the resident. RN-B removed the disposable gloves and then went to the sink and turned on the water with the right hand and wet the right hand. RN-B applied soap to the dry left hand and then performed soap hand scrubbing for 26 seconds and then rinsed the hands. Interview on 1/6/20 at 4:23 PM with the Director of Nursing (DON) confirmed that the procedure for hand washing with the alcohol based hand rub (ABHR) requires that the rubbing be performed for 20-30 seconds until dry and that rubbing with the ABHR for less than 20 seconds does not meet the procedure requirements. The DON confirmed that the policy for soap hand washing steps includes wetting both of the hands prior to applying soap. The DON confirmed that applying soap to a dry hand does not follow the policy.",2020-09-01
519,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2017-08-22,241,E,0,1,T1Q411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006.05(21) Based on observation and interview, the facility failed provide dignity for resident by ensuring 1) one resident (Resident 94) was treated with dignity while staff provided personal cares 2) one resident's (Resident 28) urinary catheter bag was not covered and 3) one resident's (Resident 28) personal information was not posted for all visitors to have access to read. The census was 17. Findings are: [NAME] Observation on 08/22/2017 at 7:50 AM of RN-A (Registered Nurse) performed peri-cares on Resident 94 in preparation for inserting a urinary catheter. Resident was alert and talkative to the nurse during the cares. RN-A explained to the resident the procedure and pulled back the covers and pulled down the brief. The resident had a shirt on, no pants, and the covers were pulled to the bottom of the bed past the feet. RN-A performed peri-cares and did not cover the resident during any of the procedure. When the peri-care procedure was completed. RN-A left the resident exposed without any covers or clothing from the waist down, while RN-A went to the sink and washed hands. RN-A then proceeded to prep for the next procedure of the urinary catheter procedure. During the urinary catheter procedure, the steps involve covering the resident with a drape for dignity and to provide a sterile field. RN-A did not drape the Resident 94 during the procedure. RN-A did not ask the resident before or during the procedure if the resident wanted to be uncovered during any of these procedures. Interview on 08/22/2017 at 12:31 PM with the DON (Director of Nursing) confirmed the expectation was to have the resident covered as much as possible during procedures of peri-cares and catheter insertions/cares to promote the residents' dignity. B. Review of Admission Form dated 07-26-17 revealed an admission date of [DATE] and admitting [DIAGNOSES REDACTED]. Observation on 08-22-17 at 09:35 AM of the Resident 28 lying in bed with the urinary catheter bag hung from the bed. The catheter bag was not in a cover bag and the urine was revealed towards the door and was observed when walking by the room. Interview on 08-22-17 at 5:06 PM with the DON confirmed the catheter bags were to be in a cover at all times to hide the urine and promote resident dignity. C Observation on 08-22-17 at 9:35 AM in Resident 28's room revealed a large (approximately 3 x 2 foot) white board on the wall directly when walked into the room on the right side. On the board was wrote the following resident personal information for all to who entered the room to view: Resident Name: Resident 28's first name Nurse: (Nurse's name was wrote) Pain Management: last dose 6:10 PM, next dose in 2 hours Today's goals: 1) pain control 2) increase dietary intake 3) use call light Diet: regular Foley catheter: inserted [DATE] at 1910 Fall Risk: yes Weight bearing: assist x 2 Oxygen - PRN (as needed) DC (discontinue) TED's (brand name for support stocking) Interview on 08/22/2017 at 5:06 PM with the DON revealed the facility used the white boards as a communication board in all the residents' rooms between the resident's family's, the resident, and the staff.",2020-09-01
520,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2017-08-22,428,D,0,1,T1Q411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12B Based on record review and interviews, the facility failed to ensure a drug regimen review was completed monthly on one resident (Resident 10) out of 5 sampled residents. The facility census was 17. Findings are: Review of Resident 10's Admission Form dated 06-09-13 revealed an admission date of [DATE]. Review of the monthly pharmacy reviews for the past 1 year revealed missing monthly review for the months of January, March, and (MONTH) (YEAR). Interview on 08-22-17 at 4:55 PM with the Assistant Director of Nursing confirmed the absence of the monthly pharmacy reviews.",2020-09-01
521,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2017-08-22,441,D,0,1,T1Q411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to utilize hand washing and prevent cross contamination of supplies during provision of skin wound cares for one resident (Resident 93) out of one resident sampled. The facility also failed to utilize sterile technique when inserting a urinary catheter for one resident (Resident 94) out of one resident sampled. The census was 17. Findings are: [NAME] Observation on 08/22/2017 at 7:50 AM of RN-A (Registered Nurse) performed peri-cares on Resident 94 before inserting a urinary catheter. RN-A washed both hands with soap and water and applied gloves. RN-A performed peri-cares on the resident with disposable wipes. Instead of disposing of the soiled wipes with BM (bowel movement) into a plastic bag or trash can, RN-A laid the soiled wipes directly onto the resident's bed linen. When peri-cares were completed, RN-A took the soiled wipes from the bed and moved the wipes over and laid them directly on a vinyl chair seat in the room and proceeded went and washed RN-A's hands. When the catheterization procedure was completed, RN-A picked up the disposable equipment from the procedure and grabbed the soiled disposable wipes from the chair and disposed of it all into the trash can. RN-A finished by washing both hands with soap and water. RN-A did not clean the chair or change the bed linens. Observation on 08/22/17 at 7:50 AM of RN-A perform a urinary straight catheritization on Resident 94. RN-A first washed both hands with soap and water. RN-A moved off the resident's drinking glasses from the overbed table, but did not clean off the table before opening up the catheter kit. Once the kit was opened, RN-A opened a pair of sterile gloves and applied. RN-A then opened up the sterile packages from inside the sterile catheter kit. RN-A did not drape the resident with the sterile disposable drapes to provide a sterile field to help reduce or prevent cross contamination. RN-A placed RN-A's left hand on the resident's labia causing the left hand to now be contaminated, and kept the right hand sterile. RN-A cleansed the resident with the [MEDICATION NAME] swabs then inserted the catheter tube. The tube entered the vagina instead of the urethra. Another staff person entered the room so RN-A asked the staff person to obtain another catheter kit. While waiting, RN-A visited with the resident then clasped the left contaminated gloved hand with the right sterile gloved hand. RN-A then pulled at the gloves to fit better on each hand. The new catheter arrived and RN-A opened the catheter kit and packages and inserted the catheter without first changing the gloves or perform hand hygiene. Review of the facility policy Urinary Catheterization and Care dated 5/2017 revealed the procedure of inserting a urinary catheter should adhere to aseptic (sterile) technique. The directions on how to insert a urinary catheter was referred to Mosby Clinical skills Checklist which was not printed in the policy. Review of Mosby Fundamentals of Nursing's Potter and Perry 6th edition, the clinical skills for Inserting a Straight or and Indwelling catheter revealed the drape provides a sterile field and maintains the principles of surgical asepsis. B. Observation on 08/22/2017 at 10:10 AM of RN-A perform wound cares on Resident 93. RN-A washed hands with soap/water, applied gloves, then placed wound treatment supplies (scissors, roll of tape, and dressing packages) on the resident's bed covers on the bed next to the resident. Observed on the bed sheet next to the resident's right lateral ankle was a quarter size amount of yellow/brown dried drainage. RN-A first removed the old dressing from the right lateral ankle wound and RN-A informed the resident about the draining the wound had and the need to change the bed sheets. RN-A sprayed the wound with wound cleanser and wiped the wound off with gauze. RN-A then placed the dirty gauze directly on top of the scissors. Without changing the gloves, RN-A opened the [MEDICATION NAME] dressing and grabbed the scissors from under the soiled gauze and cut an approximate 1 x 2 inch piece. With the contaminated gloves, RN-A placed the [MEDICATION NAME] dressing onto the cleaned wound and finished the dressing with gauze and tape. RN-A removed the gloves and applied new gloves. RN-A removed the old dressing from the left heel wound and cleansed with spray and gauze. RN-A did not change gloves after working with the dirty aspect of wound care and before beginning clean wound care. With the same pair of scissors and without having had cleaned them between wounds, RN-A cut another piece of [MEDICATION NAME] dressing from the same package as before and applied to the wound and finished the dressing with gauze and tape. RN-A removed the gloves and applied the 3rd pair of gloves but did not perform hand hygiene. RN-A rolled the resident on to the resident's side with the resident's assistance and applied a cream to both wounds. Interview on 08-22-17 at 10:15 AM with RN-A confirmed RN-A was aware hands should have been washed between changing of gloves. Review of Wound Care policy dated 7/2015 revealed to change gloves and cleanse hands after removal of the soiled dressing. Interview on 08/22/2017 at 12:31 PM with the ADON (Assistant Director of Nursing) / Infection Control Nurse confirmed staff were to perform hand hygiene with either soap/water or hand foam after removing gloves. The ADON also confirmed gloves should be changed after the contaminated aspect of wound care was performed and before new dressings were applied. The ADON revealed when catheters were inserted a sterile technique was to be used and sterile technique was broke when RN-A clasped the left gloved contaminated hand with the right sterile gloved hand. The ADON revealed every resident's room was provided with a trash can and was to be used for disposable wipes during peri-cares.",2020-09-01
522,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,578,E,0,1,E0UY11,"Based on record reviews and interviews, the facility failed to provide written information on Advance Directives to 5 residents (Residents 6, 71, 3, 69, and 68) out of 5 residents sampled. The facility census was 18. Findings are: Record review of Resident 6, 71, 3, 69, and 68's medical record revealed absence of written documentation of education given to the resident or legal representatives about advance directives. Interview on 09/25/18 at 09:14 AM with the SSD (Social Service Director) revealed it had not been the facility practice to educate residents or their legal representatives in writing about advance directives.",2020-09-01
523,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,609,E,1,1,E0UY11,"> Licensure Reference Number 175 NAC 12-006.02(8) Based on interview and record reviews, the facility failed to report incidents of abuse to the State Agency for Resident 114 out of 3 sampled residents. The facility census was 18. Findings are: Record review of Resident (114) reveals resident had verbal complaint of sexual abuse on 5/31/18. The facility did not report abuse to the State Agency within 2 hours as required. Interview with MDS-RN(Minimum Data Set) on 9/25/18 at 4:15 PM revealed that the facility does not call or report abuse within 2 hours. Interview with MDS-RN on 9/25/18 at 4:15 PM confirmed that the facility has an Abuse and Neglect policy and procedure statement of whom to report abuse and injury to whom in the facility, and it confirms that the facility has no record of time or date on required reporting to the State Agency.",2020-09-01
524,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,638,D,0,1,E0UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B2 Based on record review and interview, the facility failed to ensure to complete an MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) every 3 months on one resident (Resident 1) out of one resident sampled. The facility census was 18. Findings are: Record review of Resident 1's quarterly MDS dated [DATE] and annual MDS dated [DATE] ARD (Assessment Reference Dates) revealed a calendar time frame of 95 days between the ARD's. The required time frame between ARD was 92 or less. Interview on 9-26-18 at 12:55 PM with MDS-Coordinator confirmed the (MONTH) ARD was 4-4-18 and the (MONTH) ARD was 7-7-18 and the difference in dates was 95 days.",2020-09-01
525,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,655,E,0,1,E0UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record review and interviews, the facility failed to develop a baseline Careplan to address an immediate healthcare need of pain for a resident who had an amputation and a resident who had pain with dressing wound changes. This affected 2 residents (Resident 3 and 71) out of 2 residents sampled. The facility census was 18. Findings are: [NAME] Review of Resident 3's undated face sheet revealed the date of admission as 9-23-18. Review of Resident 3's undated Abstract form revealed the [DIAGNOSES REDACTED]. Interview on 9-26-18 at 1:13 PM with NA-E revealed the resident was 1 assist with ambulation and cares because of the wound on the foot. Interview on 9-26-18 at 1:23 PM with the MDS-Coordinator (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) revealed the resident had not lived in the facility long enough to have the admission MDS completed yet. Review of the Pain Group forms for Resident 3 revealed the resident complained of left foot pain and rated the pain at a 5 on a scale of 0-10. Interview on 9-26-18 at 3:47 PM with Resident 3 in the resident's room revealed the resident had some pain with the toe but also had [MEDICAL CONDITION] in the legs because of the diabetes. The resident revealed the resident dealt with pain in other places on the body such as neck and shoulders pain, but at times the hands and elbows also had pain. The resident revealed the lack of movement and walking increased the pain the resident experienced. The resident revealed the best nonpharmalogical interventions were to move around and apply heat to the achy joints. Review of Resident 3's Careplan revealed acute pain related to the amputation but the only intervention documented was pain medication. The Careplan was absent of any nonpharmalogical pain interventions. Interview on 9-26-18 at 3:51 PM with LPN-F (Licensed Practical Nurse) confirmed the Careplan did not have nonpharmalogical interventions. LPN-F revealed the nurse was not aware the Careplan's were to have nonpharmalogical interventions. B. Review of Resident 71's undated Abstract form revealed the admission date of [DATE]. Review of Resident 71's undated Abstract form revealed the [DIAGNOSES REDACTED]. Interview on 9-24-18 at 9:19 AM with LPN-A revealed the resident was admitted with the pressure ulcer to the right buttock and it was a stage 4 (fFll thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. The wound often includes undermining and tunneling). LPN-A revealed the wound was treated with a wound vac (a therapeutic technique using a negative -pressure [DEVICE] in acute or chronic wounds to enhance healing using a sealed wound dressing connected to a vacuum pump). Review of Resident 71's undated Physician orders [REDACTED]. on 9/20/18 for complaints of pain. Review of the admission skin assessment dated [DATE] revealed the right buttock had an open blister 12 x 0.2 cm (centimeters) with small amount of serous (clear) drainage and the wound edges were red. The 2nd blister was fluid filled and measured 7 x 0.2 cm. The stage 4 pressure ulcer on the right buttock measured 8 x 7 x 2 cm and had purulent (thick yellow, green, tan or brown) drainage. The assessment revealed the pressure ulcer had been surgically debrided (dead tissue had been surgically removed). Observation on 9-24-18 at 9:44 AM of Resident 71's wound vac dressing change to the stage 4 pressure ulcer performed by an RN and LPN. The resident's bilateral buttocks were fiery red with irritation and had small areas where the skin was open approximately 1 x 0.5 cm in size. Observation of the pressure sore revealed a gapping open wound with beefy red tissue on one edge and bright pink tissue on the other side. In the bottom center of the wound was a whitish color of the bone exposed approximate 2-3 cm with some eschar (dead tissue) observed. Throughout the procedure, frequently the nurses asked the resident if the resident had pain while peeling off the sticky dressing from the irritated skin. At one point the resident jumped during the procedure as if in pain. Interview on 9-24-18 at 9:44 AM with MDS-C revealed the wound nurse felt the resident's skin on the buttock's was reacting to the wound vac dressing which caused it to be fiery red. MDS-C revealed the nurses addressed with the Physician on 9-24-18 to consider changing the dressing to something else because of the discomfort with the dressing changes and skin injury the dressing had caused to the buttocks. Review of the Resident 71's admission Careplan was absent to address the potential or actual problem of pain and absent of any interventions to assist the resident with pain. Interview on 09/25/18 at 2:50 PM with LPN-F revealed the initial Careplan was done for Resident 71 and the careplan did not address pain with dressing changes.",2020-09-01
526,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,756,E,0,1,E0UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B Based on record reviews and interviews, the facility failed to ensure MRR (Medication Regimen Reviews) for 2 residents (Resident 6 and 5) out of 2 residents who had no irregularities sampled, were documented in the residents' medical record. The facility census was 18. Findings are: [NAME] Review of Resident 6's undated 'Abstract' form revealed the resident was admitted on [DATE]. Interview on 9-26-18 at 7:45 AM with the DON (Director of Nursing) revealed the RP (Registered Pharmacist) documented all the MMRs on the PN (Progress Note) side of each resident's Physician order [REDACTED]. Review of Resident 6's Physician order [REDACTED]. Review of the MCS forms for (MONTH) and (MONTH) revealed Resident 6 had a MRR completed each month and had NIN (no irregularities noted). Interview on 9-26-18 at 8:30 AM with the RP revealed the RP did monthly MRR's on all residents and if the resident had NIN it was documented on the MCS form for communication to the DON and Medical Director but was not documented in each resident's medical record. The RP documented the MRR in the resident's medical record only if there was an issue which required to be addressed with the attending Physician.",2020-09-01
527,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,761,E,0,1,E0UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 Based on observation, record review, and interviews, the facility failed to ensure 7 medication labels on 2 residents (Resident 71 and 2) matched the Physician orders [REDACTED]. The facility census was 18. Findings are: [NAME] Observation on 9-24-18 at 7:36 AM of LPN-A (Licensed Practical Nurse) administered Enoxamparin NA (Sodium) Injection 40 mg (milligrams) /0.4 ml (milliliter) subcutaneously in the right side of the abdomen to Resident 71. Review of the label on the medication was absent of the time/how often and the route to give this medication to the resident. Review of the Physician orders [REDACTED]. B. Observation on 9-24-18 at 8:11 AM of LPN-A administered to Resident 2. -Levetiracetatam 500 mg/5 ml gave 5 ml. The label on the bottle was absent the directions of how much and how often to administer to the resident. Review of the undated Physician orders [REDACTED]. -Ranitadine 150 mg/10 ml gave 10 ml. The label on the bottle was absent the directions of how much and how often to administer to the resident. Review of the undated Physician orders [REDACTED]. -Multivitamin 30 ml gave 15 ml. The label on the bottle was absent the directions of how much and how often to administer to the resident. Review of the undated Physician orders [REDACTED]. -[MEDICATION NAME] 5 mg/5 ml gave 10 ml. The label on the bottle was absent the directions of how much and how often to administer to the resident. Review of the undated Physician orders [REDACTED]. -Fluiticasone 16 grams gave 2 nasal sprays in each nares. The label on the bottle was absent the directions on which nares to spray and how often to administer to the resident. Review of the undated Physician orders [REDACTED]. Interview on 9-26-18 at 8:30 AM with RP (Registered Pharmacist) confirmed the labels on the liquid bottles, injectable's, and nasal sprays were absent of the directions on how often and when to administer the medications.",2020-09-01
528,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,812,D,0,1,E0UY11,"Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to serve food in a manner to prevent food borne illnesses. Sample size 4. Facility census 18. Findings are: On 09/23/17 at 6:36 PM observation of nursing staff, revealed that nursing staff took 2 pieces of white bread from a loaf of bread in the kitchette with bare hands, walked over to Resident 12's tray, picked up spoon, placed a large amount of chicken salad on bread, laid the bread on resident's tray and cut the sandwich with a knife in two. Staff then handed half of the sandwich to Resident 12 and continued to have bare hands on other part of sandwich. The Staff Member did not do any hand hygiene before or after working with this resident and their food. Interview on 09/24/18 at 0800 AM with DON (Director of Nursing) revealed it was the expectation of the nursing staff to sanitize hands before and after trays were being distributed to residents and not to handle food with bare hands. The staff should sanitize hands prior to and after working with each resident and there food.",2020-09-01
529,CHI HEALTH ST FRANCIS,285081,2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-09-27,880,E,0,1,E0UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12.006.17 Based on observations,record reviews, and interviews, the facility failed to ensure TBP (Transmission Based Precautions) were followed by staff on 2 residents (Resident 64 and 70) out of 3 residents sampled. The facility census was 18. Findings are: [NAME] Observation on 9-23-18 at 6:28 PM revealed a Nurse Aide distributed food trays from a kitchen food warmer cart down the hall to the residents' rooms and then would take the individual trays into the resident's room. Observation revealed on the outside of room [ROOM NUMBER] was an isolation cart and a sign on the wall which was marked with droplet and 'contact Transmission Based Precautions. The directions indicated for all persons entering the room to wear PPE (Personal Protective Equipment) of a gown, mask, and gloves. The Nurse Aide took the meal tray from the food cart and entered room [ROOM NUMBER] without any PPE on. The NA approached the resident and without wearing gloves touched the resident's overbed table and extended it and layed the meal tray on it. The NA was within 1-2 feet of the resident and talked to the resident. The NA then went outside the room to the isolation cart and donned the PPE of a gown, mask and gloves. The NA re-entered the room and approached the resident and set up the tray. When the NA went to leave the room, first the NA took off the mask, then the gloves, then the gown. However, the NA could not get the gown untied so it was taken off by going up and over the NA's uncovered head. The NA did wash both hands for 20 seconds. Review of Resident 64's Careplan revealed the resident had an infection [MEDICAL CONDITION] due [MEDICAL CONDITIONS]; pneumonia due [MEDICAL CONDITION], and [MEDICAL CONDITION] in the right leg wound. The resident was on IV (intravenous) antibiotics and was in contact and droplet isolation because of the infections. Observation on 9-27-18 at 8:24 AM revealed RN-B (Registered Nurse) provided medication to Resident 64 inside the resident's room and the nurse had PPE on of a gown and gloves. The nurse had several procedures to perform and throughout the procedure had to leave the room on 3 different occurrences to obtain a needed/forgot items. On each occurrence, the RN discarded the gloves, then the gown and without performing any type of hand hygiene, the RN left the room and proceeded out of the residents room and down the hall. B. Observation on 09/23/18 at 6:36 PM in Resident 70's room the resident sat in the wheelchair and had 2 visitors each with a pair of gloves on. Outside the resident's room was an isolation cart with a sign that revealed the resident was in contact isolation and person's entering were to wear a gown and gloves. LPN-D was in the room with vital sign equipment and the nurse did not have any PPE on such as gloves or a gown. The NA (Nurse Aide) in the hallway handed the meal tray to LPN-D in the resident's room. LPN-D took the tray and sat it on the over-bedtable and prepped the resident and the tray. Review of the facility policy titled 'Isolation Precautions' dated 8/2018 revealed the Droplet TBP guidelines revealed to wear a mask if within 3 to 6 feet of the patient or when entering the room, wear gloves with all contact with the patient or environment, and gowns were to be worn as with Standard Precaution, hand hygiene was to be followed as to wash carefully after any contact with patient or environment, even when gloves were worn. Contact TBP guidelines revealed to mask as needed for standard precautions, gloves to enter the room, ; gowns to be worn for all contact with the patient or anything in the room.",2020-09-01
530,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2020-01-07,684,D,1,0,1TJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-006.09D Based on record review and interview, the facility failed to monitor progress of vascular ulcers for 1 (Resident 7) of 7 sampled residents. The facility had a total census of 50 residents. Findings are: A review Resident 7's Admission assessment dated [DATE] revealed Resident 7 had 7 vascular ulcer measured as follows: -left lower extremity lateral 1 cm x 7 cm -right anterior foot 2 cm x 3 cm -right dorsal foot 2 cm x 3 cm -left lower extremity lateral 3.5 x 6.5 cm -right lateral extremity 3 cm x 2.4 cm -right lateral extremity posterior 4.5 cm x 3 cm -right lower extremity lateral 6.5 cm x 6 cm A review of Resident 7's skilled charting notes 11/17/19 to 12/12/19 and progress notes from 11/15/19 to 1/7/20 did not reveal any documentation of size or progress of vascular ulcers. In interviews on 1/7/20 at 9:25 AM and 9:50 AM, Registered Nurse A reported that vascular ulcers are not measured. Charting on vascular ulcers is done by exception. Registered Nurse A reported the facility did not have a policy on documentation of progress of skin breakdown other than pressure ulcers. In an interview on 1/7/20 at 11:54 AM, the Director of Nursing confirmed that of weekly measurements of stasis (vascular) ulcers needed to be completed.",2020-09-01
531,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2017-02-07,279,D,0,1,GG4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C Based on record review and interview, the facility failed to develop a plan of care related to suicidal thoughts and actions for Resident 52 and for hospice care and services for Resident 6. This practice affected 2 of 29 residents sampled. The facility census was 54. Findings are: Record review of the facility's policy titled Care Plan, Interdisciplinary dated 8/1997 revealed that the care plan would contain projected resident centered, measurable goals with anticipated dates of accomplishment which focus on resident strengths. The care plan would also include specific approaches and interventions to be used as indicated by disciplines which would aid in the achievement of the goals and which were oriented toward preventing declines in the level of functioning of the resident. Record review of Resident 52's Admission Record revealed that Resident 52 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 52's Pre-Admission Screening and Resident Review (PASRR) (an evaluation conducted to determine eligibility for placement/continued stay in a nursing facility) revealed that the resident was being received to the facility from a Psychiatric center. Resident 52 required admission to the Psychiatric center related to suicide attempts or gestures. The PASRR rational for service decision statement revealed that the resident would benefit from safety planning and this may be helpful due to recent suicidal ideation and previous history of psychiatric hospitalization s. It may also be helpful so that staff and Resident 52 recognize when psychiatric interventions may be necessary. Observation of Resident 52 on 2/6/17 at 8:42 AM revealed Resident 52 was in a wheelchair in the hallway. Resident 52's movements were slow. The resident self propelled with use of one foot. The resident's response and speech were slow and soft. Resident 52 had expression of sadness, did not initiate conversation and used one word answers to questions . Record review of Nurse's Notes dated 10/27/16 at 6 AM -2 PM shift revealed that Resident 52, who was admitted on [DATE], was depressed, refusing medications, and expressed thoughts of suicide. Resident 52 was placed on 15 minute checks. Record review of Nurse's Notes dated 10/28/16 at 1030 AM revealed that a call was placed to Resident 52's physician to request an appointment for suicidal thoughts and comments. No appointment was obtained. An order was then received to send Resident 52 to the emergency room for evaluation. Record review of Nurse's Notes dated 11/3/16 at 2:00 PM revealed that Resident 52 returned from admission to the hospital. Record review of Resident 52's Psychiatric consult dated 11/9/17 revealed that it was suggested that Resident 52 receive psychiatric therapy at a stated facility related to the resident's present illness. Record review of Resident 52's medications revealed they included the following: *-[MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] *-[MEDICATION NAME] for Anxiety *-[MEDICATION NAME] for [MEDICAL CONDITION] with psychotic episodes. Record review of Resident 52's Comprehensive Care Plan revealed no focus for Resident 52's depression or related medications. Record review revealed that upon admission from the Psychiatric Center no plan of care was developed for the resident's thoughts of suicide. There were no interventions for staff interventions to recognize or when to intervene when the resident expressed thoughts of harm to self. Interview on /07/2017 at 8:24 AM with the facility's Director of Social Services (SSD) confirmed that a review of Resident 52's PASRR was conducted and that upon admission the facility the SSD was aware that Resident 52 was being admitted from a psychiatric facility with suicidal thoughts and actions. The SSD confirmed that Resident 52 did not have a focus on the Comprehensive Plan of Care to identify, set goals, or staff interventions for Resident 52's psychiatric illnesses. Interview on 02/07/2017 at 9:56 AM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 52 did not have a care plan upon admission or upon readmission to the facility regarding planning to address suicidal ideation history as per the facility policy. The ADON confirmed that the resident was on psychiatric medications that were not reflected on Resident 52's plan of care. B. Record Review of Resident 6's Face Sheet revealed that Resident 6 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Hospice Interdisciplinary Team Report dated 1-5-17 revealed Resident 6 was on Hospice and had been receiving hospice services for end of life care since 8-8-16. The Report revealed that Resident 6 had been getting hospice nurse visits weekly and as needed, hospice nurse aide visits twice a week, and visits from the hospice social worker and chaplain monthly and as needed. Review of a progress note dated 1-26-17 for Resident 6 revealed that the hospice nurse was in the facility and wrote new orders for Resident 6. Review of Resident 6's Comprehensive Care Plan with an initiation date of 10-19-15 revealed no care plan for Hospice care or Services. An interview with the Assistant Director of Nursing (ADON) on 2-7-17 at 8:47 AM confirmed that Resident 6 was receiving hospice services through an outside provider. The ADON confirmed that Resident 6 did not have a care plan for hospice services and confirmed that it should have been on Resident 6's Comprehensive Care Plan to coordinate care between the facility and the hospice company.",2020-09-01
532,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2017-02-07,319,D,0,1,GG4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D5 Based on observation, record review, and interview; the facility failed to provide additional psychiatric therapy services for Resident 52 as recommended by the psychiatric consultant. This affected 1 of 1 sampled residents. The facility census was 54. Findings are: Record review of Resident 52's Admission Record revealed that Resident 52 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 52's Pre-Admission Screening and Resident Review (PASRR) (an evaluation conducted to determine eligibility for placement/continued stay in a nursing facility) revealed that the resident was being received to the facility from a Psychiatric center. Resident 52 required admission to the Psychiatric center related to suicide attempts or gestures. The PASRR rational for service decision statement revealed that the resident would benefit from safety planning and this may be helpful due to recent suicidal ideation and previous history of psychiatric hospitalization s. It may also be helpful so that staff and Resident 52 recognize when psychiatric interventions may be necessary. Observation of Resident 52 on 2/6/17 at 8:42 AM revealed Resident 52 was in a wheelchair in the hallway. Resident 52's movements were slow. The resident self propelled with use of one foot. The resident's response and speech were slow and soft. Resident 52 had expression of sadness, did not initiate conversation and used one word answers to questions . Record review of Nurse's Notes dated 10/27/16 at 6 AM -2 PM shift revealed that Resident 52, who was admitted on [DATE], was depressed, refusing medications, and expressed thoughts of suicide. Resident 52 was placed on 15 minute checks. Record review of Nurse's Notes dated 10/28/16 at 1030 AM revealed that a call was placed to Resident 52's physician to request an appointment for suicidal thoughts and comments. No appointment was obtained. An order was then received to send Resident 52 to the emergency room for evaluation. Record review of Nurse's Notes dated 11/3/16 at 2:00 PM revealed that Resident 52 returned from admission to the hospital. Record review of Resident 52's Psychiatric consult dated 11/9/16 revealed that it was suggested that Resident 52 receive psychiatric therapy at a stated facility related to the resident's present illness. Interview with the Assistant Director of Nursing (ADON) on 2/7/17 confirmed that Resident 52 did have [MEDICAL CONDITION] and a plan to harm self on the second day at the facility. The ADON confirmed that Resident 52 isolated self in room from others. The ADON confirmed that Resident 52 had been seen once by the psychiatric provider from 11/3/16 to present (2/7/17). The ADON confirmed that the Psychiatric provider did suggest resident seek therapy at a named facility. The ADON confirmed that this had not occurred.",2020-09-01
533,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,550,D,0,1,4MTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(21) Based on interviews, record reviews, and observations; the facility failed to ensure 1 resident (Resident 43) was treated with dignity during dining of the 13 residents that required assistance or cueing for dining. The facility staff identified the census at 47. The findings are: A review of Resident 43's Admission Record revealed that Resident 43 was admitted to the facility 9-10-13 with the [DIAGNOSES REDACTED]. An observation conducted on 4-10-18 at 12:46 PM revealed that Nursing Assistant (NA) C stirred Resident 43's potatoes, meatloaf, and mixed vegetables all together and was feeding this to the resident. An observation conducted on 4-10-18 at 12:58 PM revealed NA C placed a large amount of food on Resident 43's fork, and without speaking to the resident, put the fork to the resident's mouth. Resident 43 pulled their head back away from the fork as NA C followed the resident's mouth with the fork until the resident opened their mouth and took a bite. An observation conducted on 4-10-18 at 1:02 PM revealed NA C placed a large amount of food on Resident 43's fork, and without speaking to the resident, put the fork to the resident's mouth. Resident 43 pulled their head back away from the fork as NA C followed the resident's mouth with the fork. The resident had their head back as far back as it would go and NA C kept the fork up to the resident's lips until they took a bite. An interview conducted on 4-10-18 at 1:37 PM with NA C revealed that NA C usually mixes Resident 43's foods together. NA C reported that it was easier to get food into Resident 43's mouth if it was all mixed together. An observation conducted on 4-12-18 at 8:49 AM revealed NA D was assisting Resident 43 with breakfast. NA D would put the bite to the resident's lips and the resident would open their mouth. The resident was not observed to pull their head up and away from the bite. An interview conducted on 4-12-18 at 10:56 AM with the Dietary Manager revealed that Resident 43 received their food served separately and that staff were not supposed to mix everything together. The Dietary Manager reported they had not seen Resident 43 pull their head back away from a bite of food. An interview conducted on 4-12-18 at 11:05 AM with NA D revealed that when they assisted Resident 43 with eating they would touch the bite to the resident's lips and the resident would take a bite. NA D reported that when Resident 43 was full they would stop opening their mouth. NA D reported that they had never seen Resident 43 pull their head back away from the fork. NA D reported they did not usually mix Resident 43's food together. An interview conducted on 4-12-18 at 11:07 AM with the Director of Nursing revealed that staff should not mix a resident's food together. The Director of Nursing reported they had never seen Resident 43 pull their head back away from a bite.",2020-09-01
534,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,584,E,0,1,4MTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.18 A(1) Based on observation and interview, the facility failed to ensure the cleanliness and condition of ventilation covers, walls, floors, fixtures and ceilings in 11 (resident rooms 202, 203, 206, 209, 210, 303, 304, 306, 307, 310 and 509) of 36 occupied resident rooms. The facility census was 47. Findings are: Observation on 4/11/18 between 10:30 am and 10:50 AM during the environmental tour with Maintenance Assistant (MA) A revealed the following concerns: - Ventilation covers dust covered: rooms [ROOM NUMBERS] - Soiled base of toilets and floors behind toilets: rooms 202, 206 and 303 - Cracked linoleum behind toilet: room [ROOM NUMBER] - Wall gouged in the bathroom room [ROOM NUMBER] - Water stains on the ceiling in rooms 206, 304 and 306 - Ventilation cover loose from the ceiling in room [ROOM NUMBER] - Cobwebs present between a pipe and the wall and ceiling in bathroom of room [ROOM NUMBER] - Knob and cord missing from the bathroom call system in bathroom of room [ROOM NUMBER] - Window blinds broken and falling off in room [ROOM NUMBER] Interview 04/11/18 at 10:50 AM with MA A confirmed that the above areas of concern had not been identified prior to the environmental tour and needed to be cleaned and repaired.",2020-09-01
535,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,676,D,0,1,4MTO11,"Licensure Reference Number 175 NAC 12-006.09 D 1(b) Based on observation, record review and interview; the facility failed to provide cueing and supervision with eating to maintain the ability to eat independently for 1 resident (Resident 38) of 13 residents that required assistance, supervision, or cueing with eating. The facility census was 47. Findings are: Record review of Resident 38's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 3/6/18 revealed that Resident 38 exhibited moderate cognitive impairment, required supervision and set up help with eating and had a weight of 102. Record review of Resident 38's Comprehensive Care Plan (CCP, a written plan that describes a residents problems and interventions to address concerns to ensure care of the resident) dated 12/17/14 revealed that Resident 38 had potential nutritional problem and required assistance with Activities of Daily Living related to confusion and Senile Dementia. An Intervention included to cue and supervise as needed. Observation on 4/9/18 between 12:00 PM and 12:33 PM revealed that Resident 38 received a tray of food that included ground meat with gravy, vegetables and cake. Resident 38 picked up a fork and started to eat the cake but dropped some onto the lap. Resident 38 spent the next 5 minutes wiping the cake from the lap and became distracted and started picking at the pants. Resident 38 then picked up the spoon and ate some cake. Resident 38 become distracted often throughout the meal and did not eat any of the meat or vegetables on the plate. Resident 38 did eat 75% of the cake. Staff did not come over to Resident 38 at any time during the meal to provide cueing or supervision or to check and see if an alternate would be preferable to Resident 38. Observation on 04/10/18 between 12:10 PM and 12:46 PM revealed that Resident 38 received ground meat with gravy, 2 halves of potato un-buttered, green beans and cake. Staff did not ask Resident 38 if help was needed to butter or cut the potatoes. Resident 38 attempted to cut the potato into bites and dropped several pieces onto the lap, spent several minutes wiping them off and began drinking milk independently. Resident 38 took one bite of meat after spilling the potato. At 12:24 PM resident picked up a knife and tried to cut the potato again. After trying to cut it with no luck, Resident 38 gave up and drank more milk. Resident picked up a spoon, ate a bite of cake and drank more milk. Resident 38 took another bite of cake, tried to eat another bite of potato with a spoon and spilled it on the lap. Resident 38 continued to eat the cake. At 12:32 PM, Resident 38 put the spoon down, pushed away from the table and wiped at the lap. Between 12:10 PM and 12:32 PM staff did not return to the table to offer assistance with cutting the potato or to cue Resident 38 to continue eating. At 12:37 PM, RN [NAME] came over and asked Resident 38 if the resident was going to try to eat a little more, and, without waiting for an answer, walked away. Resident 38 picked up a knife, got a bite of meat on the edge of the knife and ate the meat off the knife. Resident 38 put the knife down and picked up the spoon and took another bite of cake. Resident 38 spilled it on the lap and spent a couple of minutes trying to wipe it off the lap. Resident 38 continued to try to eat but kept dropping the food off of the spoon and fork. At 12:46 PM, Resident 38 pushed herself away from the table and self propelled away from the dining room. Total consumption for the meal was 25% of cake, 1 bite of meat, 1 bite of potatoes, no green beans and 3/4 of a glass of milk. Observation on 04/11/18 08:04 to 8:30 AM revealed Resident 38 received a breakfast of french toast sticks, a small cup of syrup, ground sausage and hot cereal. Resident 38 picked up a french toast stick and took a bite. Resident 38 then ate all of the syrup with a spoon. Resident 38 attempted to get a bite of sausage onto the spoon and, as (gender) brought it to (gender) mouth, spilled the sausage onto the lap. Resident 38 spent a few minutes wiping off the lap. Resident 38 ate 3 bites of the hot cereal and then drank 75% of the milk. Resident 38 became distracted several times during the meal. Total consumption for the meal was half of a french toast stick, no ground sausage, 3 bites of hot cerealand 75% of milk. Staff did not provide any cueing, supervision or offer any assistance during the meal. Interview on 04/11/18 at 08:40 AM with the Dietary Manager (DM) confirmed that Resident 38 should have been cued and supervised with meals and tended to do better with finger foods. The DM confirmed that Resident 38 would probably do better with eating if supervision and cueing were provided to ensure that the resident did not have problems with spilling food from the utensils. Record review of a list of residents revealed that a total of 13 residents required supervision and cueing with eating in the facility dining room and that Resident 38 was identified on that list.",2020-09-01
536,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,689,D,0,1,4MTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18 E Based on observation, record review and interview; the facility failed to complete ongoing evaluations of smoking safety and provide equipment to ensure safe smoking practices for 1 (Resident 37) of 8 residents that smoked. The facility census was 47. Findings are: Record review of a facility Smoking Policy dated revised 2012 revealed the following information : - Smoking assessments will be performed for those wishing to smoke quarterly and as needed. - Smoking restrictions to ensure resident safety may include but are not limited to the use of fire-proof aprons, supervision and fire-proof gloves (revised and effective 4/14/18). - Any smoking related privileges, restrictions and concerns (for example need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. - Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer at all times while smoking. Record review of Resident 37's Comprehensive Care Plan (CCP, a written document that identified potential concerns and interventions to address those concerns to ensure care of the resident) dated 2/23/18 revealed that Resident 37 had the potential for alteration in cognition and showed periods of fluctuation of attention and impaired decision making skills. Resident 37 exhibited an alteration in activity of daily living skills related to right side paralysis and required moderate to extensive assistance with activities of daily living. The care plan identified that Resident 37 smoked, would be able to go outside at smoke times and smoke without injury to self, required a smoking apron as needed for safety (this was crossed out in the CCP) and smoking assessments were to be completed as needed to ensure safety while smoking. Observation on 4/10/18 at 9:17 AM revealed Resident 37 outside in the smoking area smoking a cigarette. Resident 37 had a black winter coat over their lap area and observation revealed the presence of white ashes on top of the coat and several circular burn holes in the fabric of the coat. Resident 37 did not have a protective smoking apron in place to prevent ashes from [MEDICAL CONDITION] fabrics. There were no staff present to provide supervision. Observation on 04/10/18 at 12:55 PM revealed that Resident 37 was seated in a wheelchair inside the door to the smoking area. Resident 37 had [MEDICAL CONDITION] the fabric of a black coat on their lap and on the shoulder of the shirt worn. Interview on 04/10/18 at 01:00 PM with Resident 37 confirmed that Resident 37 went out to smoke with other residents and did not wear any kind of protective apron to keep ashes from burning their clothing. Observation on 04/10/18 at 01:04 PM revealed that Resident 37 was seated in the outside smoking area, smoking a cigarette, with a black coat over their lap and no protective apron to prevent ashes from falling and burning the fabric of the coat. [NAME] ashes were present on the coat. No staff were present to provide supervision. Observation on 04/11/18 at 09:05 AM revealed that Resident 37 was seated in the outside smoking area and had regular cotton gloves on while smoking a cigarette. Resident 37 had a coat over their lap and no protective apron to prevent ashes from falling and burning the fabric of the coat. [NAME] ashes were present on the coat on the lap. No staff were present to provide supervision. Record review of a Progress Note entitled Smoking Safety Evaluation dated 2/23/18 revealed that the last smoking safety assessment for Resident 37 was completed on 2/23/18. It revealed that Resident 37 was able to smoke without supervision if the rules were followed. Recent evidence was noted that Resident 37 had been smoking in the bathroom in the facility. Resident 37 was reminded that smoking was a privilege and cigarettes and lighter were returned to the nurse after smoking. Record review of a Safe Smoking assessment dated [DATE] revealed that Resident 37 was alert, drowsy, had limitations in range of motion, exhibited dimished response with reflexes, cigarettes were lit by others and did not dispose of ashes in ash tray. Will continue to monitor for safety 9/18/17. Record review of Resident 37's Medical Record showed no evidence that a safe smoking evaluation had been done between 6/13/17 and 2/23/18. Interview and observation on 04/11/18 at 09:05 AM with the facility Administrator confirmed that Resident 37 needed to re-evaluated for smoking safety and confirmed that Resident 37 had burn holes in a black coat over their lap. The Administrator confirmed that Resident 37 should have had fire retardant gloves on and had ashes on the coat in their lap. The Administrator confirmed that Resident 37 should have had a smoking apron on for safety. .",2020-09-01
537,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,838,F,0,1,4MTO11,"Based on record review and interview, the facility failed to develop a facility assessment to ensure services were available to residents. This had the potential to effect all residents in the facility. The facility census was 47. Review of the Facility assessment in progress revealed the facility is currently in the information gathering stage and does not have a fully developed facility assessment. Interview on 4/11/2018 at 3:00 PM with the Director of Nursing revealed the facility assessment is not completed at this time. Information is being collected to develop one.",2020-09-01
538,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,842,D,0,1,4MTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.16A Based on record review and interview, the facility failed to ensure physicians orders for medications were obtained on admission for 1 resident (Resident 16) of 5 residents sampled. The facility staff identified the census at 47. The findings are: A review of Resident 16's Admission Record revealed Resident 16 was admitted to the facility on [DATE]. A review of Resident 16's medical record revealed there were no physician's orders present in the record for the resident's medications from admission. A review of Resident 16's Medication Administration Record [REDACTED]. A review of Resident 16's Medication Administration Record [REDACTED]. A review of Resident 16's Medication Administration Record [REDACTED]. An interview conducted on 4-12-18 at 9:43 AM with Registered Nurse (RN) F confirmed there were no physician's orders for medications present in Resident 16's medical record. RN F confirmed that the resident's medication list was printed on 4-12-18 and sent to the physician for signature and that the resident had been receiving medications since admission. An interview conducted on 4-12-18 at 10:43 AM with RN F and the Administrator revealed that Resident 16 was admitted from home and came with bottles of medications and that the nurses were giving medications based on the information on the prescription bottles. The Administrator confirmed there was not a physician's order stating that the medications brought in by the family were current and that the resident should continue those medications. RN F and the Administrator reported that the nurses could not give medications without a physician's order.",2020-09-01
539,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2018-04-12,923,E,0,1,4MTO11,"Licensure Reference Number 175 NAC 12-007.04 D Based on observation, record review and interview; the facility failed to ensure that the ventilation system was operational in 5 (Rooms 303, 304, 306, 307 and 310) of 36 occupied resident rooms. This had the potential to affect odor control in the 300 hall of the facility. The facility census was 47. Findings are: Observation during the environmental tour on 4/11/18 between 10:30 and 10:50 AM with facility Maintenance Assistance (MA) A revealed no working ventilation system in the bathrooms in Resident Rooms 303, 304, 306, 307 and 310. The MA took a one ply square of toilet paper and held it flat against the ventilation system cover in the bathrooms of Resident Rooms 303, 304, 306, 307 and 310. The ventilation system in those rooms did not hold the paper to the outside of the ventilation cover which indicated that there was no air draw and the ventilation system was not working. Interview on 4/11/18 at 10:50 AM with the MA A confirmed that there was no air draw in those bathrooms. The MA A confirmed that the ventilation systems were not working and was not sure if they were routinely checked for draw to ensure they were operational. The MA confirmed that if they were not working, this could have an affect on odor control in the facility. Record review of documentation of ventilation checks revealed that the ventilation system had been checked monthly for draw and the last ventilation system check had been completed on 3/6/18. Interview on 04/11/18 at 11:39 AM with the facility Administrator confirmed that the ventilation system had last been checked over a month ago and agreed that the system should be checked more frequently to ensure the system remained operational.",2020-09-01
540,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,576,F,0,1,0UPJ11,"Licensure Reference Number 175NAC 12-006.05(12) Based on observation and interview, the facility failed to ensure mail was delivered on Saturdays. This had the potential to affect all residents in the facility. The facility census was 44. Findings are: Observation on 06/11/19 at 1:45 PM revealed a sign at the nurse's station which identified that mail is not delivered in the facility on Saturday. Interview with 13 residents during the facility resident council meeting on 6/11/19 at 1:10 PM confirmed mail was not received on Saturdays. Interview with the South Sioux City post office staff confirmed that mail is delivered in the community on Saturdays. Interview with the facility Administrator on 6/11/19 at 1:50 PM confirmed that the facility does not take mail delivery on Saturdays as there is no one in the facility to deliver mail on Saturdays.",2020-09-01
541,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,582,E,0,1,0UPJ11,"Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to ensure beneficiary notices were completed to include the type of care provided, reason for ending of services, and the anticipated cost of services. This affected 3 (Residents 18, 16, and 6) of 3 residents reviewed. The facility census was 44. Findings are: [NAME] Record review of Resident 18's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) (A letter that identifies Medicare services ended) revealed no documented information related to care received, reason Medicare may not pay, or estimated cost of services. B. Record review of Resident 16's SNFABN revealed no documented information related to care received, reason Medicare may not pay, or estimated cost of services. C. Record review of Resident 6's SNFABN revealed no documented information related to care received, reason Medicare may not pay, or estimated cost of services. The SNFSBN was provided one day after the end of services. Interview with the facility Director of Nursing on 6/12/19 at 2:50 PM confirmed that Resident 18, 16, and 6 SNFABN's were not completed as required and that Resident 6's SNFABN should have been provided before the date of end of services.",2020-09-01
542,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,606,D,1,1,0UPJ11,"> Licensure Reference Number: 175 NAC 12-006.04A3 Based on record review and interview, the facility failed to ensure criminal background checks were completed on 1 of 5 staff files reviewed. The facility census was 44. Findings are: Review of Nursing Assistant (NA) A's employee file revealed no criminal background check in the personnel file. Interview on 6/11/2019 at 11:40 AM with the business office manager revealed no background check was in the employee file, and unable to find criminal background check in the emails from the company. Interview on 6/11/2019 at 12:00 PM with the business office manager revealed contact had been made with the company providing the background check and the company had no record of a background check being completed.",2020-09-01
543,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,609,E,1,1,0UPJ11,"> Licensure Reference Number: 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit completed investigations of alleged abuse within 5 working day to the state agency for 8 of 8 residents reviewed. Residents 14, 37, 6, 11, 28, 21, 34. The facility census was 44. Findings are: [NAME] Review of the facility report for resident 28 revealed the facility did send the report to the incorrect number. Review of the facility's undated policy titled Abuse and Neglect Reporting revealed the following: - An internal investigation will be completed by the facility within 5 working days of the notification of the allegations. - The facility manager or administrator will send a copy of the completed internal investigation including the facility conclusions within five working days to the state agency. Interview on 06/11/19 at 10:57 AM with the Administrator revealed the investigations have been sent to an incorrect number instead of to the state agency number listed in the abuse policy. B. Review of the facility investigations provided for last 12 months revealed an investigation was completed for Resident 37's fall on 2/28/2019. Interview on 06/11/19 at 1:28 PM with the facility administrator revealed an investigation was completed, however, no confirmation that the investigation was submitted to the state agency was with the file. C. Record Review of the facility investigation for Resident 14 dated 1/5/2019 reveals that an investigation was completed for resident 14. However, the investigation was not sent to the designated state agency. An interview with the Administrator on 6/12/2019 at 3:20 PM confirmed that there was no fax transmittal confirmation for the investigation to the state agency. D. Record Review of the facility investigation for Resident 34 dated 5/25/2019 reveals that an investigation was completed for resident 34. However, the investigation was not sent to the designated state agency. An interview with the Administrator on 6/12/2019 at 3:20 PM confirmed that there was no fax transmittal confirmation for the investigation to the state agency. Record Review of the facility investigation for Resident 34 dated 3/23/2019 reveals that an investigation was completed for resident 34. However, the investigation was not sent to the designated state agency. An interview with the Administrator on 6/12/2019 at 3:20 PM confirmed that there was no fax transmittal confirmation for the investigation to the state agency. E. Record Review of the facility investigation for Resident 6 dated 3/10/2019 reveals that an investigation was completed for resident 6. However, the investigation was not sent to the designated state agency. An interview with the Administrator on 6/12/2019 at 3:20 PM confirmed that there was no fax transmittal confirmation for the investigation to the state agency. Resident #19 F. 06/12/19 08:36 AM Record Review of the facilities investigation for Resident 11 , Intake number NE 754 The Facility was unable to provide evidence that the incident was sent to DHHS, They did do an investigation, no Injuries were sustained, his Wander Guard device was tested and secured. Assisted Living Residents and staff have been alerted to the potential concerns with opening the interior Assisted Living door. 06/12/19 01:00 PM An interview with Administrator revealed that she had been following an older Policy for Abuse/Reporting policy and procedure that had the wrong fax number for DHHS [NAME] 06/12/19 10:29 AM Record Review: Of incident number NE 977 the facility cannot show evidence that they faxed the incident to DHHS, the facility did not provide an investigation report. 06/12/19 01: 00PM An interview with the Administrator did acknowledge that she was using the Policy for Abuse Reporting that had the wrong fax number for DHHs (Matney Colonial Manor) Abuse/reporting policy and Procedure",2020-09-01
544,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,693,D,0,1,0UPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09D6 (1) Based on observation, record review, and interview; the facility failed to ensure the head of the bed was at the physician ordered height of 45 degrees during tube feedings (a liquid form of nourishment that is delivered to your body through a flexible tube). This affected one (Resident 4) of one resident observed. This practice had the potential to create fluid buildup in the lungs resulting in infection. The facility census was 44. Findings are: Record review of Resident 4's Admission Record dated 7/16/18 revealed [DIAGNOSES REDACTED]. Record review of Resident 4's Care Plan (a medical document that outlines the specific information for providing care to an individual resident) dated 5/21/19 identified Resident 4 receives all nutrition and hydration per peg tube (a flexible tube placed through the skin into the stomach that is used for tube feeding). Record review of the physician fax dated 4/7/19 noted significant rhonchi (an abnormal lung sound indicating fluid or obstruction in the lungs) in Resident 4's right and left lungs and a cough with congestion (an abnormal accumulation of fluid). Record review of a communication from a medical clinic dated 4/16/19 noted that Resident 4 had some congestion in the lungs. The communication noted that it was found that Resident 4 had been getting the tube feedings while lying a little too flat though the order had been to have Resident 4 elevated at all times. Observation of the tube feeding for Resident 4 on 6/11/19 at 11:14 AM revealed that the head of the bed was elevated at less than 45 degrees during the tube feeding per visual measurement. Measurement of the head of the bed elevation with a protractor (a measuring instrument used to measure angles) for Resident 4 on 6/11/19 at 3:00 PM confirmed that the head of the bed was measured at 25 degrees elevation. Record review of the facility policy titled Enteral Tube Feeding via Gravity Bag dated (MONTH) 2011 contained a step to position the head of the bed at 30-45 degrees for feeding unless medically contraindicated (a condition that serves as a reason to withhold a certain medical treatment that would cause harm to a patient). Record review of the Physician's Orders dated 4/15/19 revealed that the head of the bed was to be up at 45 degrees at all times for Resident 4. Interview with the Director of Nursing (DON) on 6/11/19 at 3:00 PM confirmed that Resident 4's bed was not at 45 degrees. The DON confirmed that the bed of Resident 4 was at 25 degrees per measurement with a protractor.",2020-09-01
545,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,698,D,0,1,0UPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to evaluate and provide care for a [MEDICAL TREATMENT] for Resident 7. The facility census was 44. Findings are: Record review on 06/11/19 at 10:00 AM of the Treatment Administration Record (TAR) and Care Plan did not show any information about the [MEDICAL TREATMENT], location , or how to care for and monitor the site. An interview on 06/11/19 10:33 AM with the Director of Nursing ( DON ) revealed that the TAR and the Care Plan did not include information about the [MEDICAL TREATMENT] or charting of the Residents access site. There was no documentation on either site that refer to the [MEDICAL TREATMENT] access.",2020-09-01
546,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,755,E,1,1,0UPJ11,"> Licensure Reference Number 175NAC 12-006.12E 1b Based on record review and interview, the facility failed to ensure narcotic count was verified and documented to be correct with 2 staff at change of shift for 10 (Residents 19, 42, 2, 13, 7, 15, 29, 95, 96)of 10 residents with orders for narcotics.The facility had a census of 44. Findings are: Record Review of the Narcotic log from 5/24/19 thru 6/8/19 revealed several shifts that only one signature was recorded on the narcotic log when the off going nurse and the oncoming nurse did the narcotic count. Interview on 06/11/19 02:34 PM with the Director of Nursing confirmed that two signatures were not being recorded after the narcotic count was done by the off going nurse and the oncoming nurse.",2020-09-01
547,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,880,F,0,1,0UPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.17D Based on observation, record review, and interview; the facility failed to ensure hand washing and gloving occurred in a manner to prevent cross contamination (a process by which bacteria or other germs are transferred from one surface to another or from one resident to another). This affected two (Residents 4 and 13) of two residents observed. This practice had the potential to cause wound infection during wound care, cause lung infection during tube feeding, and cross contamination infections. The facility failed to develop and implement and infection control tracking program which had the potential to affect all residents. The facility census was 44. Findings are: [NAME] Review of the facility policy titled Hand washing/Hand Hygiene dated (MONTH) 2012 revealed employees must wash their hands for at least 15 seconds using soap and water before and after changing a dressing, after handling soiled (dirty) or used dressings, after handling soiled equipment or utensils, and after removing gloves. Review of the facility Wound Care policy dated (MONTH) 2010 revealed the following steps: 2. Wash and dry hands thoroughly. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard. Wash and dry your hands thoroughly. 10. Wear gloves when touching the wound. 13. Dress the wound. 16. Discard disposable items, discard all soiled laundry, remove disposable gloves, and wash and dry your hands thoroughly. Review of the Care plan (a medical document that outlines the specific information for providing care to an individual resident) dated 5/21/19 identified that Resident 13 had an open pressure ulcer (damaged skin from staying in one position too long) on the left ankle and an open pressure ulcer on the coccyx (a bony area at the bottom of the spine) due to immobility due to [MEDICAL CONDITION] (decreased function of the legs). Observation of wound care for Resident 13 on 6/11/19 at 10:41 AM revealed that Licensed Practical Nurse (LPN) Z put on gloves and cleaned the top of the cart with disinfectant wipes. LPN Z removed the gloves and performed hand washing with soap and water for 11 seconds. LPN Z put on a new set of gloves. LPN Z then disinfected the bandage scissors with a disinfectant wipe and removed the gloves and performed hand hygiene with soap and water for 9 seconds. LPN Z removed the dressing from the coccyx wound on Resident 13 and then removed the gloves and performed soap and water hand washing for 8 seconds before putting on new gloves. LPN Z put on new gloves and removed the dressing from the wound on Resident 13's left ankle and performed hand washing with soap and water for 9 seconds after removing gloves. Interview on 6/12/19 at 2:52 PM with the Director of Nursing (DON) confirmed that hand washing was to be performed for 15-20 seconds and performed upon starting a dressing change and after removing a dressing. The DON confirmed that hand washing was to be performed between touching dirty and clean surfaces. B. A review of the policy titled Hand washing/Hand Hygiene dated (MONTH) 2012 revealed that employees must wash their hands for at least 15 seconds using soap and water under the following conditions: Before and after handling peripheral vascular catheters (a flexible tubing inserted into a blood vessel used to provide medications or fluids) and other invasive devices (a medical device inserted into the body through the skin or other openings) that includes a peg tube (a flexible tube placed through the skin into the stomach), and after removing gloves. A review of the policy titled Enteral Tube Feeding via Gravity Bag dated (MONTH) 2011 contained a procedure step to wash hands and dry thoroughly prior to initiating tube feeding (a liquid form of nourishment that is delivered to your body through a flexible tube). It contained a step to wash hands upon removal of gloves when tube feeding was completed. Observation of the tube feeding for Resident 4 on 6/11/19 at 11:14 AM revealed that Registered Nurse (RN) Y performed hand washing with soap and water for 3 seconds and then shut off the water with a bare hand prior to beginning the tube feeding. RN Y put on new gloves and injected air into the peg tube and listened for air sounds over Resident 13's stomach and verified correct peg tube placement. RN Y initiated the tube feeding. RN Y removed the gloves and performed hand washing with soap and water for 7 seconds after tube feeding was completed. Interview with DON on 6/12/19 at 2:52 PM confirmed hand washing was to be performed for 15-20 seconds and before starting and upon completion of tube feeding. C. A record review on 6/11/19 at 9AM of the Antimicrobial Stewardship program policy (ASP) revealed that it is the responsiblity of the facility is to ensure appropriate use of antimicrobials through development and implementation of institutional policies, procedures, and compliance to ASP related processes. Record review revealed no Infection Prevention Monitoring Program Policy. An interview on 06/12/19 at 09:08AM with Director of Nursing and Infectious Disease Nurse revealed that they currently do not have a tracking program in place for infectious prevention monitoring.",2020-09-01
548,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,881,F,0,1,0UPJ11,"The facility failed to show a process for documentation of periodic review of antibiotic usage. This had the potential to affect all residents. This practice has the potential to effect all residents. The facility staff identified a census of 44. Findings are: A review of the facilities Antimicrobial Stewardship Program Policy (ASP) reveals the responsibilities include to ensure appropriate use of antimicrobials through development and implementation of institutional policies, procedures, treatment algorithm, monitor facility antimicrobial use, antimicrobial resistance patterns, and compliance to ASP-related processes. An interview with the Director of Nursing (DON) and the Infectious Disease nurse on 6/12/19 at 9:08 AM revealed that they currently are not tracking antibiotic use, resistance pattern and compliance to ASP-related processes.",2020-09-01
549,"CONTINENTAL SPRINGS, LLC",285082,3200 G STREET,SOUTH SIOUX CITY,NE,68776,2019-06-13,923,E,0,1,0UPJ11,"Licensure Reference Number: 175 NAC 12-007.04D Based on observation, record review and interview; the facility failed to ensure a working exhaust ventilation system in 3 of 9 resident rooms. Rooms 301, 303 and 310. The facility census was 44 Findings are: During environmental tour the ventilation systems in rooms 301, 303, 310 did not function in the bathrooms. No air draw was seen with a 1 ply square of toilet paper. Interview on 6/12/2019 at 10:00 AM with the Maintenance supervisor and owner confirmed that the ventilation system was not working. Review of the facility floor plan revealed nine residents rooms on the 300 center hall that housed 13 residents.",2020-09-01
550,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,550,D,0,1,YJWT11,"Licensure Reference Number: 175 NAC 12-006.05(21) Based on observations, interviews, and record review, the facility failed to assist one sampled resident (Resident 117) with dressing appropriately before coming to the dining room. Facility census was 128. Sample size was 29. Findings are: On 1/15/19 at 7:30 AM, Resident 117 was observed sitting in the dining room with several other residents. Resident 117 was wearing a plain undershirt, pajama pants, and regular socks without shoes. In an interview on 1/15/19 at 8:23 AM, LPN(Licensed Practical Nurse)-A revealed that Resident 117 was not dressed for the day but was still wearing pajamas as bathing was scheduled to be done soon. LPN-A stated that the resident would be dressed for the day after bathing was completed. At 8:31 AM on 1/15/19, breakfast was served to Resident 117 who was still in the dining room wearing pajamas. The resident did not attempted to eat but was observed walking in both the hallway and the dining room. The resident was redirected back to the table by LPN-A repeatedly. On 1/15/19 at 8:59 AM, Resident 117 was taken from the dining room to the tub room. At 9:20 AM the resident returned to the dining room wearing clean, neat clothing and shoes but no socks. Socks were quickly brought to the dining room and put on the resident there. The resident was then encouraged to eat the meal which had been sitting on the table since 8:31 AM. On 1/17/19 at 10:15 AM in an interview, RN(Registered Nurse)-B who served as the ADON (Assistant Director of Nursing) for Memory Support and the DON (Director of Nursing) verified that residents should be dressed before coming to the dining room even if scheduled for bathing. Both stated that residents might choose to come in pajamas if hungry but agreed that if food was not provided for an hour there was time for the resident to dress first. The MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used to develop resident care plans) for Resident 117 which was completed on 1/2/19 showed the need for extensive assistance with dressing and bathing.",2020-09-01
551,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,600,D,1,1,YJWT11,"> Licensure Reference Number: 175 NAC 12-006.05 (9) Based on record reviews and interviews, the facility failed to identify a criminal record for abuse for an employee (Nurse Aide-D) providing direct resident care resulting in a alleged abusive incident by the employee toward one non-sampled resident (Resident 27). Sample size was 29 current residents. Facility census was 128. Findings are: Record review of a Nebraska State Patrol Criminal History record revealed a RAP Sheet for NA (Nurse Aide)-D completed on 12/4/2018. The report revealed an Arrest Date of 10/5/2005 with a charge of Assault Child Abuse (1 Count). Further review of the Court Event revealed a Felony-3 disposition of Guilty by Conviction with a sentence of Prison 40 to 60 months Court Cost for the charge of Commit child Abuse Intentional/Injury. The report further documented NA-D was incarcerated at the State Department of Corrections from 7/20/2006 to 5/1/2008. Record review of NA-D's employment file revealed the facility hired NA-D for housekeeping on 7/17/18 and was transferred to direct care as a Nursing Assistant 8/1/17. Record review of a facility investigation of Abuse-Physical dated 12/3/2018 revealed Resident 27 was admitted to the facility's memory support unit on 4/22/2017. NA-D had been employed by the facility 1 year and 9 months and was an overnight nurse aide that frequently worked on the memory support units. On 11/26/2018 at approximately 2 a.m. the report documented another Nurse Aide (NA-W) was helping a resident when overhearing NA-D direct conversation toward Resident 27. The report recorded NA-D said Fine, if you are going to bed like this I will leave you with Poopy pants if you want to be (expletive curse word). Before leaving the room NA-W witnessed NA-D pick up residents pillow and throw it at the resident. A statement by NA-D to the Social Services staff regarding the incident revealed NA-D confirmed cursing at the resident. The report indicated NA-D was terminated. The outcome of the facility investigation of the alleged physical abuse was documented as founded. Interview with the facility Administrator on 1/16/19 at 10:20 a.m. confirmed that NA-D was hired by the facility and placed in a position of direct care staff Nurse Aide on 8/1/17. The Administrator confirmed NA-D was terminated from employment by the facility after confirming an investigation of abuse by NA-D toward Resident 27. The Administrator stated the facility had no knowledge of the prior felony conviction for child abuse by NA-D.",2020-09-01
552,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,606,D,1,1,YJWT11,"> Licensure Reference Number: 175 NAC 12-006.04A3(3) Based on record reviews and interviews, the facility employed a court convicted felon as a Nurse Aide providing direct care for residents on the special care memory support units (potential of 58 residents). The hiring resulted in the employee being terminated following a alleged abusive incident by the employee toward one non-sampled resident (Resident 27). Sample size was 29 current residents. Facility census was 128. Findings are: Record review of a Nebraska State Patrol Criminal History record revealed a RAP Sheet for NA (Nurse Aide)-D completed on 12/4/2018. The report revealed an Arrest Date of 10/5/2005 with a charge of Assault Child Abuse (1 Count). Further review of the Court Event revealed a Felony-3 disposition of Guilty by Conviction with a sentence of Prison 40 to 60 months Court Cost for the charge of Commit child Abuse Intentional/Injury. The report further documented NA-D was incarcerated at the State Department of Corrections from 7/20/2006 to 5/1/2008. Record review of NA-D's employment file revealed the facility hired NA-D for housekeeping on 7/17/18 and was transferred to direct care as a Nursing Assistant 8/1/17. Record review of a facility investigation of Abuse-Physical dated 12/3/2018 revealed Resident 27 was admitted to the facility's memory support unit on 4/22/2017. NA-D had been employed by the facility 1 year and 9 months and was an overnight nurse aide that frequently worked on the memory support units. On 11/26/2018 at approximately 2 a.m. the report documented another Nurse Aide (NA-W) was helping a resident when overhearing NA-D direct conversation toward Resident 27. The report recorded NA-D said Fine, if you are going to bed like this I will leave you with Poopy pants if you want to be (expletive curse word). Before leaving the room NA-W witnessed NA-D pick up residents pillow and throw it at the resident. A statement by NA-D to the Social Services staff regarding the incident revealed NA-D confirmed cursing at the resident. The report indicated NA-D was terminated. The outcome of the investigation of physical abuse was documented as founded. Interview with the facility Administrator on 1/16/19 at 10:20 a.m. confirmed that NA-D was hired by the facility and placed in a position of direct care staff Nurse Aide on 8/1/17. The Administrator confirmed NA-D was terminated from employment by the facility after confirming an investigation of abuse by NA-D toward Resident 27. The Administrator stated the facility had no knowledge of the prior felony conviction for child abuse by NA-D.",2020-09-01
553,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,607,D,1,1,YJWT11,"> Licensure Reference Number: 175 NAC 12-006.05 (9) Based on on record reviews and interviews, the facility failed to follow their abuse policy and procedures for pre-screening potential employees for negative findings on the Child Abuse and Neglect registry. The failure resulted in one sampled employee Nurse Aide-D with a court substantiated finding being employed by the facility providing direct resident care to residents on the memory support units. The facility terminated the employee for an alleged abusive incident by the employee toward one non-sampled resident (Resident 27). Sample size was 29 current residents. Facility census was 128. Findings are: Record review of NA (Nurse Aide)-D's employee file revealed the facility employed the staff member as a housekeeping aide on 7/17/17 and moved the employee to a direct care position as a Nurse Aide on 8/1/17. Record review of NA-D's employment file revealed the employee applied at the facility on 1/27/17. The employee documented No for the question Have you ever been convicted of a felony or misdemeanor other than a minor traffic accident on the application. Record review of the application revealed NA-D signed approval for the facility to obtain information from the Nebraska Child Abuse and Neglect Central Registry (CAN Registry) on 2/3/17. Review of NA-D's file revealed no documents showing the results of the CAN registry check. NA-D's file revealed a criminal background history for the previous 7 years (2010-2017) revealed no criminal history. Interview with the business office manager following the review of NA-D's employee file on 1/16/19 confirmed there was nothing in NA-D's file regarding the CAN registry finding and that it may have been misfiled. The business office manager stated they would continue trying to track down the report. Interview with the Administrator on 1/16/19 at 5:00 p.m. revealed the CAN registry finding for NA-D could not be found and stated the previous business office manager may have lost it. The facility contacted the CAN registry and obtained a copy dated 4/17/2017 for NA-D. Record review of the document dated 4/17/2017 obtained by the facility revealed the finding for NA-D recorded: CPS Registry: Court Substantiated. Date: 10/5/2005. Record review of a Nebraska State Patrol Criminal History record revealed a RAP Sheet for NA (Nurse Aide)-D completed on 12/4/2018. The report revealed an Arrest Date of 10/5/2005 with a charge of Assault Child Abuse (1 Count). Further review of the Court Event revealed a Felony-3 disposition of Guilty by Conviction with a sentence of Prison 40 to 60 months Court Cost for the charge of Commit child Abuse Intentional/Injury. The report further documented NA-D was incarcerated at the State Department of Corrections from 7/20/2006 to 5/1/2008. Record review of a facility investigation of Abuse-Physical dated 12/3/2018 revealed Resident 27 was admitted to the facility's memory support unit on 4/22/2017. NA-D had been employed by the facility 1 year and 9 months and was an overnight nurse aide that frequently worked on the memory support units. On 11/26/2018 at approximately 2 a.m. the report documented another Nurse Aide (NA-W) was helping a resident when overhearing NA-D direct conversation toward Resident 27. The report recorded NA-D said Fine, if you are going to bed like this I will leave you with Poopy pants if you want to be (expletive curse word). Before leaving the room NA-W witnessed NA-D pick up residents pillow and throw it at the resident. A statement by NA-D to the Social Services staff regarding the incident revealed NA-D confirmed cursing at the resident. The report indicated NA-D was terminated. The outcome of the investigation of physical abuse was documented as founded. Record review of the facility policy for Abuse and Neglect Prevention Standard revised in (MONTH) of (YEAR) revealed the following in the section entitled: Screening. All potential team members will be screened for history of abuse, neglect, or mistreating members of a vulnerable population. The facility will not employ individuals who: i. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . Interview with the facility Administrator on 1/16/19 at 10:20 a.m. confirmed that NA-D was hired by the facility and placed in a position of direct care staff Nurse Aide on 8/1/17. The Administrator confirmed NA-D was terminated from employment by the facility after confirming an investigation of abuse by NA-D toward Resident 27. The Administrator stated the facility had not obtained or recognized the CAN registry finding of abuse which was in violation of the facility policy.",2020-09-01
554,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,636,D,0,1,YJWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record review and interviews, the facility failed to complete the required Admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) for one sampled resident (Resident 103). Sample size was 29 current residents and 5 closed records. Facility census was 128. Findings are: MDS records for Resident 103 revealed the following: The resident entered the facility on 10/30/18 and was discharged to an acute hospital on [DATE]. The resident re-entered the facility on 11/7/18 and was discharged to an acute hospital on [DATE]. The resident re-entered the Faciltiy on 11/29/18. The resident had PPS (Prospective Payment System MDS used for re-reimbursement purposes) assessments done on 12/6/18; 12/13/18; 12/27/18; and 1/3/19. There were no records that a comprehensive Admission MDS had been completed. Interview on 1/16/19 at 11:00 a.m. with the facility MDS Coordinator, RN (Registered Nurse)-V verified Resident 103 had initially entered the facility on 10/30/18 and was hospitalized twice after admission with a re-admit on 11/29/18. RN-V confirmed Resident 103 had not had a comprehensive admission MDS completed as required. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.16 (MONTH) (YEAR). This manual is an instructional manual given to facilities on completing MDS assessments. The Admission assessment is a comprehensive assessment for a new resident, under some circumstances, a returning resident that must be completed by the end of day 14, counting the day of admission to the nursing as day 1 .",2020-09-01
555,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,656,D,0,1,YJWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C Based on observations, record reviews, and interviews, the facility failed to identify and develop care plan interventions pertaining to: 1) pain concerns for one sampled Resident (Resident 54); and 2) the use of supplemental oxygen for one sampled resident (Resident 105). Sample size was 29 current residents. Facility census was 128. Findings are: [NAME] Record review of Resident 54's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed the resident was admitted to the facility on [DATE]. Record review of a Quarterly review MDS assessment on 11/20/18 revealed the resident reported during interview that pain was present frequently and rated the pain as mild. Interview with Resident 54 on 1/14/19 at 3:49 p.m. revealed the resident had a chronic left hip problem needing surgical intervention. The resident described due to the problem the resident experienced ongoing pain on most days. The resident stated that a surgery was scheduled related to the problem. An Orthopedics document signed by the resident on 1/9/19 revealed Resident 54 was scheduled for a Left hip conversion, total hip surgery on 2/2/29. A 'Physician Communication Form dated 12/7/2018 revealed the physician had evaluated Resident 54 and described new pain L (left) hip- sharper. Record review of Resident 54's Care plan printed on 1/17/19 revealed no focus problems identified for the resident's ongoing hip pain requiring upcoming surgery. There were no goals or interventions developed regarding the resident's pain. Interview with the DON (Director of Nursing) on 1/17/19 at 9:45 a.m. confirmed Resident 54's care plan had not been developed to address the ongoing left hip pain and upcoming surgery. B. Observation on 01/14/19 at 04:25 p.m. Resident oxygen concentrator is located in Resident 105's room and Resident 105 is out of the room. Observation on 01/16/19 at 10:28 a.m. Resident 105 is sitting in the recliner and has nasal cannula in place with oxygen running at 1 liter. Observation on 01/16/19 at 11:30 a.m. Resident 105 is sitting in the recliner observing television and has nasal cannula on with oxygen concentrator running at 1 liter. Resident Interview 1/16/19 at 10:30 a.m. Resident 105 reported being on 1 liter of oxygen to keep her oxygen saturations above 90%. Record Review of Resident 105's Admission Face Sheet revealed that Resident 105 was admitted to the facility on [DATE]. Record review MDS dated [DATE] identified Resident 105 being on oxygen. Record review of Resident 105 care plan identified that no care plan had been developed to address Resident 105's oxygen use. Staff interview on 01/16/19 at 12:05 p.m. Director of Nursing verified there was no care plan developed to address Resident 105's oxygen use even though Resident 105 had physician orders [REDACTED]. Director of Nursing reported this would be addressed immediately and that Resident 105 would have a care plan in place addressing the use of oxygen. Staff interview on 01/17/19 at 10:40 a.m. Staff interview with Administrator verified a care plan should have been developed to address Resident 105's oxygen use.",2020-09-01
556,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,677,E,0,1,YJWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, record review, and interview the facility failed to provide the care and treatment to ensure the ability for 1 unsampled resident (Resident #30) to maintain good nurtition. Census: 128 residents. Sample size: 29 residents. Findings are: An observation on 01/16/19 at 07:40 AM revealed Resident #30 had a bowl of oatmeal and a plate with pureed scrambled eggs for breakast. Resident #30 was attempting to eat the oatmeal out of a bowl by leaning down and forward to the bowl in order to scoop the oatmeal into his mouth with a spoon. A tablemate, Resident #6 called out to NA-Q (nurse aide). (NA-Q, NA-Q), (Resident #30) is dumping food on the table. (NA-Q), (Resident #30) isn't getting a whole lot to eat. There was no response from NA-Q and no assistance offered to Resident #30 from NA-Q or any other staff. An observation on 01/16/19 at 12:15 PM revealed Resident #30 had a piece of cake in a small dessert dish and lunch in a modified plate that had high edges. Resident #30 leaned forward and down toward the table (cake) and used a spoon to assist in getting cake into mouth. The cake tumbled fromt he spoon. Resident #30 caught the piece of cake between mouth and the table in order to take a bite of cake. Resident #30 repeated the process until the cake was eaten. Resident #30 pushed dessert dish away slightly from the edge of the table and attempted to use the spoon to drage the lunch plate toward self in order to be able to eat. Resident #30 was able to catch the edge of the plate with the edge of a spoon but was unsuccessful in moving the plate closer in order to reach the food. Resident #30 attempted to scoop food into spoon but the plate/food was too far away for resident to reach the food adequately and scooped food onto the table, unable to get the food to mouth. NA's and licensed staff in the dining room throughout the meal time without offering assistance. On 1/16/19 at 1:30 PM a review of the care plan for Resident #30 revealed Resident #30 is care planned for a liberal geriatric, no added salt, puree diet with mechanical soft desserts and snacks due to the resident having a pocketing and choking hazard. It also revealed it is care planned for staff to allow adequate time for Resident #30 to ingest meal and to offer assistance as needed , and to assist as needed with eating. The record review also revealed that Resident #30 is at risk for potential impaired nutritional status, [DIAGNOSES REDACTED], difficuly in swallowintg and history of weight loss. On 1/16/19 at 12:45 PM an interview with MA-P (Medication aide) and NA-Q confirmed Resident #30 was unable to get to the lunch meal food in order to eat it because the plate was positioned too far away. NA-Q moved the plate of food closer to Resident #30 but offered no further assistance. On 1/17/18 at 09:30 AM an interview with RN-B (Registered Nurse) confirmed the lack of appropriate hand hygiene and the lack of staff monitoring resident behaviors during their dining experience. RN-B also confirmed the lack of staff engaging with residents. RN-B stated, We have young staff. They don't understand the elderly, let alone dementia. On 1/17/18/at 10:00 AM an interview with the Director of Nursing confirmed the lack of appropriate hand hygiene and the lack of staff monitoring resident behaviors during their dining experience. The Director of Nursing also confirmed the lack of staff engaging with residents. On 1/17/18 at 10: AM an interview with the Administrator confirmed the lack of appropriate hand hygiene and the lack of staff monitoring resident behaviors during their dining experience. The Administrator also confirmed the lack of staff engagin with residents.",2020-09-01
557,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,689,D,0,1,YJWT11,"Licensure Reference Number 175 NAC 12-006.09D7a Based on observation, record review and interview, the facility staff failed to turn off oxygen in 1 resident (Resident 119) room when the resident was not in the room. This affected 1 sampled resident (Resident 119) of 29 sampled residents and 4 closed records. The facility census was 128 residents. Findings are: Observation of Resident 119's room found the oxygen running in the room and the resident was out of the room on these dates: -1/14/2019 at 5:22 PM, -1/15/2019 at 7:10 AM, -1/16/2019 at 8:42 AM. Record review revealed Resident 119 was admitted to the facility 3/16/18. Review of the Doctor order for oxygen at 3 L per nasal cannula. Review of the MDS ( (Minimum Data Set, a federally mandated assessment and tracking tool) dated 1/7/19 coded oxygen. Interview with the ADON (Assisted Director of Nurses) on 1/17/2019 at 11:15 am revealed the oxygen should be turned off when the resident was not in the room.",2020-09-01
558,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,740,D,1,1,YJWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D5 Based on record reviews, observations, and interviews, the facility failed to develop an effective behavioral management program to address repeated and on-going resident to resident interactions for one sampled resident (Resident 73). Facility census was 128. Sample size was 29. Findings are: On 10/30/18, a facility incident report revealed that at 7:30 AM that morning Resident 73 was holding another resident (Resident 117) by the wrist. When that resident attempted to go another way, Resident 73 tugged on the other resident's arm and held on tightly. LPN(Licensed Practical Nurse)-A intervened, but Resident 73 became more upset grabbing the nurse and still not letting the other resident go. LPN-A had to seek help from other staff to get the residents separated. Resident 73 was taken down the hall by staff, and an order was obtained for [MEDICATION NAME] to be offered to Resident 73 when agitated or upset. On 11/7/18, a facility incident report revealed that at 2:00 PM that afternoon Resident 73 was standing next to the DON (Director of Nursing) when another resident (Resident 117) approached and hit Resident 73 on the right shoulder. Resident 73 tapped the other resident on the shoulder and stated, That kind of hurt. The other resident again raised a fist to Resident 73, but the DON was able to step between the residents and redirect them. The report stated that these residents had a history of [REDACTED]. On 11/30/18, a facility incident report revealed that at 2:30 PM that day Resident 73 and another resident (Resident 46) were observed holding hands. When the other resident attempted to walk away, Resident 73 pulled on that resident's arm. LPN-A tried to separate the residents, but Resident 73 squeezed even tighter on the other resident's right forearm before they could be separated. Resident 73 was then taken to the dining room and offered a snack. Resident 73 remained upset and was offered [MEDICATION NAME] but refused to take it. On 12/27/18, a facility incident report revealed that at 2:15 PM Resident 73 and another resident (Resident 25) were participating in an activity involving tossing a beach ball on a table. Resident 73 reached over and batted the ball out of the other resident's hands who became agitated and began cussing at Resident 73. Resident 73 made a rude gesture toward the other resident who then slapped Resident 73 on the left arm. The report stated that these two residents were to be kept separated during future activities, and this was reflected in the Care Plan for Resident 73. On 1/1/19, a facility incident report revealed that at 8:00 PM Resident 73 approached another resident (Resident 19) and grabbed that resident's walker with both hands refusing to let go. Staff attempted to redirect Resident 73 who then became combative with staff. The other resident then hit Resident 73 on the right arm before staff could separate them. On 1/14/19 at 12:56 PM while waiting for lunch, Resident 73 was observed approaching another resident (Resident 30) from behind and began walking fingers up the back of that resident's head, over the top of the head, and onto the forehead before a staff member responded. At that point, NA(Nursing Assistant)-C called to Resident 73 asking the resident to sit down. NA-C then approached Resident 73 and assisted the resident back to their seat at a different table where a bowl of peaches was available and the resident began to eat. On 1/14/19 at 3:55 PM, Resident 73 was observed approaching another resident (Resident 27) while that resident was sitting in a wheelchair in the hallway. Resident 27 swatted at Resident 73 but did not actually strike the resident due to inability to reach far enough. Resident 73 then walked around behind the wheelchair and pushed Resident 27 up the hall stopping only when facing a wall just outside the dining room. At that point, RN(Registered Nurse)-E came into the hallway and separated the residents. Resident 73 then entered the dining room and began talking to other residents with frequent hand gestures. At 4:30 PM, a different resident (Resident 46) grabbed Resident 73's arm from behind. NA-F who was approaching with another resident immediately separated Resident 73 and Resident 46. Resident 73 did not seem disturbed in any way by this interaction and continued talking in an animated fashion as before with residents in the dining room. On 1/4/19 at 4:40 PM during an interview, Resident 73's spouse reported that there were on going incidents of minor altercations among many residents and that the facility was quick to notify family when these occurred and would monitor the residents involved for injuries. On 1/15/19 at 4:35 PM, Resident 73 was observed approaching another resident who was sitting near the exit door of the dining room and patted that resident on the shoulder. Staff members in room included NA-G who was the Life Enrichment staff member on duty and LPN-H, but no one responded to this behavior. Resident 73 then returned to the hallway and began walking with another resident (Resident 117). When they reached the far end of the hallway, the other resident sat down on the couch. Resident 73 patted the other resident on the back and arm and asked the resident to continue walking. After the other resident continued to refuse to get up, Resident 73 resumed walking and continued a pattern of circling the hallway sometimes entering other residents' rooms. On 1/15/19 at 4:05 PM, an interview with NA-F and NA-I revealed that Resident 73 liked to walk but was pleasant when doing so and did not take other residents' belongings. Therefore staff simply observed this resident going in and out of rooms, talking to other residents, touching them, and so forth, but both stated staff would remove the resident from a room or situation if they felt it was necessary. They also reported that staff could watch residents walking in the hall on a monitor at the nurses' desk and would respond if something happened. On 1/15/19 at 4:48 PM, LPN-H revealed that Resident 73 was in a marching band when younger and enjoyed walking up and down the hallway often [MEDICATION NAME] while doing so. LPN-H verified that staff allowed Resident 73 to go in and out of other residents' rooms and to interact with other residents at will but do separate residents who appear to be upset or agitated with one another. On 1/16/19 at 4:00 PM an interview with NA-G who served as the Life Enrichment staff member for the 500 hallway revealed that Resident 73 enjoyed participating in exercise but must have a personal personal ball to avoid conflict with other residents. NA-G verified that the resident's Care Plan indicated that the resident carried a baby doll at all times, but NA-G also stated that the resident would carry the doll all day and become tired while doing so. It was difficult for staff to get the resident to put the doll down. Therefore, the doll was no longer provided for the resident routinely. On 1/17/19 at 8:00 AM, an interview with RN-J, MDS(Minimum Data Set, a federally mandated comprehensive assessment tool used to develop resident care plans) coordinator for the facility's Memory Support units verified that there were no specific interventions on this resident's Care Plan related to the resident's interactions with other residents except Resident 25. RN-J revealed that interventions following resident to resident interactions were usually put in place for the other resident involved as it was often Resident 73 who was hit. When asked whether Resident 73's behavior might have provoked the other residents, RN-J stated that was possible. RN-J was not aware of Resident 73 seeing any Behavioral Health practitioners. On 1/17/19 at 8:30 AM, an interview with the Memory Support Social Service assistant and the facility Social Worker revealed that Resident 73 had exhibited mothering behaviors toward other residents which they believed led to multiple situations where other residents hit this resident. The Memory Support Social Service assistant stated that Resident 73's spouse had rejected a suggestion that the resident go to a Behavioral Health unit but could not say whether other behavioral health options had been suggested to the spouse or attempted. This staff member also verified that interventions were often developed related to other residents rather than for Resident 73 which was why few specific interventions were on Resident 73's Care Plan. On 1/17/19, an interview with RN-B who was the ADON (Assistant Director of Nursing) for the Memory Support units began at 9:45 AM. RN-B verified that Resident 73 had not seen a Behavioral Health Practitioner due to the spouse's refusal to allow the facility to send the resident to a Behavioral Health Unit for treatment. RN-B could not say whether the spouse had been asked about utilizing local Behavioral Health Practioners and also revealed that the spouse had not been asked about this type of care for a very long time. At 10:15 AM, the DON joined the interview and verified that Care Plan interventions were usually put in place for other residents when Resident 73 was involved in resident to resident incidents. Both the DON and RN-B agreed that this resident's behavior contributed to these recurring resident to resident conflicts.",2020-09-01
559,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,761,D,0,1,YJWT11,"Licensure Reference Number 175 NAC 12-006.12E7 Based on observations and interviews, the facility failed to label bottles of liquid nutritional supplements with the date on which they were opened on 2 of 4 sampled medication carts. This had the potential to impact 1 sampled resident (Resident 80) and 2 non-sampled residents (Resident 75 and Resident 79) who were taking these supplements daily. Facility census was 128. Findings are: On 1/16/19 at 4:25 PM, observation of the medication cart on the 400 wing of the facility was completed with RN(Registered Nurse)-L. A bottle of UTI-Stat (a liquid supplement used for the management of urinary tract infections and for urinary tract health) was in the cart and was opened. RN-L revealed that this supplement was used by Resident 75 daily but was not used by other residents on the unit. RN-L verified that the bottle should be dated when opened to ensure efficacy of the product. On 1/16/19 at 4:50 PM, observation of the medication cart of the 300 wing of the facility was completed with LPN(Licensed Practical Nurse)-M. A bottle of UTI-Stat and a bottle of Pro-Stat (a liquid supplement containing 15 grams of protein in each fluid ounce) were both noted to be in the cart and opened. LPN-M revealed that Resident 80 received both of these supplements daily and that Resident 79 received Pro-Stat daily. LPN-M verified that these bottles should be dated when opened and discarded after 30 days. On 1/17/19 at 8:45 AM, an interview with the DON (Director of Nursing) verified that bottles of liquid supplements should be dated when opened and discarded after 30 days to ensure efficacy of the product when administered to residents.",2020-09-01
560,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,812,F,0,1,YJWT11,"Licensure Reference Number: 175 NAC 12.006.11E Based on observations and interviews the facility staff failed to complete proper sanitation of Food thermometers, to prevent cross contamination while preparing meals. This failure had the potential to affect all residents. Facility census was 129. Findings are: Observation on 01/16/19 at 11:20 a.m. DM (Dietary Manager)-T cleaned all the food thermometers with the same alcohol based wipe and them laid them all back down on the counter that had not been cleaned or sanitized after food preparation. Staff interview on 01/16/17 12:47 p.m. DM-T verified having used the same alcohol based wipe on all of the thermometers and then laid them all back down on the counter that had not been wiped or sanitized, there for having the potential to cross contaminate all food items being served. Staff interview on 01/17/19 10:30 a.m. DM (Dietary Manager)-U Verified that DM-T should not have used the same disinfecting wipe on all the food thermometers and should not have lade the thermometers on the counter top that had not been wiped down and disinfected. Staff interview on 01/17/19 at 10:42 a.m. Administrator verified that DM-T should not have wiped the all the thermometers down with the same alcohol based wipe and then laid them all back down on the counter that had not been wiped down or disinfected, as this could cause cross contamination. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; and (5) At any time during the operation when contamination may have occurred.",2020-09-01
561,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-01-17,880,E,0,1,YJWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17D Based on observation and interview the facility failed to provide a sanitary environment by preventing cross-contamination for 8 unsampled residents and 5 sampled residents. Census: 128 residents. Sample size: 29 [NAME] An obervation on 01/16/19 at 07:30 AM revealed Resident #25 seated at a dining room table holding a chocolate pudding cup with a small amount of pudding the bottom of the container. Resident #25 was putting own fingers into the pudding cup, licking own fingers and hand, licking the cup, scooting the cup across the table surface smearing the chocolate across the table, licking own fingers and hand and smearing the mix of sputum and chocolate pudding on the table. Resident #25 stood and took the cloth napkin and fork from tablemate (Resident #29), seated at the same table. Empty pudding container was left on the table. Resident #25 placed the fork beloning to Resident #29 back on the table. Resident #25 kept the napkin belonging to Resident #29 wrapped up in hand and began scooting the table. As Resident #25 pushed the table, the table leg/foot brushed past the right foot of Resident #29. NA-Q (nurse assistant) approached the table being pushed by Resident #25 and said, So, is (Resident #25) moving the table? NA-Q walked past as Resident #25 continued pushing the table without intervening. Resident #25 began wiping the pudding and sputum smeared table with the napkin belonging to Resident #29. Resident #25 began wandering toward Resident #19 with soiled napkin in hand and pudding on pants. NA-C escorted Resident #25 back to delegated chair for meal. Resident #25 began licking the pudding container, own fingers, and hand. An observation on 01/16/19 08:40 AM revealed MA-P (medication aide) was feeding Resident #19, stood up, went to and began rubbing the arms of Resident #57. MA-P was attempting to rouse Resident #57 so the resident would eat breakfast. After MA-P roused Resident #57, MA-P returned to feeding Resident #19. No hand hygiene was performed between contact with different residents. An observation on 1/16/18 at 08:40 AM also revealed NA-C sitting on a stool with wheels assisting Resident #25 with breakfast. NA-C left the side of Resident #25, rolled around to Resident #73, running hands across the shoulders and chair of Resident #117. NA-C began feeding Resident #73. No hand hygiene performed. While still sitting on wheeled stool, NA-C scooted from Resident #73 to another table, patted and rubbed Resident #27 and Resident #17 on the shoulders. NA-C went to the sink and performed appropriate hand hygiene, donned gloves, sat on wheeled stool between Resident #19 and Resident #74. NA-C picked up the walker belonging to Resident #19 and moved it to the side, and began feeding Resident #74, gloves still on, no hand hygiene performed between touching objects and feeding resident. An observation on 1/16/18 at 08:45 AM revealed Resident #25 standing at breakfast table touching the bowl and plate of Resident #117 and Resident #117 taking and eating a partially eaten piece of toast from the plate of Resident #25. NA-Q was standing at the table watching the exchange and offered no intervention. NA-C rose from other table and took Resident #25 out of the kitchen to the restroom. An observation at 01/16/19 08:50 AM revealed NA-C assisting Resident #25 back to her seat at the breakfast table. Resident #25 was cursing and jibbering loudly. NA-C sat and began assisting Resident #74 with her breakfast, no hand hygiene performed. NA-C rose and moved a walker belonging to Resident #19, walked to another table. Resident #30 was pulling the cereal bowl and spoon from the plate of Resident #26. NA-C removed the hand of Resident #30 from the cereal bowl and spoon belonging to Resident #26. NA-C left the bowl & spoon for Resident #26 to finish breakfast. On 1/17/18 at 09:45 AM an interview with RN-B (Registered Nurse) confirmed staff weren't [MEDICATION NAME] appropriate hand hygiene, the lack of staff monitoring resident behaviors during their dining experience in order to prevent staff to resident and resident to resident cross-contamination, and to provide a sanitary environment. On 1/17/18/at 10:15 AM an interview with the Director of Nursing confirmed staff weren't [MEDICATION NAME] appropriate hand hygiene, the lack of staff monitoring resident behaviors during their dining experience in order to prevent staff to resident and resident to resident cross-contamination, and to provide a sanitary environment. On 1/17/18 at 10:45 AM an interview with the Administrator confirmed that staff weren't [MEDICATION NAME] appropriate hand hygiene, the lack of staff monitoring resident behaviors during their dining experience in order to prevent staff to resident and resident to resident cross-contamination, and to provide a sanitary environment. B. Observations on 1/14/19 at 12:45 AM in the 500 hall dining room revealed NA(Nursing Assistant)-C was wearing gloves while feeding a resident peaches which were available on all tables. NA-C then began assisting another resident, took that resident's cup to the sink and prepared hot cocoa. While the cocoa was warming in the microwave, NA-C removed the gloves and washed hands before returning the cocoa to the resident. On 1/14/19 at 5:30 PM during the evening meal service on the 500 hall, NA-N was observed carrying juice cups to residents two at at time holding the cups by the top rims. NA-N was not wearing gloves. NA-N then picked up a fork and fed a bite of cake to Resident 74. NA-N encouraged the resident to continue eating and then went to the refrigerator and removed a container of juice from which a cup was filled and delivered to another resident. NA-N then left the dining area briefly. No hand hygiene was performed by NA-N during these observations. On 1/15/19 at 8:45 AM during breakfast in the 500 hall dining room, NA-O was sitting between Resident 26 and Resident 92. NA-O picked up a spoon and fed a bite of cereal to Resident 26. NA-O then handed a cup to Resident 26 before picking up another spoon and feeding cereal to Resident 92. This pattern of feeding both residents continued for several minutes with no hand hygiene performed by NA-O. On 1/15/19 at 8:50 AM, MA(Medication Aide)-P returned to 500 hall dining area and washed hands before sitting at a table between Resident 30 and Resident 26. MA-P began assisting both of these residents with their meals by loading food on spoons and feeding them or by assisting them with drinks. No hand hygiene was performed between caring for these residents. On 1/15/19 at 9:03 AM, a plate was brought to a table where Resident 6 had recently come for breakfast. MA-P prepared the food for this resident and placed a bite on the fork. MA-P then returned to the table where Resident 30 and Resident 26 were seated and continued assisting them as before. No hand hygiene was performed during these observations. On 1/16/19 at 12:25 PM in the 500 wing dining area, NA-Q was assisting Resident 30 by loading food on a fork and feeding the resident. NA-Q then began assisting Resident 19 in the same manner. No hand hygiene was performed between residents. NA-Q then left the dining area briefly and returned at 12:30 PM. NA-Q then approached Resident 117 and shook him gently by the shoulders in an attempt to encourage him to eat his lunch. NA-Q picked up Resident 117's fork and fed the resident a bite of cake. NA-Q walked to the nurse's desk area, picked up a rolling stool, and carried it out to the table to sit next to Resident 117. Next NA-Q scooted on the stool to another table to speak and interact with Resident 27. NA-Q touched Resident 27's hands and arms before returning to the table with Resident 117. NA-Q then began assisting Resident 117 by loading food onto a fork and feeding the resident. No hand hygiene was performed during these observations. On 1/17/19 during an interview with RN(Registered Nurse)-B who served as the ADON (Assistant Director of Nursing) for the facility's Memory Support units and the DON (Director of Nursing) who had joined the interview at 10:15 AM, both of these staff members verified that hand washing between touching or feeding different residents was necessary to avoid possible cross-contamination of food. C. Licensure Reference Number 175 NAC 12-006.17B On 1/14/19, lunch observation began at 12:00 PM in the 500 hall dining area. At 12:15 PM, Resident 25 was wandering from table to table picking up silverware and returning it to the tables. On 1/14/19 at 12:56, PM, Resident 73 was observed walking fingers up the back of Resident 30's head and over onto the forehead. NA-C called to Resident 73 and redirected that resident to a seat at another table where a bowl of peaches was still available which the resident began to eat without any hand hygiene being performed by or for the resident. On 1/14/19 at 5:25 PM, Resident 73 was observed rummaging through drawers in the dining area of the 500 wing. The resident opened a drawer which contained silverware and fingered numerous pieces before closing the drawer and opening another. During this time several staff members were moving in and out of the dining area but none of them responded to the resident touching the silverware. On 1/17/19 during an interview which began at 9:45 AM, RN(Registered Nurse)-B who served as the ADON (Assistant Director of Nursing) for the facility's Memory Support units verified that staff on the 500 hall often allowed Resident 73 to wander around the unit touching people and things at will. On 1/14/19 at 5:35 PM, Resident 73 had eaten over half of a serving of cake in a bowl. Resident 73 then placed the bowl in front of Resident 117, and that resident finished eating it. Staff members in the dining area did not respond to either resident during this exchange. Observations of laundry services included: On 1/14/19 at 12:15 PM, Laundry Staff member-S was observed delivering clean clothing to residents' rooms on the 500 hall. The clothes were laying in neat stacks inside an open top basket style cart with no covering. After clothes were taken into rooms and put away, the hangars were brought back into the hallway and were hung on the edges of the cart. When asked, this employee stated that they worked in laundry, housekeeping, and dietary as needed. Staff member-S stated that this style of cart was always used to return laundry. On 1/15/19 at 9:24 AM, Staff member-S was observed carrying clean mealtime coverups which were held in the staff member's arms next to the chest. The staff member was approached by Resident 25 who began touching the edges of the cloths . After the resident stepped away, Staff member-S entered the dining room on the 500 hall, opened a cabinet, and put the items away on a shelf before closing the cabinet door. Staff member-S then returned to an open cart like the one used the previous day to return resident clothing. This cart contained sheets, towels, and other linens some of which were placed into a covered rack in the storage room on the 500 hall. The staff member then took the open cart off the 500 hall and onto the 400 hall and began putting linen away there also. When asked, Staff member-S stated that there were two linen racks on the 400 hall which were being refilled from the cart at that time. On 1/16/19 at 11:25 AM Laundry Staff member-R was observed placing clean sheets, bedspreads, towels, wash cloths, and gowns from an uncovered cart into the linen rack in the 500 hall storage closet. When asked, Staff member-R revealed that they had worked in the laundry for over two year and verified that this style of cart was always used to return laundry. The open cart was then taken off of the 500 hall by Staff member-R. The Laundry Supervisor provided a copy of the facility's Laundry Audit on 1/17/19 which revealed that stored and transported linen should be covered.",2020-09-01
562,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,241,E,0,1,GKVB11,"Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interviews, the facility failed to ensure that 1) transfer slings were removed from wheelchairs before residents were taken into the dining room for seven sampled residents (Residents 4, 71, 1, 48, 36, 107 and 18), 2) transfer belts were removed from residents' waists after seated in the dining rooms for four sampled residents (Residents 106, 122, 123 and 134), 3) vital signs were not taken in the dining room for one sampled resident (Resident 18) and 4) tablecloths were not removed until two residents were finished with their meals (Residents 113 and 93) to promote dignity in public areas. The facility census was 102 with 15 current sampled residents and three closed records. Findings are: [NAME] Observations of the 600 wing dining room on 1/11/17 at 9:30 AM and 11:30 AM revealed Residents 4, 71, 1 and 48 seated in wheelchairs with the mechanical lift transfer slings draped over the back and sides of their wheelchairs. Further observations on 1/12/17 at 9:10 AM revealed Residents 4, 36, 1, 107, 48, 71 and 18 seated in wheelchairs in the dining room with the mechanical lift transfer slings draped over the back and sides of their wheelchairs. B. Observations of the 600 wing dining room on 1/11/17 at 9:30 AM and on 11:30 AM and on 1/12/17 at 9:10 AM revealed Resident 122 seated in a chair wearing a transfer belt (canvas belt placed around the resident's waist to aid in assisting staff to ambulate with the resident). Observations of the 500 wing dining room on 1/11/17 at 11:45 AM revealed Resident 106 seated in a chair wearing a transfer belt. Observations of the 500 wing dining room on 1/17/17 at 1:20 PM revealed Resident 123 seated in a chair wearing a transfer belt. Observations on the 600 wing dining room on 1/17/17 at 1:30 PM revealed Resident 134 seated in a chair wearing a transfer belt. C. Observations of the 600 wing dining room on 1/11/17 at 9:45 AM revealed NA (Nursing Assistant) - A obtained a blood pressure and pulse for Resident 18 while seated in the dining room with other residents and staff present. D. Observations of the 600 wing on 1/11/17 at 9:45 AM revealed Resident 113 seated at the dining room table with a supplement drink. Further observations revealed NA - B folded the tablecloth leaving about four inches next to the resident. Observations of the 500 wing dining room on 1/17/17 at 1:30 PM revealed Resident 93 seated at the table. Further observations revealed NA - C removed the tablecloth while the resident was still drinking juice. Interview with the Director of Nursing on 1/17/17 at 2:00 PM confirmed that the staff should remove transfer slings from wheelchairs and transfer belts after use to promote the residents' dignity in the dining rooms. Further interview confirmed that the staff should not obtain vital signs in public areas and should not remove tablecloths until the residents' were finished with their drinks to promote dignity for the residents.",2020-09-01
563,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,278,D,0,1,GKVB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B (3) Based on record reviews and interview, the facility failed to accurately code urinary incontinence on the admission MDS (Minimum Data Set, a federally mandated assessment tool used for care planning) for one sampled resident (Resident 84). The facility census was 102 with 15 current sampled residents and three closed records. Findings are: Review of the Face Sheet, printed 1/11/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE], revealed that the resident was occasionally incontinent of bladder (less that seven episodes of urinary incontinence during the assessment period). Review of the Urine Output Report, printed 1/12/17, revealed that the resident had 10 episodes of urinary incontinence during the assessment period (9/15/16 - 9/21/16) for the admission MDS. Interview with the Assistant Director of Nursing on 1/12/17 at 11:15 AM confirmed that the admission MDS was not coded accurately related to the resident's urinary incontinence. The ADON confirmed that the MDS should have been coded as frequently incontinent (seven or more episodes of urinary incontinence, but at least one episode of urinary continence).",2020-09-01
564,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,279,D,0,1,GKVB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on record review and interviews; the facility failed to ensure that care plans were developed to include: 1) a problem or concern with [MEDICAL CONDITION]/weight loss for one sampled resident (Resident 12), 2) a problems or concern with incontinence for 2 sampled residents (Resident 96 and 143 and, 3) a problem or potential for dehydration with the use of a diuretic for one sampled resident (Resident 143). The current sampled census was 15 with 3 closed record reviews. The facility census was 102 at the time of survey. Findings are: [NAME] Review of the Face Sheet for Resident 12 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS(Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) submitted for Resident 4 as an Admission assessment submitted on 10/31/16 revealed a weight of 146 pounds then a 15 day after Admission assessment with a weight of 143, and a 30 day after admission assessment with a weight of 128. Interview on 1/11/17 at 1:40 PM with the (Registered Dietician) RD - [NAME] revealed that when Resident 12 had been admitted to the facility the resident was a post surgical repair of a [MEDICAL CONDITION] with [MEDICAL CONDITION] to the lower extremities and did have thigh high [NAME] hose in place. Further interview revealed that the resident's weight was up from the normal weight of the resident upon admission with [MEDICAL CONDITION] to the lower extremities. Review of the Care Plan for Resident 12 revealed no written documentation of problem or concern for [MEDICAL CONDITION] to the lower extremities or the use of thigh high [NAME] hose. Review of the Interdisciplinary Progress Notes/Admit Nutritional Assessment for Resident 12 dated 11/8/16 revealed a usual body weight for the resident of 130 pounds. Further review revealed no written documentation of the resident from 11/2/16 through 12/1/16 with a significant weight loss due to increased activity and decreased swelling. Interview with the Administrator, the (Director of Nursing) and the (Assistant Director of Nursing) on 1/18/17 at 11:30 AM verified that the care plan for Resident 12 had not been developed to include that the resident had [MEDICAL CONDITION] and required the use of compression to the lower extremities with thigh high [NAME] hose. Further interview revealed that the resident did have [MEDICAL CONDITION] upon admission to the facility post op of having a [MEDICAL CONDITION] repair and did have some weight gain with the [MEDICAL CONDITION]. Further interview confirmed that the Interdisciplinary notes and the care did not include assessments of the [MEDICAL CONDITION] or written documentation of the [MEDICAL CONDITION] and potential weight loss. B. Review of the Face Sheet for Resident 96 revealed an admitted to the facility of 7/5/16. Further review revealed no written documentation of incontinence for this resident. Review of the Scheduled Toileting for Resident 96 dated 7/5/16 through 7/7/16 revealed episodes of incontinence. 7/21/16 through 7/27/16 revealed written documentation of episodes of incontinence. Review of the Care Plan dated 7/1/16 for Resident 96 revealed no written documentation of problems/ or concerns with incontinence. Review of the Interdisciplinary Progress Notes for Resident 96 dated 7/29/16 through 8/17/16 did revealed written documentation of the resident with incontinence episodes. Interview on 1/17/17 at 3:00 PM with (Licensed Practical Nurse) LPN - F verified that the scheduled toileting was for Resident 96 who was no longer at the facility. The LPN did verify that the resident did have incontinence while at the facility. Interview on 1/17/17 at 1/18/16 at 11:30 AM with the Administrator, the DON and the ADON confirmed that written information on the Toileting Schedule and in the Interdisciplinary Progress Notes for Resident 96 did contain information that the resident was incontinent. Further interview verified that the care plan for Resident 96 had not been developed to include that the resident was incontinent. C. Review of the Face Sheet printed 1/11/17 for Resident 143 revealed an admission date of [DATE] to the facility. Further review revealed a [DIAGNOSES REDACTED]. Further review revealed no written documentation of incontinence as a diagnosis. Review of the MDS(MInimal Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated as submitted on 11/8/16 as a Quarterly review for Resident 143 revealed that the resident did have incontinence. Further review revealed the use of a Diuretic. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan dated 8/20/16 for Resident 143 revealed no written documentation of a problems or concerns of incontinence, frequency of urination or the potential for dehydration with the use of diuretics. Interview on 1/17/17 at 3:00 PM with LPN - F verified that Resident 143 did have episodes of urgency and incontinence. Further interview revealed that the resident was also on diuretics and did have the potential for dehydration due to the diuretic use. Continued interview verified that the care plan had not been developed to include incontinence, urgency of urination or the potential for dehydration for Resident 143. Interview on 1/18/17 at 11:30 AM with the Administrator, the DON and the ADON verified that the care plan for Resident 143 had not been developed to include the incontinence, urgency in urination or the use of diuretics with the potential for dehydration for this resident.",2020-09-01
565,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,282,D,0,1,GKVB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews and interviews; the facility failed to implement care plan interventions related to 1) use of a Wanderguard (device placed on resident's wrists or ankles to set of the door alarm as the resident attempts to leave the secured unit) for one sampled resident (Resident 175) and 2) monitoring blood pressure and pulse weekly for one sampled resident (Resident 159). The facility census was 102 with 15 current sampled residents and three closed records. Findings are: [NAME] Review of the Face Sheet, printed 1/11/17, revealed that Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of the resident on 1/12/17 at 8:00 AM and 12:00 PM and on 1/18/17 at 12:30 PM revealed the resident seated in the dining room on the 500 wing which is a secured unit. Further observations revealed no Wanderguard on the resident. Review of the Care Plan, problem onset 12/22/16, revealed that the resident was an elopement risk related to wandering behaviors, and long and short term memory impairment. Approaches included place Wanderguard on resident that sounds alarms when the resident leaves building. Check Wanderguard daily. Interview with LPN (Licensed Practical Nurse) - D, Charge Nurse, on 1/18/17 at 10:15 AM revealed that the resident does not have a Wanderguard. Further interview revealed that no residents have a Wanderguard in the secured unit. Interview with the DON (Director of Nursing) on 1/18/17 at 10:20 AM confirmed that the care plan interventions were not implemented as the resident did not have a Wanderguard in place. B. Review of the Face Sheet, printed 1/11/17, revealed that Resident 159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, problem onset date 10/28/16, revealed that the resident was at risk for altered cardiac function related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Approached included monitor pulse and BP (blood pressure) weekly and prn (as needed). Review of the TAR Treatment Administration Record, dated (MONTH) (YEAR), revealed no documentation of weekly pulse or blood pressure. Interview with the DON on 1/18/17 at 10:30 AM confirmed that the weekly blood pressure and pulse should have been done and documented on the TAR as directed on the care plan.",2020-09-01
566,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,323,D,0,1,GKVB11,"Licensure Reference Number 175 NAC 12-006.09D7a Based on observations and interviews, the facility failed to ensure that oxygen concentrators were not left running in the resident rooms for 4 sampled residents (Resident 13, 29, 45, and 114). The current sampled census was 15 with 3 closed record reviews. The facility census was 102 at the time of survey. Finding are: Observation on 1/10/17 at 12:30 PM of the oxygen concentrator running with the tubing lying on the bed of Resident 114. Further observation revealed that the room was a semi-private room with Resident 39 identified as the roommate. Observation on 1/11/17 at 9:00 AM of the oxygen concentrator running and the tubing lying on the bed of Resident 114. Observation on 1/17/17 at 2:15 PM of the oxygen concentrator running and left draped over the concentrator in Resident 13's room. Observation on 1/17/17 at 2:20 PM of the oxygen concentrator running and left draped over the concentrator in Resident 45's room. Interview on 1/17/17 at 2:30 PM with (Registered Nurse) RN - F verified that the oxygen concentrators were on and running in the following residents rooms (Resident 13, 39, 45 and 114) while the residents were not in the rooms. Further interview verified that the concentrators should have been shut off when the residents were changed to portable oxygen tanks. Continued interview confirmed the safety potential for the residents with oxygen saturated items in the resident's rooms. Interview with the Administrator, the Director of Nursing and the Assistant Director of Nursing on 1/18/17 at 11:40 AM confirmed that oxygen concentrators were not to be left on while the residents were no longer in the resident rooms. Further interview verified a safety potential for Residents 13, 39, 45, and 114) for the oxygen saturated items in the rooms.",2020-09-01
567,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,329,D,0,1,GKVB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to 1) obtain a supporting [DIAGNOSES REDACTED]. The facility census was 102 with 15 current sampled residents and 3 closed records. Findings are: [NAME] Review of the Face Sheet, printed 1/11/17, revealed that Resident 159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed an order, dated 12/27/16, for [MEDICATION NAME], antipsychotic medication, for Unspecified dementia with behavioral disturbance and [MEDICATION NAME], antianxiety medication, for Anxiety disorder every four hours as needed. Further review revealed an order, dated 1/4/17, for [MEDICATION NAME], antidepressant medication, daily. Review of the Care Plan, goal date 2/8/17, revealed a problem, potential for injury or side effects related to [MEDICAL CONDITION] medications. Approaches included see behavior/intervention monthly flow record for targeted behaviors/potential side effects and monitor resident (sic) behavior and report any negative observations to physician. Further review revealed a problem, anxiety/mental distress as evidenced by crying and looking for mommy and daddy. Review of the Behavior/Intervention Monthly Flow Record, dated (MONTH) (YEAR), for [MEDICATION NAME], revealed instructions to monitor increased agitation. Further review revealed no specific targeted behaviors that the resident demonstrated to indicate increased agitation. Review of the Behavior/Intervention Monthly Flow Record, dated (MONTH) (YEAR), for [MEDICATION NAME] revealed instructions to monitor anxiousness. Further review revealed no specific targeted behaviors that the resident demonstrated to indicate anxiousness. Further review revealed no Behavior/Intervention Monthly Flow Record to address depression. Interview with the DON (Director of Nursing) on 1/18/17 at 10:30 AM confirmed that there was no documentation in the medical record of supporting [DIAGNOSES REDACTED]. Further interview confirmed that specific targeted behaviors were to be documented on the Behavior/Intervention Monthly Flow Record. The DON confirmed that specific targeted behaviors were not identified or monitored to ensure the therapeutic benefits of the [MEDICATION NAME] and [MEDICATION NAME]. B. Review of the Face Sheet dated as printed 1/11/17 for Resident 88 revealed an admission date of [DATE] to the facility. Further review revealed a [DIAGNOSES REDACTED]. Review of the Care Plan dated 4/22/16 for Resident 88 revealed a problem of alteration in pain with interventions of medications per physician orders [REDACTED]. Review of a Pain Evaluation Tool dated 4/19/16, 7/5/16, 9/20/16 for Resident 88 revealed that the resident did have current and past pain indicated on the tool. Review of the Medication Administration Record [REDACTED]. Review of the PRN MedicationTreatment Record for Resident 88 revealed no written documentation of completion in the follow up for the result of the pain and the effectiveness of the PRN(as needed) medications of [MEDICATION NAME] on 1/7/17 at 8:25 AM, 1/10 at 2:40 PM, 1/11 at 7:50 AM, and 1/11 at 3:05 PM. Continued review revealed no written documentation of completion on the effectiveness or result of the pain medication [MEDICATION NAME] on 1/10/17 at 2:40 PM for leg pain. Further review revealed no written documentation of completion on the effectiveness or results to Tylenol administered for leg pain on 1/11/17 at 3:05 PM. Interview on 1/17/17 at 3:00 PM (Registered Nurse) RN - H reveled that Resident 88 have a [DIAGNOSES REDACTED]. Further interview verified that once pain medications were administered to residents the nurse administering signed the administration record and within 1/2 hour to 1 hour followup was to be completed by a nurse in regards to the effectiveness of the pain medications and documented on the PRN Medication/Treatment Record. Interview on 1/18/17 at 11:15 AM with the Administrator, the DON, and the Assistant Director of Nursing verified that Resident 88 did have routine and prn medications for pain and did have a history of chronic pain issues. Further interview confirmed that when prn mediations were administered, follow up with the residents was to be completed within 1/2 hour to 1 hour after the administration of the prn medication to ensure the effectiveness of the medications. Continued interview verified that effectiveness was to be monitored and documented by the nurse or oncoming nurse during the shift. Further interview verified that the pain medications identified above had been administered to Resident 88 and the effectiveness of the medications had not been monitored per the facility policy.",2020-09-01
568,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,371,F,0,1,GKVB11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observations, record review, and interview, the facility failed to prevent the buildup of condensation and ice where frozen food items were stored inside the walk-in freezer. The failure had the potential of causing hazardous bacterial growth which could potentially contaminate food items affecting all facility residents. The facility census was 102 residents. Findings are: Initial tour of the facility kitchen on 1/10/17 beginning at 10:50 a.m. revealed the entry door to the walk in storage freezer had buildups of ice and frost running across the entire bottom seal of the door, on the handle to the door and along the seams of the door leading into the walk in refrigerator. Further observation of the walk in storage freezer revealed: when entering the floor had a buildup of slippery ice on the floor; the ceiling was caked with ice buildup and condensation 1/2 inch thick; the condenser was covered in ice buildup and condensation; and the hose to the condenser was completely covered in a buildup of ice and condensation. The hose to the condenser was in contact with stored frozen food items of pies and whipped topping and boxes of food items stored had buildups of ice crystals on top of the boxed items. Further observation revealed a buildup of ice in the walk in refrigerator with dripping water above stored food items on the east wall. Observation with the facility maintenance man on 1/17/17 at 2:05 p.m. confirmed the entry door to the walk in storage freezer had buildups of ice and frost running across the entire bottom seal of the door, on the handle to the door and along the seams of the door leading into the walk in refrigerator. Further observation of the walk in storage freezer revealed: when entering the floor had a buildup of slippery ice on the floor; the ceiling was caked with ice buildup and condensation 1/2 inch thick; the condenser was covered in ice buildup and condensation; and the hose to the condenser was completely covered in a buildup of ice and condensation. The hose to the condenser was in contact with stored frozen food items of pies and whipped topping and boxes of food items stored had buildups of ice crystals on top of the boxed items. Further observation revealed a buildup of ice in the walk in refrigerator with dripping water above stored food items on the east wall. Interview with the facility maintenance man on 1/17/17 at 2:05 p.m. verified the kitchen walk-in freezer had difficulty sealing and verified the ongoing severity of buildup of ice and condensation in the freezer which indicated the sealing problem needed to be investigated and corrected. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-303.12- (A) Packaged food may not be stored in direct contact with undrained ice. Source: Quality Assurance & Food Safety, (MONTH) (YEAR) quotes the Food and Drug Administration and the United States Department of Agriculture/Food and Safety Inspection Service related to condensation in guidance documents with the most recent a draft guidance from the Food Safety Modernization Act. The preventive rule discusses condensation buildup as a hazard for listeria, salmonella, and molds that produce mycotoxins (substances produced by mold growing in food that cause illness or death when ingested by man).",2020-09-01
569,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,467,E,0,1,GKVB11,"Licensure Reference Number 175 NAC 12-007.04D Based on observations and interview, the facility failed to ensure that the bathroom ventilation system was functioning for seven sampled residents (Residents 159, 106, 26, 93, 25, 44 and 109). The facility census was 102 with 15 current sampled residents. Findings are: Observations of resident rooms on 1/12/17 at 8:00 AM - 8:15 AM revealed no air pull from the bathroom ventilation systems in Room 501 (Residents 159 and 106), Room 505 (Residents 26 and 93). Further observation revealed bathroom odors in these bathrooms at 8:00 AM and at 9:15 AM. Observations of resident rooms on 1/12/17 at 8:00 AM also revealed no pull from the bathroom ventilation systems in Room 512 (Resident 25), Room 510 (Resident 44) and Room 514 (Resident 109). Observations of the resident rooms listed above on 1/17/17 at 1:00 PM, accompanied by the Maintenance Director, confirmed that the bathroom ventilation system was not functioning in the bathrooms. Interview with the Maintenance Director on 1/17/17 at 1:00 PM revealed that the motor for the ventilation system in the bathrooms was not functioning. Further interview confirmed that the motor needed to be replaced so that the ventilation system would function to manage bathroom odors and to promote comfort for the residents.",2020-09-01
570,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,469,D,0,1,GKVB11,"Licensure Reference Number 175 NAC 12-006.18B Based on observations and interview, the facility failed to ensure that bathroom ceiling light fixtures were clean and free of insects for five sampled residents (Residents 138, 123, 109, 36 and 1). The facility census was 102 with 15 current sampled residents. Findings are: Observations of resident rooms on 1/12/17 at 8:00 AM - 8:15 AM revealed insects in the bathroom light fixtures in Room 509 (Residents 138 and 123), Room 514 (Resident 109) and Room 605 (Residents 36 and 1). Observations of resident rooms listed above on 1/17/17 at 1:45 PM, accompanied by the Housekeeping Supervisor, revealed that the bathroom ceiling light fixtures still contained insects. Interview with the Housekeeping Supervisor on 1/17/17 at 1:45 PM confirmed that the bathroom ceiling light fixtures needed to be cleaned to remove the insects.",2020-09-01
571,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-01-18,514,D,0,1,GKVB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.16B Based on observations, record reviews and interviews; the facility failed to ensure that 1) a dietary supplement was documented as administered for one sampled resident (Resident 123), 2) a risk of elopement/wandering assessment was completed for one sampled resident (Resident 175) and 3) bruises and weights were documented for one sampled resident (Resident 69) to ensure complete and accurate documentation in the medical records. The facility census was 102 with 15 current sampled residents. Findings are: [NAME] Review of Resident 123's FAX, dated 1/3/17 and noted on 1/4/17, revealed an order for [REDACTED]. Review of the MAR Medication Administration Record, dated (MONTH) (YEAR), revealed no documentation of the Magic Cup. Interview with LPN (Licensed Practical Nurse) - G, Charge Nurse, on 1/12/17 at 10:15 AM revealed that the resident was receiving the supplement but was not documented on the MAR. Interview with the ADON (Assistant Director of Nursing) on 1/13/17 at 11:15 AM confirmed that the staff did not document the supplement on the MAR. Further interview confirmed that the staff were to document the administration of the supplement on the MAR to ensure complete and accurate documentation on the medical record. B. Review of Resident 175's Risk of Elopement/Wandering Review, dated 12/21/16 and 12/24/16, revealed that the back page, including Summary of Review was not completed, signed or dated. Interview with LPN - D, Charge Nurse, on 1/18/17 at 10:15 AM confirmed that the front page of the document was completed but forgot to complete the back page which summarized the information on the front page. Interview with the DON (Director of Nursing) on 1/18/17 at 10:20 AM confirmed that the nurses were to complete the back page of the assessment forms to ensure complete and accurate documentation of the resident's care in the medical record. C. Review of the Acute Care Plan dated 11/21/16 for Resident 69 revealed an actual skin impairment with bruising of the left upper forearm, the left hand by the 2nd digit, the right wrist, and the right forearm. Review of the Care Plan for Resident 69 dated revealed a potential for weight loss and to monitor the weights weekly. Review of the Treatment Record dated (MONTH) (YEAR) for Resident 69 revealed an order dated 11/21/16 to monitor bruising to right upper forearm, the left hand bruise by the 2nd digit, and the right wrist bruise with to assess all areas weekly until resolved. Further review revealed no written documentation of completion on 11/9 for all 3 areas identified. Continued review revealed an order for [REDACTED]. Interview on 1/17/17 at 4:30 PM (Registered Nurse) RN - H revealed that Resident 69 . The did take an anticoagulant and wss prone to bruising and did have bruising on the right wrist and forearm, and the left upper forearm and hand by the 2nd digit that are monitored until healed. Further interview reveaeld that the resident was on weights twice a week on bath days. Interview on 1/18/17 at 11:15 AM with the Administrator, the DON and the ADON verified that Resident 69's Treatment Record dated for Jan (YEAR) did no have written documentation of completion for the monitoring of the bruising to the right upper forearm, the left hand bruise by the 2nd digit, and the right wrist bruise. Further interview verified that there was no written documentation of completion for the weights on 1/4, 1/6, 1/11 and 1/13. Continued interview confirmed that written documentation should be completed by the person assigned and only after doing the specific task.",2020-09-01
572,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,641,D,1,1,6FMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006. 09B Based on record reviews and interviews, the facility failed to identify and code resident behavioral symptoms on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments for three sampled residents (Residents 26, 47, and 52). Sample size included 32 current residents. Facility census was 119. Findings are: [NAME] Record review of Resident 26's MDS assessment records revealed a Significant change in status MDS with a reference date of 11/9/17 was completed. The MDS revealed the resident was admitted to the facility on [DATE]. Review of the MDS section for Behavior assessment revealed the MDS recorded the resident had not exhibited any behavioral symptoms during the reference period of the MDS (11/3/17-11/9/17). Record review of Resident 26's Progress Notes revealed the following entries: - 11/9/17 at 1:31 p.m. a Social Services Review recorded the resident will hit, bite, kick, or scratch staff members sometimes . - 11/9/17 at 11:16 a.m. a Nutrition/Dietary Note recorded the resident refuses some of the mechanical soft diet and supplements. - 11/9/17 at 10:08 a.m. a Nutrition /Dietary Note documented the resident on some days and others refuses meals and supplements . - 11/4/17 at 9:50 p.m. the entry recorded the resident refused blood pressure procedure. - 11/4/17 at 11:55 a.m. the entry recorded staff were unable to obtain a blood pressure due to the resident being uncooperative. - 11.4.17 at 2:01 a.m. the entry recorded the resident tried to unwrap (dressing) left arm and remove splint. - 11/3/17 at 3:52 p.m. the entry read the nurse and nurse aide were in the room to reposition the resident and check the alarm. The Resident got combative with nurse and CNA (Nurse Aide). Resident hitting at nurse and cussing . - 11/3/17 at 9:45 a.m. the entry read . Res (Resident 26) is combative with cares this AM (morning). Res was hitting, kicking, and biting . Res refused AM meds (medications), breakfast, and fluids this AM. Hospice nurse was in to see res and tried to get (resident) to eat and res refused . B. Record review of Resident 47's MDS assessment records revealed a Quarterly review MDS with a reference date of 11/29/17 was completed. The MDS revealed the resident was admitted to the facility on [DATE]. Review of the MDS section for Behavior assessment revealed the MDS recorded the resident had not exhibited any behavioral symptoms during the reference period of the MDS (11/23/17-11/29/17). Review of Resident 47's Progress Notes revealed the following entries: - 11/29/17 at 2:49 p.m. a Social Services Review note recorded the resident will yell out and make sounds/noises . - 11/25/17 at 8:02 p.m. the staff administered a dose of [MEDICATION NAME] (a tranquilizing medication used to reduce anxiety) for anxiety. - 11/25/17 at 6:36 p.m. the staff administered a dose of [MEDICATION NAME] for anxiety due to Resident showing s/s (signs and symptoms) of anxiety, (the resident) was crying and chanting, then started beating hand on the dining room table . - 11/24/17 at 6:25 p.m. the staff administered [MEDICATION NAME] to the resident for anxiety. - 11/24/17 at 5:28 p.m. the staff administered [MEDICATION NAME] to the resident for anxiety due to the resident's repetitive speech, yelling out. Interview with RN (Registered Nurse)-D on 1/31/18 at 9:50 a.m. confirmed RN-D is an MDS Coordinator for residents on the Memory Support units including Residents 26 and 47. RN-D verified Resident 26's Significant Change MDS on 11/9/17 had not recorded the behavioral symptoms documented in the resident's progress notes on this MDS. RN-D also verified the Quarterly MDS on 11/29/17 had not recorded the behavioral symptoms documented in the resident's progress notes on this MDS. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (An instructional manual on how to accurately record and document sections of the MDS), Version 1.14, (MONTH) (YEAR). Regarding the Behavior section of the MDS, the manual instructs staff to: - Identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. - Coding Instructions instruct staff to code behaviors such as Physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually; Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others); and Other behavioral symptoms not directed toward others including verbal/vocal symptoms like screaming, disruptive sounds. - Regarding Rejection of Care the manual defines this as Behavior that interrupts or interferes with the delivery or receipt of care. Care rejection may be manifested by verbally declining statements of refusal or through physical behaviors that convey aversion to or result in avoidance of or interfere with the receipt of care. Examples of rejection of care in this section of the manual include resisting personal cares, meals, or medications during the reference period of the MDS. C. Record review of nursing notes from 12/07/17 revealed that resident (52) asked a nursing aide to wash private parts during bath. Nurse Aide refused and redirected resident (52). Resident (52) became upset, Nurse Aide became uncomfortable and had another Nurse Aide finish bath. Record review of Minimum (MDS) data set [DATE]. Revealed that the facility coded the incident of resident (52) under Section E-Behavior (E0200. Behavioral Symptom-Presence and frequency). The facility Coded the behavior in Section C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive). The behavior should have been coded in Section [NAME] Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). 01/31/18 11:17 AM Interview with DON confirmed that the Minimum Data Set (an assessment form used for reimbursement for nursing home facilities). Was not coded correctly for resident (52) instead of the behavior coded as Section C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive). It should have been coded in Section [NAME] Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). 01/31/18 11:33 AM Interview with the Administrator verified that the Minimum Data Set. Was not coded correctly for resident (52) instead of the behavior coded as Section C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive). It should have been coded in Section [NAME] Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually).",2020-09-01
573,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,657,E,0,1,6FMP11,"Licensure Reference Number: 175 NAC 12-006.09C1c Based on record reviews and interviews, the facility failed to include a Nursing Assistant or Nursing Assistants with knowledge or responsibilities of care for residents in the care planning process for five sampled residents (Residents 42, 47, 28, 86, and 58). Sample size was 32. Facility census was 119. Findings are: [NAME] Record review of Progress Notes for Resident 42 revealed on 12/5/17 a Care Plan Meeting for the resident was held at 3:32 p.m. The note identified the care plan meeting was attended by the resident's family members and the IDT (Interdisciplinary Team. B. Record review of Resident 47's Progress Notes revealed on 12/12/17 a Care Plan Meeting was held for the resident at 3:00 p.m. The identified the meeting was attended by the IDT. Interview with RN (Registered Nurse)-D, an MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator on 1/31/18 at 10:00 a.m. verified RN-D was part of the Care Plan team for residents residing on the Memory Support Units including residents 47 and 42. RN-D identified the IDT attending meetings on the Memory Support Units consisted of the resident and resident's family if they choose to attend, the unit Social Services person, Dietary, therapies if the resident received therapies, the licensed Restorative Coordinator if the resident received therapies, the MDS Coordinator (RN-D), and on occasion, the ADON (Assistant Director of Nursing). RN-D confirmed that Nurse Aides familiar with the resident's care were not included in the IDT. C. Record review of Resident 28's Progress Notes revealed on 11/29/17 at 3:37 p.m. a Care Plan Meeting was held for the resident. The note identified the care plan was attended by the resident, MDS (Coordinator), life enrichment (Activity person), restorative, and social services. D. Record review of Resident 86's Progress Notes revealed a Care Plan Meeting was held on 1/17/18 at 2:59 p.m. The note identified the meeting was attended by the MDS (Coordinator), Social Services, the resident, and family members of the resident. E. Record review of Resident 58's Progress Notes revealed a Care Plan Meeting was held on 1/2/18 at 2:00 p.m. The note identified the meeting was attended by a (Family member), MDS (Coordinator), Dietary, Life Enrichment, and Social Services. Interview with the Social Services Director on 1/3/1/18 at 10:45 a.m. revealed the Social Services Director attended care plan meetings for residents residing on the medical units of the facility including Residents 28, 86, and 58. The Social Services Director verified the care plan meetings in the medical units had not included a Nurse Aide responsible or familiar with resident cares. Record review of an undated facility list of the facility's Interdisciplinary Care Plan Team members, revealed members of the IDT were: The Administrator, Director of Nursing, Social Services, Restorative Nurse, MDS Coordinator, Infection Control/Staff Educator, and Assistant Directors of Nursing. Further review of the list revealed Nurse Aides were not identified on the IDT.",2020-09-01
574,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,684,D,0,1,6FMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09 Based on observation, record review and interviews, the facility failed to follow the physician order [REDACTED]. Census was 51. Findings are: Observations of Resident 93 revealed the following: -01/29/18 at 9:20 a.m. revealed the Resident's legs were swollen and Resident was wearing TED Hose as Resident sat in his recliner. -01/30/18 at 4:24 p.m. revealed the Resident was sitting in the wheelchair in the room and Resident was wearing TED Hose. -01/31/18 at 7:38 a.m. revealed the Resident legs were swollen and Resident was wearing TED Hose as Resident sat in the recliner observing television. Record review of Resident 93's Admission Record printed on 01/30/18 revealed Resident 93 was admitted to the facility on [DATE]. Record review of Resident 93's Physician order [REDACTED]. Use Walker. Continue with TED Hose for 2 weeks. Continue Anti-coagulants per Primary Care Physician. This revealed the Physician order [REDACTED]. Interviews conducted between 01/29/18 and 01/31/18 revealed the following: -Interview with Resident 93 on 01/29/18 at 9:20 a.m. revealed the resident was wearing TED Hose and Resident 93 reported staff had assisted with placing TED Hose on both feet. -Interview with Resident 93 on 01/30/18 at 4:24 p.m. revealed the resident was wearing TED Hose and Resident 93 reported staff had assisted with placing TED Hose on his feet as they do everyday. -Interview with Resident 93 on 01/31/18 at 7:38 a.m. revealed the resident was wearing TED Hose and Resident 93 reported staff had assisted with placing TED Hose on both feet. -Interview with NA (Nursing Aide)-A on 01/31/18 at 8:10 a.m. revealed Resident 93 has the tendency to refuse to wear TED Hose and NA-A is not aware if Resident 93 is wearing TED Hose or not. NA-A revealed NA (Nursing Aide)-B had assisted Resident 93 with activities of daily living this morning and maybe NA-B would be able to identify if Resident 93 is wearing TED Hose. -Interview with NA (Nursing Aide)-B on 01/31/18 at 8:15 a.m. revealed NA-B was not aware if Resident 93 was wearing TED Hose as someone in the therapy department provided the resident 93 with assistance in dressing this morning. -Interview with Therapy Manager on 1/31/18 at 9:02 a.m. revealed the physician order [REDACTED]. Therapy Manager revealed Occupational Therapist has been placing TED Hose on Resident 93's feet. -Interview with Occupational Therapist on 01/31/18 at 9:09 a.m. revealed the Occupational Therapist had continued to place the TED Hose on Resident 93's feet as the Occupational Therapist was not aware of the Physician order [REDACTED]. -Interview with LPN (Licensed Practical Nurse)-C on 01/31/18 at Revealed the Physician order [REDACTED]. LPN-C reports no new orders for Resident 93 to continue wearing TED Hose. -Interview with DON (Director of Nursing) on 01/31/18 10:04 a.m. revealed the Physician order [REDACTED]. DON verified new Physician order [REDACTED]. -Interview with Administrator on 01/31/18 at 10:55 a.m. revealed Resident 93 Physician order [REDACTED].",2020-09-01
575,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,692,D,0,1,6FMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 12-006.09D8 Based on observations, record reviews, and interviews, the facility failed to provide encouragement and attempts to eat throughout the meal service for one sampled resident (Resident 42) at high risk for continued weight loss. Sample size was 32 current residents. Facility census was 119. Findings are: Record review of Resident 42's Admission Record printed on 1/30/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 42's Care Plan listed a Focus problem for ADL (Activities of daily living, such as eating, dressing, toileting, transferring) self-care performance deficit related to Dementia . initiated on 6/7/17 and revised on 11/21/17. Among the interventions for this problem was for staff to provide 1 assist with Eating. Another Focus problem identified on the care plan was for Potential for fluid volume deficit related to poor intake, unable to drink fluids on own, immobility initiated on 6/7/17 and revised on 8/23/17. The Interventions for this problem included directions to staff to Offer favorite beverage and Offer fluids when providing cares. Another Focus problem created on 6/7/17 and revised on 8/23/17 was for At risk for potential impaired nutritional status r/t (related to) Dementia. Intervention instructions to the staff regarding this potential problem recorded the staff were to Allow adequate time to ingest meal and offer assistance as needed and Resident fed by staff (Extensive/1 person assist). Record review of Resident 42's electronic medical record notes revealed on 1/23/17 the Dietary Manager recorded notifying the Registered Dietitian of the resident's development of a pressure area on the scapula. The Dietary Manager recorded the resident continued with poor meal intakes 0-25% consumption of a pureed diet and 10-100% of a house supplement. The Dietary manager recorded the resident's weight was 135.5 on 1/22/18 losing a pound in 30 days, and 12 pounds in 90 days. Observation of Resident 42 during the noon meal observations on 1/29/18 and 1/30/18; and breakfast on 1/31/18 revealed the resident was dependent on the staff to mobilized from room to dining room in a tilted wheelchair. Further observations revealed the resident made not attempts to feed self after the trays were delivered. The resident was dependent on staff to feed the resident and provide encouragement to eat. During the 1/30/18 noon meal, the resident was seated in the dining room at 12 noon and positioned by staff. The resident had water and milk placed at the table but had not received a tray. At 12:30 p.m. the resident's tray was delivered and set up by NA (Nurse Aide)-E. NA-E assisted the resident to consume a few bites of the pureed swiss steak and potatoes. Then NA-E proceeded to help another resident at the table. Between 12:35 p.m. and 1:10 p.m. NA-E was observed waking up Resident 42 and conversing, but NA-E did not attempt to pick up a utensil or fluid container and encourage the resident to eat more of the meal. NA-E left the unit at 1:10 p.m. NA-F and NA-G also assisted residents seated by Resident 42 throughout the meal, but did not offer or attempt to assist Resident 42 with any intake between 12:35 p.m. and 1:10 p.m. At 1:12 p.m. NA-F removed the resident from the dining table and returned the resident to the resident's room. Observation of the resident's intake revealed only a few bites had been consumed (less than 10%) of the pureed swiss steak and potatoes. Record review of Resident 42's meal intakes in (MONTH) of (YEAR) revealed the resident was refusing some meals and at other times consuming around 25% of meals. Interview with LPN (Licensed Practical Nurse)-H on 1/31/18 at 9:20 a.m. verified Resident 42 is totally dependent on staff for meal and fluid intake. LPN-H stated the resident had been declining slowly over time and does receive a supplement. LPN-H stated the resident was at high risk for nutritional declines and needed lots of encouragement to eat. Interview with the DON (Director of Nursing) on 1/31/18 at 11:25 a.m. revealed that residents at risk or with actual nutritional issues that require assistance from staff should be offered foods and fluids and encouraged to eat throughout meal times.",2020-09-01
576,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,732,C,0,1,6FMP11,"Based on observations and interviews, the facility failed to post the daily staffing information as required. This failure prevented families, residents, and visitors from having access to the required information regarding the census and numbers of direct care staff providing care in the facility. Facility census was 119. Findings are: Observation on 1/28/18 at 2:00 p.m. revealed a Nursing Staff Information form was posted in the front entry to the facility. The date on the form was incorrectly recorded 2/26/17. The form was observed not to have recorded the facility census as required, nor was the date accurate. Observation on 1/29/18 at 7:22 a.m. revealed the Nursing Staff Information form was posted in the front entry to the facility. The form was observed not to have recorded the facility census as required, nor was the date accurate as it was incorrectly recorded 2/26/17. The form was the same form observed on 1/28/18 at 2:00 p.m. Interview with the facility Staffing Coordinator on 1/29/18 at 7:22 a.m. revealed the Staffing Coordinator completed forms for each day over the weekend and verified the posted Nursing Staff Information form was from Friday 1/26/18. The Staffing Coordinator confirmed the weekend staff failed to post the daily forms for posting, which were provided them by the Staffing Coordinator.",2020-09-01
577,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,755,D,0,1,6FMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12A Based on Record reviews and interviews, the facility failed to ensure medications were obtained and available for residents to ensure administration as ordered for one sampled resident (Resident 108). Sample size was 32 current residents. Facility census was 119. Findings are: Record review of Resident 108's Admission Record printed on 1/30/18 revealed the resident was admitted to the facility on [DATE]. Further review of the record revealed among the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 108's Medication Administration Record [REDACTED] - Xarelto (a medication to reduce blood clotting and regulate heart rate) was not administered on 1/21; 1/22;; and 1/30/18 with a code of OT (code for Other/See Progress Notes) recorded on the form on those dates. The medication was ordered for daily doses at 5:00 p.m. - [MEDICATION NAME] (medication to reduce stomach acid for GERD) was not administered on 1/22 and 1/30/18 with a code of OT on those dates. The medication was ordered for daily dosage at 5:00 p.m. - [MEDICATION NAME] (blood pressure reducing medication) was not administered on 1/22/18 with a code of OT. The medication was ordered for twice daily doses at - [MEDICATION NAME] (an anxiety reducing medication) was not administered on 1/22/18 with a code of OT. The medication was ordered for a daily dose at 8:00 a.m. - [MEDICATION NAME] ([MEDICAL CONDITION] medication) was not administered on 1/22/18 with a code of OT. The medication was ordered for a daily dose at 7:00 a.m. Record review of Resident 108's Progress Notes revealed the following entries: Regarding Xarelto: - 1/21/18 at 6:42 p.m. entry read the medication was Not available. - 1/22/18 at 5:55 p.m. entry read Drug not available. Pharmacy notified. - 1/30/18 at 6:26 p.m. entry read: Drug not available. Pharmacy notified. Regarding [MEDICATION NAME]: - 1/22/18 at 5:54 p.m. the entry read: Drug not available. Pharmacy notified. - 1/30/18 at 6:26 p.m. the entry read: Drug not available. Pharmacy notified. Regarding [MEDICATION NAME]: - 1/30/18 at 6:26 p.m. the entry read: Drug not available. Pharmacy notified. - 1/22/18 at 7:51 a.m. entry read: Not available at this time. Pharm notified. Regarding [MEDICATION NAME]: - 1/22/18 at 5:55 p.m. entry read: Drug not available. Pharmacy notified. - 1/22/18 at 7:51 a.m. the entry read: Not available at this time. Pharm (pharmacy) notified. Regarding [MEDICATION NAME]: - 1/22/18 at 7:50 a.m. the entry read: Not available at this time. Pharm notified. Interview with the DON (Director of Nursing) on 1/31/18 at 11:25 a.m. confirmed Resident 108 had missed doses of Xarelto, [MEDICATION NAME], and [MEDICATION NAME] in (MONTH) of (YEAR) due to medications not being available.",2020-09-01
578,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,812,F,0,1,6FMP11,"Licensure Reference Number 175 NAC 12-006.11E Based on observations and interviews, the facility failed to date and label open bags of chicken strips, Pork chops, hamburger patties that were in the freezer. All residents could be affected. Facility census was 119. Findings are: Observation on 01/28/18 at 12:40 PM revealed packages of chicken strips, pork chops, and hamburger patties were opened in the walkin freezer in the kitchen and were not dated. Observation on 01/30/18 at 11:47 PM of walkin freezer in the kitchen revealed frozen chicken strips, Pork chops, hamburger patties were opened and not dated. Interview on 01/30/18 at 12:47 PM with the Dietary Manager confirmed that the pork chops, chicken strips and hamburger patties should have been dated after they were opened and put back into the freezer. Interview on 01/31/18 at 11:30 AM with the Administrator verified the pork chops, chicken strips and hamburger patties that were opened should be dated in the walkin freezer. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 3-201.11(C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 Labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.17 and 3-202.18 B. Observation on 1-29-18 at 11:50 am revealed water had been poured in all resident glasses and set out on the tables in the dining area prior to residents arrival for their noon meal scheduled at 12:00 pm. Observation on 1-30-18 at 7:27 am revealed water had been poured in all resident glasses and set out on tables in the dining area prior to residents arrival for their breakfast meal scheduled at 7:30 am. Observation on 1-30-18 at 11:45 am revealed water had been poured in all resident glasses and set out on tables in the dining area prior to residents arrival for their noon meal scheduled at 12:00 pm. Observation on 1-31-18 at 7:05 am revealed water had been poured in all resident glasses and set out on tables in the dining area prior to residents arrival for their breakfast meal scheduled at 7:30 am. Interview with DM (Dietary Manager) on 1-31-18 at 9:48 am verified having poured and placed all water glasses on dining tables 30 minutes early and this could cause cross contamination of water as other people may touch or even drink out of the poured glasses of water. Interview with Administrator on 1-31-18 at 11:03 am verified having poured and placing the water glasses out on the dining tables ahead of time could cause cross contamination, should other people in the area touch or drink out out of the glasses.",2020-09-01
579,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-01-31,923,E,0,1,6FMP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-007.04D Based on observations and interviews, the facility failed to ensure resident bathroom ventilation systems were in working order in Rooms 117, 119, 121, 123, 125, 709, 710, 711, 712, 715, and 717. Residents sampled was 32. Facility census was 119. Findings are: Observation on 1/29/2018 at 10:30 AM of room [ROOM NUMBER] revealed the vent in the bathroom was not working. Observation on 01/30/18 at 09:47 AM on Environment tour with the Maintenance Man revealed that bathroom vents in Rooms 117, 119, 121, 123, 125, 709, 710, 711, 712, 715, and 717 were not working. Interview on 01/30/2018 at 10:47 AM with the Maintenance Director confirmed that bathroom vents in Rooms 117, 119, 121, 123, 125, 709, 710, 711, 712, 715, and 717 were not working.",2020-09-01
580,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-04-09,600,E,1,0,JF7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview: the facility failed to protect 3 Residents (Resident 501, Resident 502 and Resident 510) after an allegation of potential abuse. This had the potential to affect 18 residents that resided on Memory Care. The facility census was 121 residents. Findings are: Review of the Facility Investigation Report dated 4/2/2018 revealed on 3/23/2018 at 5:00 PM staff witnessed NA-A (Nurse Aide) ask Resident 502 if (gender) was done being a[***]ead. Also staff witnessed NA-A state the resident had pissed self while Resident 501 was present. NA-A had told Resident 510 the resident was stupid. Review of the time sheet for NA-A revealed NA-A clocked in at 1:51 PM, out at 6:57 PM, in at 7:13 PM and out 10:00 PM on 3/23/2018. Interview with the DON (Director of Nurses) on 4/9/2018 at 10:12 AM revealed the allegations did happen. NA-A did work the whole shift on Memory Support. NA-A was not suspended that night. Review of the facility policy entitled Abuse and Neglect Prevention Standard, with a revised date of 3/2017, all observations of suspected abuse should be immediately reported to your supervisor or the facility administrator immediately, but no later than 2 hours after he allegation had been made. The suspected team member will be suspended immediately while an in-depth documented investigation was conducted.",2020-09-01
581,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-04-09,609,E,1,0,JF7C11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility failed to submit an investigation report of an allegation of verbal abuse within 5 working days to the required State Agency for 3 residents (Residents 501, 502 and 510). This had the potential to affect 18 residents that lived on Memory Support. The facility had a census of 121 residents Findings are: Review of the facility Investigation Report revealed the incident of alleged verbal abuse to Residents 501, 502 and 510 happened on 3/23/2018 at 5:00 PM. The investigation was submitted to the State Agency on 4/2/2018 at 4:27 PM. Interview with the DON (Director of Nurses) on 4/9/2018 at 10:12 AM revealed the investigation results were not submitted timely. Interview with the Administrator on 4/9/2018 at 12:30 PM revealed the knowledge the investigation reports were not to the State Agency on time. Review of the facility policy entitled Abuse and Neglect Performance Standard, dated revised 3/2017, revealed the investigation results must be submitted to the State Agency within five working days.",2020-09-01
582,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-05-22,225,D,1,0,6YW911,"> Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to follow the facility policy to report allegations of abuse. This failure had the potential to affect two of three sampled residents (Residents 508 and 503B). The facility census was 112 at the time of the complaint investigation. Findings are: [NAME] Review of the facility investigation revealed the incident that Resident 508 was forced to eat occurred on 5/10/17 at 9:30 AM. Continued review of the facility investigation revealed the incident was reported to the Administrative staff on 5/10/2017 at 4:20 PM. The State Agency was notified on 5/10/2017 at 6:00 PM. Interview with the Interim Director of Nurses and the Social Service Worker on 5/22/2017 at 8:30 AM revealed the Administrative Staff were notified of the incident on 5/10/2017 at 4:20 PM then the State Agency was not notified of the incident until 6:00 PM. The staff that reported the allegation of abuse observed the abuse at 9:30 AM and did not report the allegations of abuse to the Administrative staff until 4:20 PM. B. Review of the facility investigation revealed the incident that Resident 503B requested medication that staff didn't administer occured on 5/10/17 at 8:30 AM. Interview with the Interim Director of Nurses on 5/22/217 at 8:30 AM revealed the Administrative Staff were notified of the incident on 5/10/17 at 4:20 PM then the State Agency was not notified of the incident until 5/10/17 at 6:50 PM. Review of the facility form entitled Abuse and Neglect Prevention Standard, with a revised date of 3/2017, revealed the standard was the resident had the right to be free from abuse. Reporting must be to the Administrator or Designee or other officials (including State Survey Agency and/or Adult Protective Services here state law provided for jurisdiction in Long Term Care facilities) in accordance with state law through established procedures. Report all alleged violations involving of abuse immediately, but no later than 2 hours after the allegation has been made.",2020-09-01
583,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-06-17,600,D,1,0,MCDQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record reviews and interview; the facility failed to have interventions in place to prevent recurrent incidents of Resident to Resident sexual abuse involving three current sampled residents (Residents 1, 2 and 3) who reside on the 500 wing SPU (Special Care Unit). The facility census was 125 with seven sampled residents. 16 residents currently resided on the 500 wing SCU. Findings are: Review of Resident 1's care plan, printed 6/17/19, revealed that the resident had a history of [REDACTED]. Interventions included 8/22/18 provide direct supervision of resident while resting in the chair outside of the room; 5/1/19 keep resident separated as able when displaying inappropriate affection; 5/24/19 on Fridays, offer hot chocolate or ice cream at 1:00 PM in the dining room. Further review revealed out of character behavior with a female resident on 4/30/19 and interventions included separate residents as much as possible. Review of the Progress Notes revealed the following including: - 4/30/19 at 1:00 PM A nursing assistant reported found the resident with hand on the outside of Resident 3's pants in between legs and vagina. - 5/24/19 at 1:20 PM The resident was observed to have hand down the front of another resident's (Resident 2) pants. The residents were separated and will be separated for 24 hours. Review of the facility Abuse and Neglect Prevention Standard, dated (MONTH) (YEAR), revealed the following including: Standard: Federal Registry Statement: Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Interview with the Director of Nursing on 6/17/19 at 4:30 PM confirmed that the resident had a history of [REDACTED].",2020-09-01
584,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-06-17,689,D,1,0,MCDQ11,"> Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and interview, the facility failed to provide supervision to prevent an elopement for one sampled resident (Resident 6). The facility census was 125 with seven current sampled residents. Findings are: Review of Resident 6's care plan, goal date 7/31/19, revealed a focus area, initiated 6/11/19, elopement risk related to short term memory impairment and interventions included to monitor the resident every 15 minutes until placement on the secure memory support neighborhood, alert staff to wandering behavior, assist to call family member when resident is looking for them and intervene as soon as anxious behavior was noted to prevent behavior from escalating. Review of the Elopement/Wandering Review (V2), dated 5/6/19, revealed that the resident was a Medium Risk with a score of 6. Review of the Progress Notes revealed the following including: - 6/11/19 at 2:10 PM The nurse notified a family member that the resident was anxious, was looking for the family member and walked frequently to the front door; - 6/11/19 at 2:15 PM The resident was observed in the parking lot between two cars with a walker and the resident used the front door so door alarm was not activated. The resident was notified that the family member would be in tomorrow and the resident calmed down and got in bed; - 6/11/19 at 9:54 PM The resident's family member was notified that the resident was walking the hallways looking for doors. Interview with the Director of Nursing on 6/17/19 at 2:00 PM revealed that the resident was moved to a Special Care Unit due to elopement risk.",2020-09-01
585,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-06-17,744,E,1,0,MCDQ11,"> Licensure Reference Number 175 NAC 12-006.09D5 Based on observations, record reviews and interview; the facility failed to have interventions in place to manage ongoing aggressive behaviors and prevent resident to resident altercations involving five current sampled residents (Residents 2, 3, 4, 5 and 7) who reside on the 500 wing SPC (Special Care Unit). The facility census was 125 and the sample was seven current residents. 16 residents currently resided on the SCU. Findings are: [NAME] Review of Resident 2's care plan, printed 6/17/19, revealed that the resident had out of character responses related to dementia, wandered the corridor and into others rooms, had disruptive/inappropriate language, hit other residents and got hit by other residents. Interventions included separate residents and redirect to other activities. Review of the Progress Notes revealed the following including: - 6/4/19 at 11:30 AM The resident walked over to Resident 5 and hit the resident lightly on the arm and the residents were separated; 2:00 PM The resident was easily aggravated, cussing, yelling and hitting; - 6/7/19 at 4:50 PM The resident got into an altercation with another resident (Resident 7) over a magazine, the resident was upset and yelled and hit the other resident on the left upper arm repeatedly. The residents were separated; - 6/8/19 at 4:30 PM The resident began to yell out, struck out and attempted to scratch staff and other residents, when attempts of redirection were made the resident yelled, screamed profanities and attempted to grab other residents; - 6/9/19 at 1:30 PM The resident became upset and hit Resident 3's hand; 10:15 PM paced and yelled out, combative, attempted to strike staff and other residents, redirection was not successful; - 6/14/19 at 9:15 AM The resident slapped a nursing assistant and bit a medication aide during cares; - 6/15/19 at 6:09 PM The resident slapped another resident's arm (Resident 7) at 5:20 PM, the residents were separated. B. Review of Resident 3's care plan, printed 6/17/19, revealed that the resident experienced out of character responses due to dementia, refused care, excessive pacing and combative with cares. Interventions included 1/20/19 redirect resident when interacting with resident number (resident not identified); 12/27/18 keep residents (two numbers, residents not identified) separate during activities; 3/26/19 redirect from resident number (resident not identified) room; 6/9/19 keep resident separated from Resident 2 for 24 hours or until another intervention is put into place. Review of the Progress Notes revealed the following including: - 5/20/19 at 8:56 PM The resident was easily aggravated this shift, chased another resident (Resident 2) around the dining room and stated I'm going to kill (gender), the residents were separated. The resident pushed and hit staff and staff intervened multiple times to prevent resident altercations; - 5/21/19 at 9:14 PM The resident pushed and hit staff member, pushed, hit and squeezed and slapped bottoms. Reasoning, re-direction and buddies-forever were not successful; - 5/22/19 at 2:37 PM The resident struck out at staff; 9:50 PM The resident hit staff; - 5/24/19 at 3:04 PM The resident was holding hands with Resident 7, when the resident tried to pull hand away, Resident 7 squeezed the resident's left hand and the resident stated ouch. The residents were separated, no injuries were noted; - 5/25/19 at 9:05 PM The resident slapped staff on the face; - 5/28/19 at 7:54 PM The resident hit, kicked, squeezed arms and attempted to bite the nurse; - 5/29/19 at 10:15 AM The resident was observed rubbing Resident 4's face and Resident 4 told the resident to please stop. The resident hit the activities staff and grabbed Resident 4's arm tighter. The residents were separated and other interventions were ineffective; 9:07 PM The resident was hard to re-direct, became aggressive towards other residents; - 5/31/19 at 10:01 PM The resident touched visitors, attempted to kiss another resident and when told to stop, would not stop attempting to kiss them. The resident took another resident's walker and wouldn't give it back. The resident attempted to strike the nursing assistant several times and also attempted to strike another resident in the face. The residents were not identified; - 6/7/19 at 9:56 PM The resident made frequent attempts to kiss a male resident (not identified) and was very touchy with male residents this shift (residents not identified). The resident pulled, hit and slapped staff butts, and interventions were not successful; - 6/8/19 at 9:20 PM The resident grabbed another resident's (not identified) oxygen tubes and tanks and attempted to take them; - 6/9/19 at 10:18 PM The resident paced all eight hours of the shift, attempted to enter other residents rooms and remove their possessions and refused to return them. The resident was combative when redirection was attempted. - 6/15/19 at 5:44 PM The resident smacked Resident 2's bottom repeatedly and chased after the resident and attempted to smack the resident again. The residents were separated. Observations on 6/13/19 at 10:00 AM revealed Residents 2 and 3 seated together on a couch at the end of the hallway. Interview with the Director of Nursing on 6/17/19 at 5:00 PM confirmed that interventions in place were not effective to manage ongoing aggressive behaviors and to prevent recurrent resident to resident altercations.",2020-09-01
586,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-06-26,157,D,1,0,ZNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility staff failed to immediately notify the practitioner and responsible party after Resident 1 fell and exhibited signs of potential injury. This affected 1 of 4 sampled residents. The facility identified a census of 114 at the time of survey. Findings are: Review of Resident 1's Admission Record revealed an admission date of [DATE]. Review of Resident 1's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 4/26/2017 revealed Resident 1 had a BIMS (Brief Interview for Mental Status) score of 5 which indicated Resident 1 had severe cognitive impairment. Resident 1 was able to walk in the room and corridor with staff assistance and had no limitation in range of motion. Review of Resident 1's Progress Notes dated 6/10/2017 revealed Resident 1 was found lying on their back on the floor under the wheelchair at 1:06 AM. Resident 1 had a decrease in range of motion of the right leg and complained of pain to the lateral right thigh. Resident 1 would not straighten their legs and did not bear weight to the right leg. There was no documentation the practitioner and the responsible party were notified immediately after Resident 1 fell and exhibited signs of potential injury. Interview with Resident 1's responsible party on 6/26/2017 at 2:45 PM revealed they were not notified about Resident 1's fall until several hours after it happened. Review of Resident 1's Progress Notes dated 6/10/2017 at 10:00 AM revealed Resident 1's responsible party was notified of Resident 1's condition around 7:05 AM (6 hours after Resident 1 was found on the floor) and Resident 1 was transferred to the emergency room for evaluation by a practitioner at 8:00 AM (almost 7 hours after Resident 1 was found on the floor). Interview with RN-A (Registered Nurse) on 6/26/2017 at 1:26 PM revealed that if a change in condition or if a fracture was suspected they should immediately call the doctor. Interview with the ADON (Assistant Director of Nursing) on 6/26/2017 at 3:52 PM revealed the assessment after Resident 1 fell on [DATE] did indicate a change in condition and the practitioner and responsible party should have been notified immediately. Interview with the DON (Director of Nursing) on 6/26/2017 at 4:49 PM revealed that based on the assessment findings after Resident 1 fell , the nurse should have notified the physician by phone immediately.",2020-09-01
587,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2017-06-26,309,D,1,0,ZNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on interview and record review, the facility staff failed to obtain emergency medical services after Resident 1 fell and exhibited a change in condition including signs of potential injury. This affected 1 of 4 sampled residents. The facility identified a census of 114 at the time of survey. Findings are: Review of Resident 1's Admission Record revealed an admission date of [DATE]. Review of Resident 1's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 4/26/2017 revealed Resident 1 had a BIMS (Brief Interview for Mental Status) score of 5 which indicated Resident 1 had severe cognitive impairment. Resident 1 was able to walk in the room and corridor with staff assistance and had no limitation in range of motion. Review of Resident 1's Progress Notes dated 6/10/2017 revealed Resident 1 was found lying on their back on the floor under the wheelchair at 1:06 AM. Resident 1 had a decrease in range of motion of the right leg and complained of pain to lateral right thigh. Resident 1 would not straighten their legs and did not bear weight to the right leg. There was no documentation to obtain emergency medical services immediately after Resident 1 fell and exhibited signs of potential injury. Review of Resident 1's Progress Notes dated 6/10/2017 at 4:26 AM revealed Resident 1 continued to complain of right leg/thigh pain, especially with any movement. Review of Resident 1's Progress Notes dated 6/10/2017 at 10:00 AM revealed Resident 1 complained of extreme pain to the right hip/leg and had pain with light touch and with movement. Resident 1 was transferred to the emergency room for evaluation at 8:00 AM (almost 7 hours after Resident 1 was found on the floor). Review of Resident 1's Progress Notes dated 6/10/2017 at 11:13 AM revealed Resident 1 was admitted to the hospital on [DATE] for a fractured right femur and pelvic region (broken leg/hip/pelvis). Review of Resident 1's progress notes dated 6/8/2017 revealed Resident 1 had no signs and symptoms of pain or discomfort prior to the fall on 6/10/2017. Interview with RN-A (Registered Nurse) on 6/26/2017 at 1:26 PM revealed that if a resident exhibited signs of a change in condition they would do a full body assessment including checking vital signs and assessing the resident for pain. RN-A revealed that if a fracture was suspected they would immediately call the doctor and ask for transport to the ER (emergency room ) or the clinic if they had x-ray capabilities. RN-A would consider a suspected [MEDICAL CONDITION] a medical emergency that would require immobilization and they wouldn't want to move the resident until the ambulance got to the facility to transport the resident. Review of the facility policy patient condition changes, recognizing and responding dated (MONTH) 12, (YEAR): Recognize that the patient is experiencing a change in condition. You may see an acute change or may simply have a feeling that something isn't quite right with the patient; alternatively, the patient or a family member may voice concerns. Perform a pain assessment using techniques that are appropriate for the patient's age, condition, and ability to understand. Nurses and other multidisciplinary team members must promptly recognize and respond to subtle changes in a patients' condition.",2020-09-01
588,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2019-07-11,580,D,1,0,OLMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a(6) Based on record reviews and interviews, the facility failed to ensure that the physicians were immediately notified to evaluate the need for further medical care after 1) a fall with a head injury for one current sampled resident (Resident 3) and 2) extensive bruising for one current sampled resident (Resident 5). Both residents were on anticoagulant (blood thinning) medications and were at increased risk for abnormal bleeding and complications. The facility census was 119 with five current sampled residents. Findings are: [NAME] Review of Resident 3's Progress Notes revealed that on 6/24/10 at 5:55 AM the resident was found on the floor next to the bed. The resident had a large goose egg above the left eye, a 2.5 cm. (centimeter) skin tear, a 3 cm. x 3 cm. abrasion above the left eye and a 1 cm. x 1 cm., abrasion to the bridge of the nose and a small red area to the right wrist. Further review revealed that at 8:30 AM the resident complained of severe pain to the left forehead/left side of the face. The resident had a 10 cm. x 8 cm. purple bruise to the left forehead/eye area that was gradually getting darker, 0.5 cm. x 0.5 cm. area to the bottom lip and the resident's right hand/wrist was swollen and bruised. The swelling spread across the forehead and down into the cheek bone and the resident was unable to open the left eye. The nurse called the doctor's office at 9:30 AM and orders were received to send the resident to the emergency room for evaluation. The resident was transferred to the emergency room per ambulance at 10:10 AM. Further review revealed that at 4:38 PM the nurse contacted the emergency room and learned that the resident was to be admitted to the hospital with [REDACTED]. Review of the Physician Visit/Communication Form revealed that a FAX (facsimile) was sent to the attending physician on 6/24/19 at 7:03 AM to report the resident's fall and injuries. Review of the care plan, not dated, revealed that the resident had a potential for bleeding related to taking anticoagulant medication and interventions included monitor, document and report as needed adverse reactions to the anticoagulant therapy which included bruising. B. Review of Resident 5's Progress Notes revealed that on 7/1/19 at 1:57 AM, during a transfer to the toilet, extensive purple/deep blue bruising was observed which encircled the waist and extended into the right breast and sternum (chest) at varying height 15 to 20 cm. Bruising was noted at the right hip/buttock, one 1.3 cm. 7 cm. and one 1.9 cm x 3 cm. Areas were not present 24 hours ago. Further review revealed that the doctor was notified per fax. Further review revealed at 2:28 AM, the resident's levels of responsiveness varied during the shift, from alert and answering questions appropriately to no response to questions or stimuli. The resident leaned heavily to the left side, drooled from the mouth, would suddenly start screaming help me, help me, removed oxygen several times and oxygen saturation levels dropped from 95% to 74% without oxygen, color pale ashen, respirations labored, irregular and shallow with an occasional moist cough. Review of the Physician Visit/Communication Form, dated 7/1/19 at 2:17 AM, revealed that the physician was notified per FAX of the identified bruising and that the resident was on Clopdogul (sic), an Antiplatelet medication, and Elquis (sic), an Anticoagulant medication. Review of the care plan, not dated, revealed that the resident had a potential for bleeding related to anticoagulant therapy and/or adverse effects of medication used for platelet aggregation. Interventions included monitor/report as needed adverse reactions to anticoagulant therapy including bruising. Interview with the Director of Nursing on 7/11/19 at 10:00 AM confirmed that there was no documentation that the residents' physicians were notified immediately to determine the need for further medical care to manage abnormal bleeding.",2020-09-01
589,LINDEN COURT,285083,4000 WEST PHILIP AVENUE,NORTH PLATTE,NE,69101,2018-07-25,609,D,1,0,08P211,"> Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit abuse investigations withing 5 working days to the state agency for Resident 1 and Resident 4. Sample size was 5 residents. Census was 122 residents. Record review for Resident #1 revealed that on 4/28/18 it was documented that Resident #4 grabbed Resident #1 by the forearm causing redness to the area. Review of the facility reported incidents revealed that no report had been made regarding this incident. On 7/26/18 at 10:00 AM the DON (Director of Nursing) confirmed that a call to report the incident was made to APS regarding the resident to resident contact that occurred on 4/28/18. The DON and the Administrator confirmed that there was no investigative report submitted to the state agency for the incident that occurred between Resident #1 and Resident #4 on 4/28/18.",2020-09-01
590,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2017-05-23,166,D,1,0,I3HF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.06 Based on record review and interview, the facility failed to resolve a grievance related to missing clothing for Resident 1 of 3 residents reviewed. The facility census was 135. Findings Are: Review of the facility Resident Handbook revealed the facility recognized the rights of the residents and resident representative to express concerns. Attempts to contact the resident would be made as soon as possible and generally within 5 business days. Review of Resident 1 Admission record dated (MONTH) 22, (YEAR) revealed Resident 1 was admitted to the facility on [DATE]. Interview on 5/22/2017 at 3:00 PM with Resident 1 revealed Resident 1 did report to the facility that a jogging suit was missing. Resident 1 revealed it was taken to the laundry and never returned. Resident 1 did not think they are still looking for it. Interview on 5/23/2017 at 9:05 AM with RN (Registered Nurse) -B revealed Resident 1 did report a missing sweat suit and an investigation was started to find the missing article. However , RN-B revealed the concern was turned over to the social work department and RN-B was not aware of the resolution. Review of the facility's missing item reports revealed an email regarding the missing sweat suit dated (MONTH) 8 (YEAR) to alert staff of the missing item. Review of the facility Resident Concern Reports revealed no form was completed for Resident 1's missing sweat suit. Interview on 5/23/2017 at 9:15 AM with Social Worker (SW)-C revealed the facility offered to replace the sweat suit but Resident 1 wanted the original sweat suit returned. SW-C has no knowledge of documentation of the resolution of the concern. Review of the facility policy dated 11/25/2016 titled Abuse Prevention and Reporting revealed, in Section D Prevention item, 2 Residents, families, and employees that report concerns, incidents and grievances will be provided feedback related to the issue reported. Interview on 5/23/2017 at 10:30 AM with the Interim Administrator revealed documentation of Resident 1's concerns regarding missing items and all grievances voiced should include documentation of the resolution. Interview on 5/23/2017 at 12:00 PM with SW-D revealed no Resident Concern Report was completed and no documentation was available of the resolution of the concern.",2020-09-01
591,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2017-05-23,252,D,1,0,I3HF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number:175 NAC 12-006.05 (15) Based on observation, record review and interview; the facility failed to maintain a list of resident belongings to prevent the potential for misappropriations for Residents 1, 2, and 3 of 3 residents reviewed. The facility census was 135. Findings are: [NAME] Review of the undated facility document titled Resident Handbook revealed, in the section titled Laundry on Page 16, that after admission the care team would assist the resident in arranging clothing and completing a personal inventory form. Review of Resident 1 Admission record dated (MONTH) 22, (YEAR) revealed Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 1's medical record revealed an undated facility form titled Inventory of Personal Effects with Residents 1's name on it but no items listed on the form. Interview on 5/22/2017 at 2:34 PM with Registered Nurse (RN) - A revealed the Inventory of personal effects sheet were to be completed on admission. B. Review of Resident 2's Admission Record dated (MONTH) 22, (YEAR) revealed Resident 2 had an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 2's medical record revealed no Inventory of Personal Effects. Observation on 5/22/2017 at 2:45 PM of Resident 2's room revealed numerous items of clothing and shoes in Resident 2's closet as well as other personal items in the room. Interview on 5/22/2017 at 2:15 PM with RN-A revealed that, if the Inventory of Personal Effects was not in the chart, it should be in the overflow chart. Interview on 5/22/2017 at 2:34 with RN-A revealed no Inventory of Personal Effects was located in the overflow chart. C. Review of Resident 3's Admission Record dated 4/3/2017 revealed Resident 3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the facility Grievance reports revealed a report dated 4/17/2017. The Resident Concern Report stated Resident 3 was missing 3 pairs of sweat pants, 2 T-shirts, 2 pairs of support hose, and 3 light weight short sleeved shirts. Review of Resident 3's Inventory of Personal Effects dated 4/3/2017 revealed Resident 3's had 1 pair of slacks, 1 shirt, and 1 eyewear. Review of Resident 3's medical record revealed no other Inventory of Personal Effects to account for the missing items. Review of the Resident Concern Report revealed that, on 4/18/2017, all missing property was found with the exception of the support hose which the facility replaced. Interview on 5/22/2017 at 1:30 PM with RN-B revealed Resident 3's belongings should be documented on the Inventory of Personal Effects form and the form should be updated or another form completed to include those items located. Interview on 5/22/2017 at 1:40 PM with RN-B revealed no other Inventory of Personal Effects form was located in the resident's medical record.",2020-09-01
592,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2016-07-19,225,D,0,1,ENUN11,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02(8) Based on record reviews and staff interviews; the facility failed to investigate and submit the investigations to the State Agency (SA) within 5 working days. This affected 1 resident (Resident 28). The facility identified a census of 140 residents. Findings are: [NAME] A record review of a Nursing Progress Note dated 4/14/2016 revealed Resident 28 stated that Resident 28 had $70 in Resident 28's coat pocket before Resident 28 left and that, when Resident 28 returned from the hospital, Resident 28 discovered that it was missing. A formal complaint was initiated, and security notified. A record review of a Resident Concern Report dated 6/23/2016, revealed Resident 28 believed that $10.00 was taken from Resident 28's room by one of the nursing assistants. An interview with Social Worker A (SW A) on 7/18/2016 at 4:25 PM revealed that, while SW A did call this in to APS (Adult Protective Services), there was no investigation done other than reviewing the last 3 months of the trust fund record. SW A also confirmed that SW A called APS in (MONTH) as well. A record review of the undated Staff-to-Resident Abuse, Neglect, or Misappropriation Algorithm revealed the last step was within five working days from allegation send completed report to: Health Facility Investigations (SA). An interview with the DON (Director of Nursing) on 7/19/2016 at 8:05 AM revealed that the DON did not know why the state reports did not get completed and sent in to the SA for any of these APS reports.",2020-09-01
593,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2016-07-19,467,E,0,1,ENUN11,"LICENSURE REFERENCE NUMBER 175 NAC 12-007.04 Based on observation and interview, the facility failed to ensure bathroom ventilation fans were functional in 8 of 141 rooms in the facility. The affected rooms were 127, 136, 219, 228, 233, 236, 229, and 230. The facility census was 140. Findings are: Observations were made on 7/19/16 between 10:30 AM and 11:12 AM in rooms 127, 136, 219, 228, 233, 236, 229 and 230 of the working condition of the bathroom ventilation fans. To determine if the fans were functioning, a one ply square of toilet paper was held up to the vent to see if it had sufficient suction to pull the toilet paper up. In the above mentioned rooms there was not sufficient suction to do this, indicating they were not working at that time. Present during the above observations on 7/19/16 between 10:30 AM and 11:12 AM, were the Team Leader of Clinical Services, the Administrator and Maintenance Assistant- B. All of these staff confirmed the vent fans were not working and were unable to explain why.",2020-09-01
594,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2017-10-19,157,D,0,1,E7AB11,"**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 blood sugar results for 1 (Resident 53) of 5 sampled residents. The facility staff identified a census of 137. Findings are: Record review of Resident 53's Comprehensive Care Plan (CCP) dated 8-05-2014 had the [DIAGNOSES REDACTED]. Record review of a physician's orders [REDACTED]. Record review of Resident 53's Diabetic Flow Sheet for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following information of Resident 53's blood sugar levels: -9-02-2017 at 11:25 AM, blood sugar level was 484. -9-09-2017 at 11:00 AM, blood sugar level was 458. -9-26-2017 at 8:30 PM, blood sugar level was 462. -9-27-2017 at 10:50 AM, blood sugar level was 474. -10-02-2017 at 3:48 PM, blood sugar level was 457. Review of Resident 53 medical record revealed there was not evidence the facility had notified Resident 53's physician of Resident 53's blood sugar levels exceeding 450. On 10-18-2017 at 3:27 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview review of Resident 53's Diabetic flow sheet for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed with RN [NAME] RN J confirmed during the interview, Resident 53's physician was not notified of Resident 53's blood sugar levels over 450 for the dates of 9-02-2017, 9-09-2017, 09-26-2017 and 10-02-2017.",2020-09-01
595,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2017-10-19,318,D,0,1,E7AB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D4 Based on observations, interviews, and record reviews; the facility failed to implement a restorative program to prevent further decline in range of motion for 1 resident (Resident 126) of 2 residents sampled. The facility staff identified the census at 137. Findings are: A review of Resident 126's Admission Record dated 10-19-17 revealed that Resident 126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 126's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 8-25-17 revealed that Resident 126 had limited Range of Motion to one leg. A review of Resident 126's Care Plan dated 5-17-15 revealed no evidence that Resident 126 had contractures or limited range of motion to both lower extremities. A review of Resident 126's progress note dated 10-4-17 revealed that it was recommended to the nursing staff for Resident 126 to be a mechanical lift for transfers and that the resident's legs and left hand were more contracted. A referral was sent for therapy and a message was left for the therapy lead. A review of Resident 126's Physical Therapy Plan of Care (Evaluation Only) dated 10-5-17 revealed the resident had 50% knee extension with passive range of motion in both legs. An interview conducted on 10-18-17 at 7:36 AM with Restorative Nursing Assistant B revealed that Resident 126 was not on a restorative program. An observation conducted on 10-18-17 at 8:24 AM with Nursing Assistant (NA) A revealed that Resident 126's knees were bent upward when the resident was laying on their back and that NA A was not able to straighten the resident's legs. NA A rolled Resident 126 to their side to do both front and back perineal cleansing. Once the resident was dressed with a lift sling underneath them, NA A rolled the resident on their left side before leaving to get another NA to help with the mechanical lift. An interview conducted on 10-18-17 at 8:24 AM with NA A revealed that due to Resident 126's contractures in their legs, perineal cleansing worked better when the resident was laying on their side. NA A reported that they laid the resident to the side due to the contractures in Resident 126's legs. NA A reported that the resident, when left lying on their back, has tipped over and almost fallen off the bed. NA A reported that Resident 126's contractures seemed to be getting worse. An interview conducted on 10-19-17 at 9:46 AM with Physical Therapist (PT) C revealed that Resident 126 was evaluated for Physical Therapy when the resident returned from the hospital, but was not appropriate for physical therapy. PT C reported that they were unaware that the resident had contractures in their legs. PT C reported they had not received any requests from nursing to screen the resident due to contractures or worsening contractures and that the resident was not on a restorative program as the resident had not been in therapy. An interview conducted on 10-19-17 at 9:46 AM with Occupational Therapist (OT) D revealed that Resident 126 was evaluated for Occupational Therapy due to hospitalization for [MEDICAL CONDITION] (an infection of the deeper layers of skin and the underlying tissue) in their left arm. The evaluation indicated that the resident had full range of motion in their arm and therefore was not appropriate for occupational therapy services. OT D reported they had not received any requests from nursing to screen the resident due to contractures or worsening contractures and that the resident was not on a restorative program as the resident had not been in therapy. An interview conducted on 10-19-17 at 10:04 AM with PT C revealed that Resident 126 may have benefited from a restorative program, but they did not know how long the resident had had the contractures in their legs. PT reported that a restorative program would have prevented further contractures. An interview conducted on 10-19-17 at 10:04 AM with OT D revealed that residents in the facility with contractures should have been on a restorative program. OT D reported that therapy developed the restorative programs and then nursing followed through with the program.",2020-09-01
596,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2017-10-19,371,F,0,1,E7AB11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, and interview; the facility staff failed to ensure egg salad temperature was maintained to prevent potential food borne illness and failed to ensure staff changed soiled gloves during meal preparation. This practice had the potential to effect 134 of 137 residents who ate food from the kitchens. The facility staff identified 3 residents who did not eat food from the kitchen. The facility census was 137. Findings are: [NAME] Observation of meal service preparation on 10-18-2017 at 10:45 AM revealed a salad bar had been set up in the main dining room of the facility at include lettuces, cottage cheese, egg salad, assorted deserts cubes of pears. Further observation revealed the egg salad was sitting on top a bed of ice and not submerged to ensure a cold temperature. Observation on 10-18-2017 at 11:28 AM revealed Cook Assistant (CA) K was preparing to serve residents for lunch. Apon request the temperature of the egg salad was obtained by CA K using the facility thermometer. The temperature of the egg salad was 48 degrees fahrenheit (F). On 10-18-2017 at 11:38 AM during an interview with CA K reported that the egg salad was going to be served to the residents. Cook CA K confirmed the temperature of the egg salad was not obtained prior to the meal service. CA K consulted with the Dietary Manager and reported the egg salad should have been at 40 degrees F or below. B. An observation conducted on 10-16-17 at 11:54 AM revealed Cook [NAME] was plating resident meals and, without changing out gloves, pulled 2 slices of bread from a bag of bread, pulled a meat slice out of the container, and put together and cut a sandwich for a resident's plate. Cook [NAME] without changing gloves went back to plating more meals. At 11:56 AM Cook E, without changing gloves, pulled 2 slices of bread from a bag of bread, pulled a meat slice out of the container, put together and cut the sandwich in half, then placed the sandwich off the side on the steam table. Cook [NAME] then went to the cabinets behind the steam table and removed 1 glove. With the ungloved hand, Cook [NAME] pulled out another bag of bread then pulled 2 slices of bread out of the bag with the gloved hand and placed the bread in the toaster. Cook [NAME] went back to plating resident meals. At 11:59 AM Cook E, without changing glove, picked up the sandwich set aside before and placed it on a resident's plate. An observation conducted on 10-18-17 at 11:53 AM revealed Cook [NAME] was plating resident meals and, without changing gloves, pulled 2 slices of bread from a bag and made a sandwich for a resident's plate then went back to plating more meals. At 12:02 PM Cook E, without changing gloves, pulled 2 slices of bread from the bag, made and cut a sandwich, and placed it on a resident's plate. An interview conducted on 10-18-17 at 1:39 PM with Dietician F revealed that staff were expected to either use gloves or tongues to handle bread and meat slices and that the gloves should be changed between plating meals and touching ready to eat foods like bread and meat.",2020-09-01
597,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2017-10-19,441,D,0,1,E7AB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175NAC 12-006.17 Based on observations, record review, and interview; the facility failed to utilize hand-washing and gloving techniques to prevent potential cross contamination during the provision of a treatment for [REDACTED]. The facility Census was 137. Findings are: [NAME]Observation on 10/18/2017 at 9:05 AM of medication administration for Resident 199 revealed Registered Nurse (RN)-G dispensed a tablet from the bubble pack and dropped it on the top of the medication cart and picked it up with an ungloved hand and placed in the medication cup with other medications. Medications were taken to Resident 199's room for Resident 199 to take. During taking medications Resident 199 dropped a tablet on the floor. RN-G picked the tablet off of the floor and laid it on the table for later identification. RN-G stated another one would be obtained for Resident 199. When resident 199 completed taking medications RN-G picked up the tablet from the over bed table. The tablet was placed on top of medication cart and was identified as a Vitamin D3. RN-G dispensed another Vitamin D3 from the bubble pack into her bare hand without washing or utilizing hand sanitizer and placed the tablet into medication cup. RN-G then took the tablet into Resident 199 and Resident 199 took the tablet. Review of the facility policy dated (MONTH) 30, (YEAR) titled Medication Administration revealed Infection prevention principles will be applied to prevent contamination of medications to include: prepare/set up medications for administration on clean surfaces and follow Standard Precautions. Interview on 10/19/2017 at 8:15 AM with RN-I, Infection Control practitioner, revealed at no time should medications be handled with bare hands. Gloves should be used to handle medications. B. Observation on 10/18/2017 at 10:40 AM of wound treatment by R N-H. Resident 192 was positioned in bed. After washing hands and donning gloves RN-H collected supplies. RN-H removed old dressing. The wound area was cleansed using the same gloves. RN-H applied Saline to [MEDICATION NAME] Silver (A dressing used to heal wounds) without changing gloves or performing hand Hygiene. RN-H applied a clean dressing to area and changed gloves without performing hand hygiene prior to assisting Resident 192 into the wheelchair. Review of facility Policy dated (MONTH) 30, (YEAR) titled Hand Hygiene and Gloving revealed the following: - Gloves must be changed when going from one contaminated area to another on a resident - When going from a contaminated area/task to a clean area/task on a resident. - After completing a dirty task before going to a clean task. - Gloves do not eliminate the need for hand hygiene. - Hand hygiene is required before putting on gloves and after removing gloves. Interview on 10/19/2017 at 8:15AM with RN-I Infection Control practitioner revealed that gloves should be changed and hand washing completed after removing old dressing and applying clean dressing.",2020-09-01
598,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,561,D,0,1,ECD611,LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on interviews and record reviews the facility staff failed to provide a bath 2 times per week as requested for 1 of 1 sampled residents Resident 67. The facility staff identified a census of 136. The findings are: Interview conducted on 11/29/18 at 11:26 AM with Resident 67 revealed that Resident 67 prefers a bath twice a week and had not had a bath in a week. Interview conducted on 12/3/18 at 09:55 AM with Resident 67 revealed that Resident 67 had not had a bath all last week. Care Plan review dated 10/3/18 revealed that Resident 67 had a preference for bathing two times a week. On 12/3/18 Record Review of the bath schedule for the month of (MONTH) (YEAR) revealed the last bath that Resident 67 received was on 11/22/18 and not received a bath on 11/26 or 11/29/2018. Interview with RN C on 12/4/18 at 09:05 AM confirmed that the Resident 67 was to receive a bath on 11/26 and 11/29 and had not received a bath on 11/26 or 11/29/2018.,2020-09-01
599,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,686,D,0,1,ECD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observations, record reviews and interview, the facility staff failed to implement interventions to prevent pressure ulcer development for 1 (Resident 9) of 1 sampled resident. Findings are: Record Review of Admission Record revealed that Resident 9 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of current Physician order [REDACTED]. Review of the Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/15/18 revealed resident was at risk for pressure ulcers. Review of Current Comprehensive Care Plan dated 11/15/18 identifies Resident 9 at risk for skin breakdown related to extensive assist with bed mobility and transfers. Observation on 11/29/18 at 08:21 AM Resident 9 was sitting in the wheelchair with a sling in the chair, under the resident's body. Observation on 12/3/18 at 08:02 AM Resident 9 was sitting in the wheelchair with a sling in the chair, under the resident's body. Observation on 12/4/18 at 08:55 AM Resident 9 was sitting in the wheelchair with a sling in the chair, under the resident's body. An interview conducted 12/4/18 at 09:00 AM with RN C confirmed that there was a sling in Resident 9's wheelchair, under the resident's and that there was an order dated 7/23/18 for no sling under (resident's) body when up in chair for pressure relief.",2020-09-01
600,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,692,D,0,1,ECD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record reviews and interviews; the facility staff failed to evaluate significant weight loss for 1 (Resident 126 ) of 4 sampled residents. The facility staff identified a census of 136. Findings are: Record review of Resident 126's Comprehensive Care Plan (CCP) printed on 12-03-2018 revealed Resident 126 had [DIAGNOSES REDACTED]. Further review of Resident 126's CCP printed on 12-03-2018 revealed Resident 126 had a history of [REDACTED]. Record review of Resident 126's Weights and Vitals Summary sheet revealed Resident 126 weight were as follows: -8-22-2018,weight was 158.2 lbs. -9-19-2019, weight was 149.2 lbs. A loss of 9 lbs or 5.68% within 30 days. Review of the Resident record revealed there was no evidence the facility staff had evaluated the significant weight loss. On 12-03-2018 at 12:56 PM a interview was conducted with Registered Dietician (RD) [NAME] and RD F. During the interview RD F confirmed an evaluation of Resident 126 significant weight loss had not been completed",2020-09-01
601,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,761,D,0,1,ECD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E7 Based on observation and interview, the facility staff failed to ensure 2 insulin pens were dated when opened for 1 (Resident 66) of 1 sampled resident. The findings are: Observation on 12/06/18 at 06:40 AM of the 2C Cart 1 Medication Cart revealed: 1 [MEDICATION NAME] Injection [MEDICATION NAME] Insulin Pen and 1 [MEDICATION NAME] Injection [MEDICATION NAME] Insulin Pen, for Resident 66 was being used to administer the medication, and was not dated as to when it was opened. Review of [MEDICATION NAME] Injection [MEDICATION NAME] label revealed insulin expires 28 days after opening. Review of [MEDICATION NAME] Injection [MEDICATION NAME] label revealed insulin expires 28 days after opening. Interview conducted with LPN D on 12/06/18 at 07:05 AM confirmed that the insulin pens were being used for the resident, there was no open date on the insulin pens and the insulin pens should not have been on the medication cart. Interview conducted 12/06/2018 at 07:10 AM with RN C confirmed that the insulin pens were not dated and RN C removed them from the cart. Review of Medication Processes and Protocols Policy undated revealed that Humalog and [MEDICATION NAME] Pens are approved for medication administration for 28 days from open date.",2020-09-01
602,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,804,E,0,1,ECD611,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D The facility failed to ensure mechanically altered cold meat sandwich storage temperatures were maintained at a temperature to prevent the potential for food borne illness for 15 residents receiving mechanically altered diets. The facility staff identified a census of 136. Findings are: Observation on 12-04-2018 at 11:40 AM revealed the facility kitchen staff had prepared the lunch meal for the residents of the facility. The food items prepared included a pureed cold meat sandwich and a mechanical ground cold meat sandwich. Cook J obtained the temperature of the foods including the mechanical ground and pureed cold meat sandwiches. Cook J using the facility thermometer revealed the temperature of the mechanical ground and the pureed sandwiches were both 39 degrees. Observation on 12-04-2018 at 12:55 PM with the Dietary Services Manager (DSM) of the food temperatures revealed the DSM using the facility thermometer, that had been calibrated, revealed the mechanical ground and the pureed meat sandwich temperatures was 50 degrees. In 12-04-2018 at 1:05 PM an interview was conducted with the DSM. During the interview, the DSM confirmed the mechanical ground and pureed sandwich were too warm.",2020-09-01
603,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,812,F,0,1,ECD611,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, record reviews and interview; the facility staff failed to ensure the dishwashing machine maintained a rinse cycle temperature to sanitize dishes to prevent the potential for food borne illness. This practice had the potential to effect all residents who ate meals from the kitchen. The facility staff identified a census of 136. Findings are: Observation on 12-04-2018 at 2:38 PM with Registered Dietician (RD) F revealed the dishwasher obtained 170 degrees during the rinse cycle. Review of the instructions on the dishwashing machine revealed the rinse cycle was to obtain a temperature of 180 degrees. Record review of a log to record the temperature of the rinse cycle for (MONTH) (YEAR) revealed the following: -Breakfast Rinse Temperatures. -12-01-2018, 170 degrees. -12-02-2018, 169 degrees. -12-03-2018, 169 degrees, -12-04-2018, 169 degrees. -Lunch Rinse Temperatures. -12-01-2018, 170 degrees. -12-02-2018, 171 degrees. -12-03-2018, 170 degrees. Further review of a log to record the temperature of the rinse cycle for (MONTH) (YEAR) revealed at the bottom of the log sheet was information identifying the rinse cycle was to be 180 degrees. On 12-04-2018 at 2:38 PM an interview was conducted with RD F. RD F confirmed the dishwasher rinse cycle had not reached 180 degrees to sanitize the dishes and should have.",2020-09-01
604,IMMANUEL FONTENELLE,285085,6809 N 68TH PLAZA,OMAHA,NE,68152,2018-12-06,880,D,0,1,ECD611,"**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 hand washing and gloving techniques were utilized during the provision of care for 1 of 1 sampled residents (Resident 33). The facility census was 136. Findings are: Review of Resident 33's Admission Note dated 6/14/2018 revealed Resident 33 was admitted with a [DIAGNOSES REDACTED]. Observation on 12/04/18 at 7:09 AM of a wound dressing change for Resident 33 revealed Licensed Practical Nurse (LPN)-A entered Resident 33's room and performed hand hygiene with soap and water for 10 seconds and put on gloves to assist with holding Resident 33's legs for a treatment of [REDACTED]. LPN-A then removed the gloves, and did not perform hand hygiene with soap and water or antibacterial hand gel and left Resident 33's room and obtained clean washcloths from the linen closet. When LPN-A returned with the washcloths and put on gloves, LPN-A did not perform hand hygiene. LPN-A removed gloves after holding Resident 33's legs for Registered Nurse (RN)-B to irrigate the wound and did not perform soap and water hand hygiene or use gel. Review of the facility policy titled Hand Hygiene and gloving dated (MONTH) 30, (YEAR) revealed Hand hygiene is required before putting on gloves and after removing gloves. Hand washing with soap and water for 20 seconds will be done when hands are visibly soiled, after using the restroom and before handling food. Interview on 12/04/18 at 11:17 AM with the facility Infection Control Director revealed hand washing should be done for 20 seconds or gel used prior to putting on gloves or after removing gloves.",2020-09-01
605,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2017-02-02,329,D,0,1,6E3T11,"**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 document a clinical rationale for the continued use of an antipsychotic medication (used to manage behaviors) and an antidepressant medication (used to manage depression) for 1 (Resident 23) of 5 residents reviewed for unnecessary medication use. The facility census was 87. Findings are: Record review of Resident 23's Minimum Data Set (MDS; a comprehensive assessment used to develop a Care Plan) dated 12/18/16 revealed that Resident 23 exhibited severe cognitive impairment with a Brief Interview Mental Status score of 4, exhibited no mood concerns or behaviors, had [DIAGNOSES REDACTED]. Record review of Resident 23's Care Plan dated 12/19/16 revealed that Resident 23 used psychoactive medications related to Anxiety, Depression and Dementia without Behavioral Disturbance. Interventions included that gradual dose reduction (GDR) guidelines were to be followed. Record review of Resident 23's Physicians orders dated 8/16/16 revealed orders for [MEDICATION NAME] (an antidepressant medication) 20 milligrams (mg) every day and [MEDICATION NAME] (an antipsychotic medication) 12.5 mg every day at bedtime. Record review of Resident 23's GDR request to the physician from the Consultant Pharmacist (CP) dated 11/17/16 revealed that Resident 23 had been on [MEDICATION NAME] 12.5 mg every bedtime since 8/16/16 and a GDR was requested. The Physician marked that a dose reduction was not to be attempted at that time but no documentation of a clinical rationale to continue the medication at that dose was provided. The reason section on the request was left blank. Record review of Resident 23's GDR request to the physician from the Consultant Pharmacist (CP) dated 11/17/16 revealed that Resident 23 had been on [MEDICATION NAME] 20 mg every day since 8/18/16 and a GDR was requested. The Physician marked that a dose reduction was not to be attempted at that time but no documentation of a clinical rationale to continue the medication at that dose was provided. The reason section on the request was left blank. Interview on 02/01/2017 at 11:32:02 AM with the CP confirmed that the physician should have written a clinical rationale related to why a GDR was not attempted for the continued use of the antipsychotic and antidepressant medication for Resident 23. The CP confirmed that they did not follow up to obtain a clinical rationale from the physician for Resident 23. Interview on 02/01/2017 at 1:02:28 PM with the Director of Nursing confirmed that the reason for not doing a GDR was not documented and that they had not followed up to obtain a clinical rationale for the continued use of the antipsychotic and the antidepressant medication for Resident 23.",2020-09-01
606,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,550,E,0,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to honor resident dignity by failing to ensure Resident 55 was covered while being wheeled down the hall; pulling Resident 55 backwards in a wheelchair; failing to knock, request and wait for permission before entering the rooms of Residents 23, 33, 55, and 77; leaving a gait belt (a device applied to a resident's waist for staff to use to assist the resident with transfers) on Resident 26 while they were sitting in their wheelchair in their room for an extended period of time; failing to provide dignity during dining for Resident 14 and Resident 15 by wearing gloves while physically assisting them with eating and standing up while assisting Resident 15; and failing to ensure Resident 14 was covered. This affected 7 of 7 sampled residents. The facility identified a census of 82 at the time of survey. Findings are: [NAME] Observation of Resident 23's room on 3/05/18 at 10:35 AM revealed Resident 23's room door was closed. NA (Nurse Aide)-I walked in and did not knock or request and wait for permission to enter Resident 23's room. Observation of Resident 23's room on 3/05/18 at 10:37 AM revealed Resident 23's room door was closed. NA-N tapped on the door and walked in. NA-N did not request or wait for permission to enter Resident 23's room. Interview with Resident 23 on 3/5/2018 revealed Resident 23 was interviewable and capable of granting staff permission to enter their room if it was requested. B. Observation of Resident 33's room on 3/01/18 at 10:40 AM revealed an unidentified staff person knocked on the door and entered without requesting and waiting for permission to enter Resident 33's room. Observation of Resident 33' room on 3/01/18 at 2:08 PM revealed Resident 33's room door was closed. NA-H tapped on the door and opened it without requesting and waiting for permission to enter Resident 33's room. Review of Resident 33's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/9/2018 revealed Resident 33 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 33 was cognitively intact and capable of granting staff permission to enter their room if it was requested. C. Observation of Resident 55 on 3/01/18 at 10:12 AM revealed MA (Medication Aide)-O wheeled resident down the hall in their wheelchair. Resident 55 was wearing a hospital type gown open in the back that was displaced exposing Resident 55 from the waist down. Resident 55's undergarment was visible to passers-by in the hall. MA-O then proceeded to pull Resident 55 backwards in their wheelchair into the bath house. Observation of Resident 55's room on 3/01/18 at 2:47 PM revealed Resident 55's room door was closed. RN (Registered Nurse)-M knocked and walked into the room without requesting or waiting for permission to enter. Observation of Resident 55's room on 3/01/18 at 2:53 PM revealed Resident 55's room door was closed. NA-P tapped on the door and opened it; looked into the room and left when they saw resident interview in progress. NA-P did not request or wait for permission to enter Resident 55's room. Review of Resident 55's quarterly MDS dated [DATE] revealed Resident 55 had a BIMS score of 15 which indicated Resident 55 was cognitively intact and capable of granting permission to enter their room if requested. D. Observation of Resident 77's room on 3/05/18 at 11:19 AM revealed OT (Occupational Therapist)-Q opened the door and said they were looking for the lift. OT-Q did not knock or wait for permission to enter Resident 77's room. Observation of Resident 77 on 3/5/18 at 11:19 AM revealed Resident 77 was interviewable and capable of granting permission to enter their room if it was requested. Interview with MA-S on 3/06/18 at 2:17 PM revealed facility staff were to knock on resident doors and say who they were. We wait for the resident to tell us it is okay to enter. MA-S revealed residents were to be transferred to the bath house with a blanket covering them and staff were to make sure the residents' bodies were covered. Interview with the DON (Director of Nursing) on 3/07/18 at 8:12 AM revealed the expectation was that residents were to be covered with a blanket or a sheet or have a robe on when they were taken to the bath house. It was their expectation that residents not be exposed. The DON further revealed that staff were to knock on the residents' doors and announce who they were. The DON confirmed that staff should not open the residents' doors and walk in. Review of the facility policy Resident Rights dated 8/17 revealed the following: The resident has the right to: Be treated with consideration, dignity, and respect including privacy in treatment and in care for personal needs. The facility must: treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The resident has the right to: privacy in his or her immediate living areas. No persons should enter the immediate living area of a resident without first identifying themselves and receiving permission to enter. Personal privacy and confidentiality of his or her personal and medical records. Personal privacy include accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. E. Observation on 3/01/18 at 9:16 AM identified that Resident 26 was sitting in their wheelchair watching television with a gait belt around the waist. Observation on 3/01/18 at 12:42 PM identified that Resident 26 was sitting in their wheelchair eating their lunch with the gait belt still on around their waist. A nursing staff member was sitting with the resident while they ate their meal. Interview on 3/07/18 at 11:21 AM with LPN(Licensed Practical Nurse) -A revealed that Resident 26 should not have had the gait belt left on around their waist from 9:16 AM to 12:42 PM on 3/01/18. The gait belt should have been removed after the nursing staff transferred the resident. LPN-A acknowledged that it would be considered a dignity issue with leaving the gait belt on the resident for that period of time. Interview on 3/07/18 at 1:09 PM with the DON confirmed that the gait belt should have been removed each time the nursing staff transferred the resident and not to leave it on the resident. F. On 03/06/18 during the Dinner meal, it was observed that Resident 14 was being physically assisted with eating by NA-C. NA-C was wearing gloves and standing up by the side of Resident 14's chair while assisting with eating. Resident 14 had to look up and to the left each time they took a bite of food. It was also observed that Resident 15 who was being physically assisted with eating by NA-B. NA-B was wearing gloves. [NAME] On 03/01/18 it was observed that three staff were standing in hallway during rounds. One staff person was heard to say, This (resident) here is refusing the full body lift and is very restless today. Staff were observed looking into Resident 14's room and continued down hallway. Resident 14 was laying on the bed with pants pulled down to the thighs. Resident 14's shirt was pulled up with stomach and breast exposed. The door to the room was open and Resident 14 was visible from the hallway. On 03/01/18 interview with LPN-E (Licensed Practical Nurse) revealed that the resident not being covered and the door to the room being open was a dignity issue for the resident.",2020-09-01
607,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,583,E,0,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (20) Based on observation, interview, and record review; the facility staff failed to maintain resident privacy by placing private medical information that could be potentially viewed by the public or staff not authorized to have access to the information and by discussing private medical information audible to passers-by in public areas. This affected Residents 33, 77, 7, 26, 36, and 43. This affected 6 of 6 sampled residents. The facility identified a census of 82 at the time of survey. Findings are: [NAME] Review of Resident 33's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 1/9/2018 revealed an admission date of [DATE]. Observation of Resident 33's room on 3/01/18 at 2:23 PM revealed there were 5 appointment reminder slips taped on the outside of the closet door that were visible from the window and potential visitors. Some of them were descriptive and revealed private information about Resident 33's medical condition including who the provider was and the reason for the appointment. B. Review of Resident 77's admission MDS dated [DATE] revealed an admission date of [DATE]. Observation of Resident 77's room on 3/01/18 at 10:21 AM revealed the door was open and OT-D (Occupational Therapist) was discussing private medical information including diagnosis, medical precautions, and treatment plan with Resident 77 that was audible from the nurses' station across the hall and to passers-by. Review of the facility policy Resident Rights dated 8/17 revealed the following: The facility must: treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The resident has the right to: privacy in his or her immediate living areas. No persons should enter the immediate living area of a resident without first identifying themselves and receiving permission to enter. Personal privacy and confidentiality of his or her personal and medical records. Personal privacy include accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. C. Observation on 3/01/18 at 3:04 PM of the room occupied by Resident 7, identified that there was a doctor appointment reminder taped to the resident's closet door that stated the date, time and the reason for the appointment. The reason stated on the appointment reminder was for an H & P (History and Physical). Observation on 3/06/18 at 1:32 PM of the room occupied by Resident 7, identified that there was a doctor appointment reminder taped to the resident's closet door that stated the date, time and the reason for the appointment. The reason stated on the appointment reminder was for an H & P. Review of the resident's Minimum (MDS) data set [DATE]; identified that the resident had a BIMS (stands for Brief Interview for Mental Status) score of 01, identifying the resident with severely impaired cognition. Interview on 3/06/18 at 1:56 PM with LPN (Licensed Practical Nurse)-A revealed that the charge nurse who received the appointment is the person who posted the appointment reminder on the resident's closet doors. LPN-A confirmed that they put the reason on the appointment reminder for all of the residents. LPN-A acknowledged that identifying the reason for the appointment would be a privacy issue because it did not protect the health information of the resident and the cognitively impaired residents cannot make the decision as to whether they want the reason for the appointment identified on the appointment reminder. Interview on 3/07/18 at 8:13 AM with the DON (Director of Nursing) acknowledged that the nursing staff was putting the reason for the doctor appointments and posted them on the resident's closet doors. The DON confirmed that the reason for the doctor appointment should not be put on the reminder for the cognitively impaired residents since those residents cannot make the decision as to whether they want that health information posted or not. The DON confirmed that would be a privacy concern since the health information for the resident was not protected. D. Observation on 3/01/18 at 3:18 PM of the room occupied by Resident 26, identified that there was a doctor appointment reminder taped to the resident's closet door that stated the date, time and the reason for the appointment. The reason stated on the appointment reminder was for a 12 week follow up for an ingrown toenail. Observation on 3/06/18 at 1:30 PM of the room occupied by Resident 26, identified that there was a doctor appointment reminder taped to the resident's closet door that stated the date, time and the reason for the appointment. The reason stated on the appointment reminder was for a 12 week follow up for an ingrown toenail. Review of the resident's Minimum (MDS) data set [DATE]; identified that the resident had a BIMS score of 04, identifying the resident with severely impaired cognition. Interview on 3/06/18 at 1:56 PM with LPN-A revealed that the charge nurse who received the appointment is the person who posted the appointment reminder on the resident's closet doors. LPN-A confirmed that they put the reason on the appointment reminder for all of the residents. LPN-A acknowledged that identifying the reason for the appointment would be a privacy issue because it did not protect the health information of the resident and the cognitively impaired residents cannot make the decision as to whether they want the reason for the appointment identified on the appointment reminder. Review of an undated facility document, titled Resident Rights, which is given to all residents when they are admitted to the facility; identified that, under the heading: Privacy and Confidentiality-The resident has the right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Interview on 3/07/18 at 8:13 AM with the DON acknowledged that the nursing staff was putting the reason for the doctor appointments and posted them on the resident's closet doors. The DON confirmed that the reason for the doctor appointment should not be put on the reminder for the cognitively impaired residents since those residents cannot make the decision as to whether they want that health information posted or not. The DON confirmed that would be a privacy concern since the health information for the resident was not protected. E. Observation on 03/05/18 revealed an appointment slip for a hospital follow-up was hanging on Resident 36's closet door. F. Observation on 03/02/18 revealed an appointment slip for a hospital follow-up was hanging on Resident 43's closet door.",2020-09-01
608,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,641,D,0,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09B Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) to reflect the resident's status at the time of the assessment. This affected 2 of 24 residents whose MDS assessments were reviewed during the survey, Resident 33 and Resident 82. The facility identified a census of 82 at the time of survey. Findings are: Review of Resident 33's quarterly MDS dated [DATE] revealed an admission date of [DATE]. The areas Antipsychotics were received on a routine basis only. No GDR (Gradual Dose Reduction) attempted. Documented as clinically contraindicated were marked on the assessment. Review of Resident 33's physician's orders [REDACTED]. Review of a search for antipsychotic/antimanic medications in Resident 33's physician's orders [REDACTED]. Interview with ADON-F (Assistant Director of Nursing) on [DATE] at 2:36 PM confirmed that Resident 33 had not been receiving antipsychotic medication at the time of the MDS assessment. Interview with the DON (Director of Nursing) on [DATE] at 2:37 PM confirmed that the MDS was coded in error. B. Review of Resident 82's MDS Entry Tracking Record revealed Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Discharge Tracking Record revealed Resident 82 died in the facility on [DATE]. Review of Resident 82's Progress Notes dated [DATE] revealed Resident 82 was transferred to the hospital on that date. Signs of life were present at the time Resident 82 went to the hospital. Interview with the DON on [DATE] at 2:44 PM revealed Resident 82 did not die in the facility and confirmed the discharge tracking record was coded in error.",2020-09-01
609,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,657,D,1,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09C1c Based on observations, record review and interview, the facility failed to revise the comprehensive care plan for 3 of 3 sampled residents (Residents 26, 15, and 57). The facility census was 82. Findings are: [NAME] Observation on 3/01/18 at 8:30 AM identified that Resident 26 was on transmission based precautions due to a positive test of influenza [NAME] Gloves and masks were provided outside the resident's door prior to entering the resident's room. Review of the Individual Resident Infection Report dated 2/26/18; identified the resident with URI (Upper Respiratory Infection) for influenza A with droplet precautions, started on [MEDICATION NAME], care plan updated and physician and RP (Responsible Party) notified. Review of the comprehensive care plan for Resident 26 did not identify that the resident had influenza and was not updated per the 2/26/18 Individual Resident Infection Report. Interview on 03/06/18 at 3:34 PM with the DON (Director of Nursing) confirmed that the positive test for Influenza A was not identified on the resident's comprehensive care plan as stated on the Individual Resident Infection Report dated 2/26/18. B. Review of Nurses Notes dated 03/02/18 revealed that Resident 15 had a choking episode resulting in the [MEDICATION NAME] maneuver (abdominal thrusts used in a first aid procedure to treat upper airway obstructions (blockage) by foreign objects (food,liquids)) being performed. Resident 15 was sent to the emergency room at the hospital for evaluation. Review of an undated communication sent to the physician revealed the doctor was made aware of the choking episode, the trip to the ER (emergency room ), and treatment done. The Dr. (Doctor) was also informed that the staff would monitor resident during meals and encourage resident to alternate bites and drinks. Review of Doctor Orders revealed an order for [REDACTED]. Review of undated care plan revealed the care plan had not been revised or updated to reflect new interventions or goals for the recent choking episode in dining room. Resident 15 was to have staff monitoring and be encouraged to alternate bites and drinks. Speech Therapy consult was also ordered. None of these interventions were on the care plan. C. Observation on 03/01/18 revealed Resident 57 was not in the facility. Staff stated that the resident was at an appointment getting a blood transfusion. Review of Nurses Notes dated 2/28/2018 revealed an order from the medical provider's office requesting Resident 57 be sent to short stay at the hospital for 2 units of blood. The procedure was unable to be done on 2/28/18 so Resident 57 was asked to return on 3/1/18. Review of the resident's care plan revealed no goals or interventions to reflect the blood transfusion or what to monitor for after having the transfusion. Interview on 03/07/18 with the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) Coordinator revealed the care plan had not been updated. The MDS Coordinator confirmed that they were unaware of Resident 57 receiving blood. When asked who was responsible for updating care plans, the MDS Coordinator confirmed that the MDS Coordinator, nurses or one of the two ADON's (Assistant Director Of Nurses) were responsible for completing the updates and revisions.",2020-09-01
610,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,686,G,0,1,K8KC11,"**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 have interventions in place to promote healing of a facility acquired Stage 2 (partial thickness loss of skin) pressure ulcer on the sacrum (fused bones found at the lower end of the spinal column) for 1 of 3 sampled residents (Resident # 61) and therefore the pressure ulcer worsened from a Stage 2 to a Stage 3 (full thickness loss of skin). The facility identified a census of 82 at the time of survey. Findings are: Record review of Resident 61's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 2/09/18 revealed an admission date of [DATE]. Resident 61 had a BIMS (Brief Interview Mental Status) score of 7 which indicated Resident 61 had severe cognitive impairment. Resident 61 required extensive assistance of 2 staff with bed mobility and was dependent with two plus persons physical assist with transfers. Review of Resident 61's Pressure Ulcer Record dated 1/23/2018 revealed Resident 61 had a Stage 2 pressure ulcer on the sacrum with an onset date of 1/21/2018. Observation of Resident 61 on 3/1/2018 at lunch time (12:00 PM) revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 1:30 PM revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 3:00 PM revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 3:10 PM revealed staff assisted Resident 61 to lay down in bed. The resident had not been out of the wheelchair since before 12PM. Observation on 3/06/18 at 1:14 PM revealed Resident 61 was sitting in a recliner with the sling from the lift still underneath the resident. Observation on 3/06/18 at 2:40 PM revealed Resident 61 was sitting in a wheelchair at an activity with the sling from the lift underneath the resident. Interview on 3/06/18 at 10:45 AM with NA-J (Nurse Aide) revealed that the resident was to be laid down and repositioned every 2 to 3 hours from side to side, to get resident off their bottom. Interview on 3/06/18 at 5:00 PM with LPN-A (Licensed Practical Nurse) revealed that the lift sling was not to be left underneath residents in the chair, unless care planned for that resident. Interview with OT-D (Occupational Therapist) on 3/6/2018 at 1:25 PM revealed that the mechanical lift slings were not be left under residents when they are sitting on a pressure reducing cushion in a chair because it defeated the purpose of the cushion. Review of Resident 61's Pressure Ulcer Record (V3) dated 1/23/18 revealed a Stage 2, 2.5 cm (centimeter) by 1.3 cm pressure ulcer on Resident 61's sacrum. The open area was a fluid filled blister but had erupted and was now open. Review of Resident 61's Pressure Ulcer Record (V3) dated 2/13/18 revealed the pressure ulcer worsened from Stage 2 to Stage 3. Review of Resident 61's Physician Visit/Communication form dated 2/20/18 revealed that Resident 61 had been evaluated at the would clinic for a Stage 3 pressure ulcer that measured 1.5 cm by 1.3 cm by 0.2 cm. Review of Resident 61's Pressure Ulcer Record (V3) dated 3/06/18 revealed a Stage 3 pressure ulcer on the sacrum that measured 2.0 cm by 1.7 cm which indicated the wound had gotten larger than last measurement. Observation of Resident 61 on 3/6/2018 at 10:15 AM revealed Resident 61 had a pressure ulcer present on their tailbone area. Interview with the ADON-G (Assistant Director of Nursing) on 3/6/2018 at 10:20 AM confirmed the pressure ulcer to Resident 61's tailbone area was facility acquired. Review of Resident 61's Care Plan dated 1/27/2018 revealed no documentation that Resident 61 was to be repositioned and whether or not the lift sling was to be left under the resident.",2020-09-01
611,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,689,E,0,1,K8KC11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E3 Based on observation, interview, and record review; the facility staff failed to ensure toilet risers were secured to the toilets to prevent accidents and failed to ensure hot water temperatures did not exceed the limit to potentially scald facility residents. This affected 10 of 15 residents with toilet risers (Residents 23, 19, 32, 55, 37, 31, 40, 20, 5, and 38) and 8 of 11 residents checked for water temperatures (Resident 61, 8, 49, 9, 30, 6, 49, and 30). The facility identified a census of 82 at the time of survey. Findings are: [NAME] Observation of the bathroom shared by Resident 23 and Resident 19 on 3/01/18 at 2:58 PM revealed a toilet riser (a device added to the toilet to elevate it) that was not secured to the toilet, posing a potential accident hazard. B. Observation of the bathroom shared by Resident 55 and Resident 32 on 3/1/18 at 3:05 PM revealed the toilet riser was not secured to the toilet. Interview with the facility Administrator 3/05/18 at 8:13 AM revealed the facility did not have a policy for checking the toilet risers for safe use. Interview with the DON (Director of Nursing) on 3/1/2018 at 4:27 PM revealed 7 toilet risers in the facility were not secured to the toilets. The toilet risers were in the bathrooms used by Residents 23, 19, 32, 55, 37, 31, 40, 20, 5, and 38. C. Observation of Resident 61's bathroom on 3/01/18 at 2:25 PM revealed the hot water temperature from the faucet in the sink was 124.5 degrees F (Fahrenheit). D. Observation of Resident 8's bathroom on 3/1/18 at 2:26 PM revealed the hot water temperature from the faucet in the sink was 123.6 F. E. Observation of Resident 49's bathroom on 3/1/18 at 2:29 PM revealed the hot water temperature from the faucet in the sink was 125.1 degrees F. F. Observation of Resident 9's bathroom on 3/1/2018 at 3:27 PM revealed the hot water temperature was 123.3 F. [NAME] Observation of Resident 30's bathroom on 3/1/2018 at 3:30 PM revealed the hot water temperature was 120.2 F. H. Observation of Resident 6's bathroom on 3/1/2018 at 3:33 PM revealed the hot water temperature was 120.2 F. Review of the Water Temp Log for (MONTH) (YEAR) revealed documentation the hot water temperatures had been checked one room on each unit every week and the hot water temps needed to be below 110. The direction on the log read weekly temps to be done 2 rooms on each wing (front and end rooms) 300 SPA, 200 SPA, 4/500 SPA, 600 SPA (Not over 110 degrees). Observation of Resident 61's bathroom on 3/01/18 at 3:42 PM with the MD (Maintenance Director) revealed a surveyor thermometer temperature of the hot water of 124 F. The MD thermometer read 113.1 F. The MD called on the portable radio to have a staff person check the mixer valve (the valve that controls how the hot and cold water are mixed to keep water temperatures at a safe temperature). Interview with the MD (Maintenance Director) on 3/05/18 at 8:40 AM revealed they did have to adjust the mixer valve. I. Observation on 3/01/18 at 2:29 PM in the room occupied by Resident 49 identified a hot water temperature of 125.1 degrees F (Fahrenheit). [NAME] Observation on 3/01/18 at 3:25 PM in the room occupied by Resident 30 identified a hot water temperature of 120 degrees F.",2020-09-01
612,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,755,D,1,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 174 NAC 12-006.10A3 Based on observation and interview, the facility failed to ensure that a MA(Medication Aide) gave PRN (as needed) medication under the general supervision of a licensed nurse to 2 of 5 residents (Residents 78 and 40) observed during medication administration. The facility identified a census of 82 at the time of survey. Findings are: Observation on 3/05/18 at 08:02 AM revealed MA-K received word through monitor type ear piece, from NA (Nurse Aide)-J that Resident 78 was having pain and needed pain medication. Observation on 3/05/18 at 08:02 AM revealed MA-K, checking MAR (Medication Administration Record) , noted resident had not had any PRN pain medication recently. MA-K then went to med cart and checked out one [MEDICATION NAME] tablet. MA-K then went to Resident 78's room and gave the medication to Resident 78. Observation on 9/05/18 at 10:02 AM revealed an unidentified staff person called for MA-K to come to Resident 40's room as Resident 40 was not feeling well. Resident 40 was rubbing their abdomen. MA-K talked with Resident 40, and inquired would you like to try your medication for nausea? You take that every day and you have not had it today. MA-K returned to the medication cart, took nausea medication from the cart, returned to Resident 40's room and gave Resident 40 the medication. Interview with the DON (Director of Nursing) on 3/6/ at 7:01 PM confirmed that Medication Aides were to talk to the charge nurse before giving a PRN medication.",2020-09-01
613,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,759,D,0,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview; the facility failed to ensure a medication error rate of less than 5 %. Observation of 26 medications administered revealed 2 errors which resulted in an error rate of 7.69 %. The errors affected 2 of 5 residents (Resident 61 and 20) observed during medication administration. The facility identified a census of 82 at the time of survey. Findings are: Observation on 3/05/18 at 7:56 AM revealed MA (Medication Aide)-K took medications to Resident 20 in the dining room. MA-K gave pill type medications crushed in yogurt. MA-K watched resident swallow those medications. Then MA-K sat a glass with [MEDICATION NAME] (a powdered medication mixed with water) on the table with Resident 20 and did not observe the resident swallow the [MEDICATION NAME]. Observation on 3/05/18 at 08:08 AM revealed MA-K gave all of the 08:00 AM medications to Resident 40 in the dining room while the resident was eating breakfast. The medication [MEDICATION NAME] (a medication to prevent stomach ulcers) was ordered to be given AC (before meals) and HS (bedtime). Interview on 3/06/18 at 7:00 PM with the DON (Director of Nursing) confirmed that the medications given to the residents should have been observed swallowed and given at the appropriate times.",2020-09-01
614,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,761,D,0,1,K8KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 174 NAC 12-006.12E7 Based on observation, record review, and interview; the facility failed to provide correct pharmacy labeling for medications and biologicals and failed to follow the facility's procedure of label changes when Doctor orders changed. This affected 1 of 5 residents (Residents 41). Who were observed during medication administration of 26 medications. The facility identified a census of 82 at the time of survey. Findings are: Observation on 3/06/18 at 5:06 PM revealed LPN-A (Licensed Practical Nurse) administered [MEDICATION NAME] 70/30 Insulin 10 u (units) to Resident 41 prior to supper meal. LPN-A checked the MAR (Medication Administration Record) with the label on the Insulin bottle. The label revealed 20 u to be given in the AM and 10 u with supper. The remainder of the label had been torn away. Record review of Resident 41's doctors' orders revealed that the directions of the [MEDICATION NAME] Insulin had doses changed 2/16/18 as follows: 25 u in AM and 10 u prior to supper. Interview on 3/06/18 at 5:06 PM with LPN-A confirmed the label did not have all the directions on it for the dose being given and therefore did not match the Physician order. LPN-A also confirmed the morning dose on the label was incorrect according to the Physician order. LPN-A revealed that the facility policy was when orders changed the medication should have had a small label that alerted nursing staff that the doctors' orders had changed.",2020-09-01
615,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,812,E,0,1,K8KC11,"LICENSURE REFERENCE 175 NAC 12-006.11C Based on observations, record review and interview; the facility failed to ensure that meals were served in a manner to prevent foodborne illness. This had the potential to affect all 82 residents that ate food from the kitchen. Findings are: Observation on 3/01/18 of the 600 kitchen area revealed the following: -at 12:09 PM, the nursing staff were opening packages of crackers with their bare hands and laying them on the plate touching the fruit. 5 residents in the dining room were served the fruit plate with the crackers touching the fruit after they were handled by bare hands. -12:10 PM, the DA(Dietary Aide)-R was using tongs to put orange slices on the resident's plates. The DA-R dropped an orange slice on the counter, then picked up the orange slice with the tongs and threw it into the trash. Then, using the same tongs, began placing more orange slices from the bowl and onto the resident's plates. -at 12:26 PM, 6 room trays were being prepared. The nursing staff were handling the crackers with their bare hands and placing the packages of crackers onto the plate, touching the fruit on the plate. Observation on 3/05/18 at 2:40 PM of the 600 kitchen area identified that there were 4 stacks of bowls, a stack of plates, a stack of stainless steel small cups and 2 containers of silverware that were sitting on the counter in an upright position and uncovered. The kitchen area was adjacent to the 500/600 nurse's station and 600 hall dining room without any wall or door separating the kitchen area from those two areas. Observation on 3/06/18 at 9:00 AM of the 600 kitchen area identified that there were 4 stacks of bowls, a stack of plates, a stack of stainless steel small cups and 2 containers of silverware that were sitting on the counter in an upright position and uncovered. The kitchen area is adjacent to the 500/600 nurse's station and 600 hall dining room without any wall or door separating the kitchen area from those two areas. Observation on 3/06/18 of the 600 kitchen area revealed the following: -at 12:07 PM, the DA-R touched the bottom of the uncovered bowl, filled it with chili and placed the bowl onto a plate. Then, the DA-R placed a grilled cheese sandwich onto the plate against the bowl. The DA-R was wearing a glove on the right hand only. The DA-R went to the refrigerator and got containers of individual butter tubs. The DA-R did not perform hand washing nor changed gloves after getting into the refrigerator. The DA-R placed tubs of butter onto the plates with gloved hand. -at 12:17 PM, the DA-R opened drawers and cupboards in the kitchen area, using the same gloved hand and unwashed bare hand. The DA-R got a scoop and placed sour cream into uncovered stainless steel cups and placed onto plates touching the food that was already on the plate. -at 12:19 PM, the DA-R opened the refrigerator to get a pitcher of tea and poured it into a glass of ice. Gave the glass of tea to another staff member and began to serve other resident's plates without washing hands or changing the glove on the right hand. The DA-R placed their thumb inside the bowl and placed the chili inside the bowl and served it to a resident. All 10 residents in the dining room and 2 residents that received room trays were served from the bowls that were uncovered. During the entire serving process, the DA-R did not perform any hand hygiene. Review of the facility document titled, Handwashing Competency, used by the kitchen staff, identified that kitchen staff where to wash hands whenever hands are soiled or after handling contaminated items (linens/garbage/briefs, etc.) Interview on 3/06/18 at 3:00 PM with the KM (Kitchen Manager) stated that the DA-R was a newer employee and that DA-R needed some more education on the proper handling of the food service and hand hygiene. The KM confirmed that the stack of bowls, plates and silverware in the 600 kitchen area, needed to be covered to protect from contamination.",2020-09-01
616,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,880,E,0,1,K8KC11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility staff failed to cover linens during transport into resident care areas. This had the potential to affect all of the 15 residents on the 100 hallway. The facility census was 82. Findings are: [NAME] Observation on 3/05/18 at 2:30 PM revealed unidentified facility staff on the 100 hall were passing clean linen to the resident's rooms from an uncovered linen cart. B. Observation on 3/06/18 at 2:30 PM revealed linen was being passed by unidentified facility staff on the 100 hallway. Staff were observed going from room to room passing linen and the linen cart was sitting in the hallway uncovered. Linen was exposed to environment, and other staff and residents were observed walking by in the hallway. Interview with the DON (Director of Nursing) on 3/07/18 at 2:26 PM revealed that linen was to be covered while being transported. Review of the facility Laundry Audit revised (MONTH) (YEAR) revealed stored and transported linen was to be covered.",2020-09-01
617,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2018-03-07,921,F,1,1,K8KC11,"> LICENSURE REFERENCE 175 NAC 12-006.18A Based on observations and interview, the facility failed to ensure that the overhead light fixtures in the hallways of the facility and in the kitchen were free from dead bugs and debris and the vents in the kitchen were free from brown fuzzy debris. This had the potential to affect all 82 residents that reside in the facility. Findings are: Initial tour of the kitchen on 3/01/18 at 8:20 AM identified that the overhead light fixtures in the dry storage and food pantry areas contained dead bugs and debris and the vent above the dishmachine had brown fuzzy debris hanging down from it. Observation 3/05/18 at 2:40 PM identified dead bugs and debris in the overhead light fixtures on the 100, 300, 400, 500 and 600 hallways. Observation on 3/06/18 at 11:35 AM of the kitchen; identified that the overhead light fixtures in the dry storage and food pantry areas contained dead bugs and debris and the vent above the dishmachine had brown fuzzy debris hanging down from it. Observation on 3/06/18 at 4:04 PM identified dead bugs and debris in the overhead light fixtures on the 100, 300, 400, 500 and 600 hallways. Interview on 3/06/18 at 3:00 PM with the KM (Kitchen Manager) revealed the dead bugs and debris in the overhead light fixtures in the dry storage and food pantry areas and brown fuzzy debris hanging down from the vent above the dishmachine. The KM confirmed that the overhead light fixtures and the vent were not on a routine cleaning schedule and that they should have been cleaned. Tour of the facility on 3/07/18 at 10:16 AM with the ADM (Administrator) and MD (Maintenance Director) revealed that there were dead bugs and debris in the overhead light fixtures on the 100, 300, 400, 500 and 600 hallways. The MD acknowledged that the housekeepers usually tell the maintenance department when the light fixtures need to be cleaned and that they were not on a routine cleaning schedule. The ADM and MD confirmed that the overhead light fixtures should not have contained any dead bugs and debris.",2020-09-01
618,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,583,E,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to ensure privacy for Residents 80, 18, 19, and 33 by failing to close the door during a medical procedure, and discussing private resident medical information in public areas for Resident 13, and 1 anonymous resident. This affected 6 of 24 residents reviewed during the survey process. The facility identified a census of 83 at the time of survey. Findings are: [NAME] Review of Resident 13's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/4/2019 revealed an admission date of [DATE]. Resident 13 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 13 was cognitively intact. Observation of the hall outside the dining room on 6/26/19 at 1:45 PM revealed LPN-H (Licensed Practical Nurse), was observed walking with Resident 13 outside the dining room in the hall. LPN-H was overheard from the private dining room across the hall telling Resident 13 their blood thinning medication was on hold because of the blood levels bouncing back and forth. Resident 47 was observed walking behind them. B. Review of Resident 80's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 80 had a BIMS score of 15 which indicated they were cognitively intact. IV medications were received while a resident. Observation of Resident 80 on 6/24/19 at 2:17 PM revealed RN-F (Registered Nurse) administering IV (Intravenous) medication to Resident 80 through their PICC (Peripherally Inserted Central Catheter). RN-F exposed the PICC line in Resident 80's left arm before inserting the IV tubing connected to the medication bulb into the PICC line after flushing it. RN-F left Resident 8'0's door open during the procedure. Resident 80 was sitting in their recliner in the corner of the room in view of the hallway and visible to passers-by. Resident 80's window blinds were also open and visible to the street. C. Observation of the 400 unit Nurses' Station on 06/24/19 at 2:15 PM revealed LPN-H (Licensed Practical Nurse) was overheard giving report to 2 other staff at the nurses' station on 400. LPN-H was overheard talking about a resident who was nauseated. The nurses' station was not enclosed and they could still be heard talking by passersby walking down the 100 hall. D. Observation of LPN-G on 6/27/2019 at 11:26 AM revealed they checked Resident 33's blood sugar by lancing their finger and placing a drop of blood on a monitoring strip in the glucose monitoring machine. LPN-G did not close Resident 33's door which was all the way open. Resident 33 was sitting in close proximity to their doorway and was visible to passersby. E. Observation of LPN-G (Licensed Practical Nurse) on 11:35 AM on 6/27/2019 revealed LPN-G checked a blood sugar and administered insulin to Resident 19 in the arm. Resident 19's door was all the way open and Resident 19 was visible to passersby. F. Observation of LPN-G on 6/27/2019 at 11:44 AM revealed LPN-G checked a blood sugar and administered insulin to Resident 18 in the arm. Resident 18's door was all the way open and Resident 18 was visible to passersby. Interview with the facility Administrator on 6/26/19 at 3:45 PM revealed the facility did not have a policy for privacy. The facility staff were expected to follow the Resident Rights pamphlet that the residents received at admission. Interview with the facility Administrator on 6/27/19 at 9:20 AM revealed RN-F should have closed the door when working with Resident 80's PICC line. The facility staff were expected to provide privacy. The facility Administrator revealed it was not acceptable for the staff to talk about residents' medical issues in public areas. Review of the facility Resident Rights revised 8/2018 revealed the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. The facility must respect the resident's right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications .The resident has a right to secure and confidential personal and medical records.",2020-09-01
619,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,585,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on interview and record review, the facility staff failed to follow up on grievances lodged by Resident 20's family. This affected 1 of 1 sampled residents. The facility identified a census of 83 at the time of survey. Findings are: Review of Resident 20's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/11/2019 revealed an admission date of [DATE]. Resident 20 had a BIMS (Brief Interview for Mental Status Score) of 4 which indicated Resident 20 had severe cognitive impairment. Interview with Resident 20's family members on 6/25/19 at 1:27 PM revealed they had complained about Resident 20's care numerous times to the facility staff regarding activities including taking Resident 20 outside, therapy including walking and standing, safety including making sure frequently used items such as the phone and call light were within reach, monitoring to ensure Resident 20's head phones were being charged and utilized, ensuring the hearing aides were working before use and making sure staff identified themselves when they are working with Resident 20. Resident 20's family revealed they had written instructions for the staff to follow on the dry erase board in Resident 20's room but the staff did not always follow their requests. Resident 20's family members revealed no one at the facility had followed up with them about their concerns. Review of the facility Grievance Log received from the SSD (Social Service Director) for (MONTH) (YEAR) to (MONTH) 2019 revealed no documentation of any grievances or complaints received from Resident 20's family. Interview with the DON (Director of Nursing) on 06/26/19 at 11:39 AM revealed they had not received any grievances from Resident 20's family. Interview with the facility Administrator on 6/27/19 at 9:25 AM revealed they were not aware Resident 20's family had complained about anything. Interview with the SSD (Social Service Director) on 6/27/19 at 9:35 AM, identified as the facility Grievance Officer, revealed they had not received any grievances from Resident 20's family. Review of the facility policy Complaint/Grievance Policy and Procedure revised 8/2017 revealed the following: Our facility addresses and investigates all complaints and grievances expressed to the facility. This process addresses and investigates all complaints and grievances expressed to the facility. This process provides feedback and follows up on action to address any oral or written complaint/grievance from a resident or resident's representative. The facility will designate a Grievance Officer to oversee this process. Upon the receipt of a verbal or written complaint/grievance from a resident, his/her family representative, visitor or advocate, a team member will initiate and complete the Complaint/Grievance section of the Complaint/Grievance Report form entirely. The Complaint/Grievance Report form will then be given to the Grievance Officer and logged onto the Monthly/Complaint Grievance log which is printed .and kept in the Grievance binder. Within 3 days of receiving a grievance, the Grievance Officer will also assign a due date for completion. The designated department supervisor will complete the Documentation of Investigation section on the Complaint/Grievance Report form. The designated person will also be responsible to complete the Resolution section on the Complaint/Grievance Report form and inform the complainant of the results within 5-7 days of the initial onset of the report.",2020-09-01
620,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,600,D,1,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > State Licensure Number 175 NAC 12-006.05 (9) Based on record reviews and interviews, the facility failed to ensure 3 residents (Resident 3, 30, and 53) were free from the adverse behaviors of one resident (Resident 49) out of one resident sampled. The facility census was 83. Findings are: Review of Resident 49's Admission Record dated 7-1-19 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident 49's PN (Progress Notes) dated 5-3-19 revealed the resident was initially admitted to a room but was moved to room [ROOM NUMBER] on 5/3 due to increased confusion and decreased safety awareness. On 5-4-19 the resident was found wandering during the night shift in the dining room and had to be redirected. On 5-8-19 Resident 49 was again moved from room [ROOM NUMBER] to room [ROOM NUMBER] for closer monitoring due to impulsiveness. The resident was alert but with short-term memory impairment, impaired decision making ability, and increased confusion in the evenings. On 5-13-19 the PN revealed the resident wandered around aimlessly at times. Staff continued to monitor the resident. Review of PN dated 6-14-19 revealed Resident 49 was last seen in the hallway as the resident had refused to go to bed yet. Resident 49's wheelchair was in the room across the room by the window. The staff assisted Resident 49 back to the resident's room and instructed the resident not to go into other residents's room Per the documentation, (gender) did not understand why. Review of the facility investigation report to the State Authority revealed the incident was reported and the new intervention to protect Resident 49 was to move Resident 49 to another unit and dining room which was done on 6-17-19. On 6-15-19 the resident required frequent redirection when the resident became turned around or confused. The resident self-transferred and occasionally used the wheelchair to propel self in the hallways. On 6-16-19 Resident 49 was exit seeking at an outside door to go find the resident's automobile and staff had to redirect away from the exit door. On 6-17-19 Resident 49 was moved to another room, room [ROOM NUMBER] on another unit. The SSD (Social Service Director) discussed with Resident 49's spouse about moving the resident to a Memory Care Unit (which this facility did not provide) and the spouse denied because of another move causing the resident more confusion. On 6-23-19 at 7:40 PM Resident 49 was observed laying in room [ROOM NUMBER], Resident 8's, a female resident, bed while the dependent resident with dementia sat in a wheelchair in a nightgown and a blanket covering the resident. The staff redirected Resident 49 out of the room. The SSD was informed. On 6-24-19 a nurse observed Resident 49 wander into room [ROOM NUMBER] again and the resident of 404 was laying in bed. Staff went in and redirected the resident back out of the room. On 6/24/19 was the first documented intervention to assist Resident 49 to find the resident's room. The SSD called the spouse to bring in a 'press light to be placed on the outside of the resident's room door. On 6/26/19 Resident 49 attempted to open the door to room [ROOM NUMBER] to enter. Interview on 7-1-19 at 2:11 PM with NA -J (Nurse Aide) revealed Resident 49 wandered into other residents' rooms. The staff were to keep an eye on Resident 49 and redirect the resident as needed. The resident was easy to redirect. NA-J revealed NA-J was not aware of Resident 49 going into any female rooms since being on the 400 unit. Review of Resident 49's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5-22-19 revealed the resident did not wander. Review of Resident 49's Careplan revealed absence of documentation about the resident having any behaviors of wandering and absence of any interventions to protect the other residents from Resident 49's wandering into their rooms. Review of the staff Kardex revealed absence of documentation about Resident 49's wandering or interventions to protect other residents from Resident 49 wandering into their rooms. Review of Resident 49's monthly Behavior Logs for the month of (MONTH) 2019 revealed monitoring did not start until 6-26-19 for Resident attempting to or entering other resident rooms. Review of the (MONTH) 2019 Behavior Logs revealed absence of any monitoring for wandering. Interview on 7-1-19 at 2:24 PM with the ADON (Assistant Director of Nursing) of the 400 unit where Resident 49 moved to room [ROOM NUMBER]. The ADON revealed the suggestion of using STOP signs on other residents' room to prevent Resident 49 from entering those rooms had been discussed, but the IDT (interdisciplinary team) decided against it. Interview on 7-1-19 at 2:24 PM with the DON (Director of Nursing) confirmed Resident 49 started wandering and went into other resident rooms when the resident lived on the 5/6 unit in (MONTH) 2019. The facility moved Resident 49 to a different unit, room [ROOM NUMBER]. On this unit 2 interventions had been initiated, a statue was placed outside of Resident 49's door and a small 'spot light' like a porch light, was placed outside the room door to help the resident identify the resident's room. The DON thought the statue was placed after the incident with Resident 49 going into room [ROOM NUMBER]'s room. The DON confirmed the absence of documentation in either of the residents' medical records or an internal investigation to document the interventions. Interview on 7-1-19 at 4:24 PM with the SSD confirmed there was absence of documentation in Resident 49's careplan of the resident behavior of wandering and absence of documentation about the interventions to protect other residents. The SSD also confirmed the monitoring on the Behaviors Logs for the resident's wandering did not start until 6-26-19.",2020-09-01
621,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,609,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interviews, the facility failed to ensure the staff informed the facility's Administrative staff immediately of a fall with possible fracture for one resident (Resident 76) out of 3 residents sampled, which required emergent evaluation at the hospital. Findings are: Review of Resident 76's facility investigation report revealed on 6-28-19 at 7:20 AM the staff transferred the resident from the bath chair to the wheelchair with the use of the sit to stand lift when the resident moved one of the resident's legs which caused the resident to lose the resident's balance. The staff could not get the resident and the lift to re-balance so lowered the resident to the floor, then utilized the FBL (full body lift) to transfer the resident back to the wheelchair. The resident was assessed with [REDACTED]. The resident was transferred to the hospital and diagnosed with [REDACTED]. Neither the ADM (Administrator) or the DON (Director of Nursing) were notified until Monday, 7-1-19 morning when they arrived to work, which was over 48 hours after the facility staff were aware of the fractured leg. The DON reported the incident to the survey team Monday morning at 9:04 AM since the survey team was in the building for the annual survey. Interview with the DON on 7-1-19 at 6:15 PM confirmed the staff reported the fracture to the Administrative team late and should have notified the ADM or the DON as soon as they knew the leg was fractured.",2020-09-01
622,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,625,D,0,1,TSQB11,"Based on record review and interviews, the facility failed to notify the family of the bed hold policy within 24 hours for one resident (Resident 67), out of two resident sampled, when Resident 67 was sent to the hospital. The facility census was 83. Findings are: Review of Resident 67's PN (Progress Notes) dated Friday, 6-7-19 revealed the resident had respiratory difficulty and was sent to the emergency room to be evaluated and then was admitted in the Hospital. On Monday 6-10-19 the Social Service Department called the resident's spouse and discussed the bed hold policy. Review of the Resident Transfer Record dated 6-7-19 revealed bed hold policy was attached and sent with the resident to the hospital. Review of a copy of a written bed hold letter dated 6-11-19 was documented as sent to Resident 67's family on 6-11-19 and the reason the resident was admitted to the hospital was also included in the letter. Interview on 06/27/19 at 3:29 PM with LPN-G (Licensed Practical Nurse) revealed the process of the nurses was to send the bed hold policy to the hospital with the resident. Then the nurses were to call the family when they knew the resident was being admitted to the hospital and ask about the bed-hold and document the conversation in the PN's/ Review of Resident 67's PN's revealed absence of documentation of notification of the bed hold policy to the family within 24 hours of the resident's admission to the hospital. Interview on 6-27-19 at 2:30 PM with the ADM (Administrator) revealed the facility had a process set up for the weekend on-call Administrative Nurses to call the family/legal representatives about the bed-hold to ensure the family/legal representatives were notified within the 24 hours. The ADM was unsure why it did not occur on the weekend instance of Resident 67 for the 6-7-19 admission.",2020-09-01
623,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,638,D,0,1,TSQB11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility staff failed to complete a Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) at least every 3 months for Resident 40. This affected 1 of 24 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 83 at the time of survey. Findings are: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15 dated (MONTH) (YEAR) revealed The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. Review of Resident 40's completed MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) list revealed an Admission MDS was completed 11/22/2018. A Quarterly MDS was completed 2/9/2019. The next quarterly was completed 6/20/2019, 131 days after the last quarterly assessment was completed. Interview with MDS-C (Minimum Data Set Coordinator) on 6/26/19 at 4:16 PM confirmed Resident 40's last Quarterly MDS was late. Interview with the facility Administrator on 6/26/19 at 3:42 PM revealed the facility did not have a policy for completing MDS assessments. The facility staff were to follow the RAI (Resident Assessment Instrument) manual.",2020-09-01
624,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,641,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) per RAI (Resident Assessment Instrument) manual for the BIMS for Resident 12 and failed to document a pressure ulcer on Resident 78's MDS and inaccurately documented a pressure ulcer on Resident 38. This affected 3 of 24 resident's whose MDS assessments were reviewed during the survey process. The facility identified a census of 83 at the time of survey. Findings are: [NAME] Review of Resident 12 quarterly MDS dated (MONTH) 28, 2019 revealed Resident 12 was understood and understands. Resident 12's BIMS (Brief Interview for Mental Status) was marked not assessed and the staff assessment for mental status was completed. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.15 dated (MONTH) (YEAR) revealed the Steps for Assessment for the BIMS included the following: 1. Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language,or cue cards. 2. Determine if the resident is rarely/never understood verbally, in writing, or using another method. If rarely/never understood, skip to C0700-C1000, Staff Assessment of Mental Status. 3. Review Language item (A1100), to determine if the resident needs or wants an interpreter. Coding Instructions Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Skip to C0700, Staff Assessment of Mental Status. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Proceed to C0200, Repetition of Three Words. Coding Tips Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard no information code (a dash - ) entered in the resident interview items. Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done Interview with the SSD (Social Services Director) on 6/25/19 at 12:24 PM revealed Resident 12's MDS was coded in error. Interview with the SSD on 6/26/19 at 10:11 AM confirmed that they did not complete the section of the MDS for Resident 12's BIMS consistent with the RAI manual. Interview with the facility Administrator on 6/26/19 at 3:42 PM revealed the facility did not have a policy for coding MDS assessments. The facility staff were expected to follow the RAI manual. B. Review of Resident 78's admission MDS dated [DATE] revealed no unhealed pressure ulcers were present. Review of Resident 78's Medicare 5 day MDS dated [DATE] revealed Resident 78 had a pressure ulcer (A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) present, stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister), that was not present upon entry/reentry or prior assessment. Review of Resident 78's Medicare 14 day MDS dated [DATE] revealed Resident 78 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Resident 78 had a pressure ulcer present, stage 2, that was not present upon entry/reentry or prior assessment. Review of Resident 78's 30 day MDS dated [DATE] revealed an admission date of [DATE]. No unhealed pressure ulcers was marked. Interview with the DON (Director of Nursing) on 6/26/19 at 10:34 AM revealed Resident 78 had an area behind their left knee that was pinched that resulted in a blister so it was coded on the MDS as a pressure ulcer. Review of Resident 78's Non-pressure Skin Condition Record dated 6/18/2019 revealed Resident 78 had a scab present 8 cm length by 0.5 cm width to an area behind the left knee. On 6/25/2019 the area measured 0.6 cm length and 1 cm width. There was no documentation the area was healed. Interview with the DON on 7/01/19 at 1:13 PM revealed the MDS person felt it was pressure since it was caused by the leg wraps Resident 78 had been wearing at the time. Interview with MDS-C (MDS Coordinator) on 7/01/19 at 3:57 PM revealed the pressure ulcer to Resident 78's left leg was not healed and should have been coded on the 30 day MDS. C. Record review of Resident 38's Admission Record dated 6-26-19 revealed a date of admission 12-26-12 with [DIAGNOSES REDACTED]. Review of the facility matrix provided by the DON (Director of Nursing) revealed Resident 38 had a pressure ulcer stage 2 (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising). Review of the MDS dated [DATE] revealed the resident had two stage 2 PU (Pressure Ulcers). Review of Resident 38's PN (Progress Notes) from 4/17/19 through 6/24/19 revealed documentation on 4/17/19 about the finding of the 2 pressure ulcers and the request from hospice for a special air mattress. After that date there was absence of documentation about the pressure ulcers. Review of the Pressure Ulcer Record Assessment completed on 4-17-19 of the right buttock revealed a stage 2 pressure ulcer measured at 0.5 cm (centimeter) X 0.5 cm and a 0.2 cm X 0.2 cm wound. On the left buttock a stage 2 pressure ulcer measured at 2.2 cm X 0.4 cm abrasion. [MEDICATION NAME] was applied to the areas. There was absence of any further Pressure Ulcer Record Assessments completed after 4-17-19. Review of April, May, and (MONTH) Medication and Treatment records revealed absence of any treatments for the pressure ulcers. Review of the Careplan revealed two stage 2 pressure ulcers to the right buttock and 1 stage 2 pressure ulcer to the left buttock initiated on 4-23-19 without any revision dates. Interview on 6/26/19 at 3:01 PM with the ADON (Assistant Director of Nursing) revealed the open areas on the resident's buttocks had been healed for quite some time. The ADON reviewed the chart and confirmed there was absence of any other documentation besides the day the wound was found in the PN. The ADON revealed the wound was not a PU but a maceration and was healed within a few days. We reviewed the documentation present in the chart and the ADON confirmed there was lack of documentation about the PU not being a PU in the chart. The ADON then revealed there might be documentation on the bath forms. The ADON went to the bath house and returned with 2 'Non-pressure skin condition records' with documentation dated 4-17-19 which revealed location left cheek (with the drawing on the diagram had a circle on the left buttock) and measurements of 2.2 cm x 0.4 cm of partial thickness, reddened, initial evaluation and [MEDICATION NAME], moisture excoriation documented on the form. Documented on 4/22/19 Non-Pressure Ulcer form was absent of an assessment but was documented to continue with [MEDICATION NAME] moisturizing cream and turn the resident side to side and the wound blanched. On 4/29/19 it was documented on the Non-Pressure Ulcer form resolved. Interview with ADON revealed the wound was never a DU but always a macerated wound. ADON revealed the ADON was brand new in (MONTH) to this position as ADON but had been a charge nurse at the facility. The ADON confirmed the documentation did not have an assessment of the wound on 4/22/19 so the lack of The documentation could not show if it was improving or declining. The ADON revealed the ADON was not aware the MDS had entered it as a pressure ulcer on the MDS or that it was on the Careplan. Interview on 6-27-19 at 2:55 PM with the MDS Coordinator confirmed the MDS dated [DATE] for Resident 38 was entered as a pressure ulcer and the MDS Coordinator was not aware of the Non-Pressure Ulcer sheets that were documented on in the bath house on the same day. Interview on 7-1-19 at 7:54 AM with the DON (Director of Nursing) confirmed the wounds on the buttocks were not pressure ulcers but had been reassessed as maceration wounds.",2020-09-01
625,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,656,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(5) Based on interview and record review; the facility staff failed to follow Resident 50, 55, and 78's care plan to do an AIMS (Abnormal Involuntary Movement Scale-an assessment used to detect adverse side effects cause by antipsychotic medication-medication used to treat [MEDICAL CONDITION]) assessment upon admission, quarterly, and PRN (as needed). This affected 3 of 24 residents whose care plans were reviewed during the survey process (Resident 78). The facility identified a census of 83 at the time of survey. Findings are: [NAME] Review of Resident 78's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/10/2019 revealed an admission date of [DATE]. Resident 78 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident 78 had moderately impaired cognition. Resident 78 received antipsychotic medication 6 days of the 7 days look back period. Antipsychotics were received on a routine basis only. Review of Resident 78's Care Plan dated 5/10/2019 revealed Resident 78 used antipsychotic medications. An AIMS was to be completed when antipsychotic medication was in use initially, quarterly and PRN. Review of Resident 78's Order Summary Report for (MONTH) 2019 revealed an active order for [MEDICATION NAME] Tablet 25 MG (quetiapine [MEDICATION NAME]) Give 0.5 tablet by mouth at bedtime, an antipsychotic medication. Review of Resident 78's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation that Resident 78 was receiving the [MEDICATION NAME]. Review of Resident 78's assessments and medical record revealed there was no documentation an AIMS assessment had been completed. Interview with the DON (Director of Nursing) on 7/01/19 at 1:18 PM confirmed there was no AIMS assessment completed for Resident 78. The DON confirmed an AIMS assessment should have been completed. B. Review of Resident 50's Admission record dated 6-26-19 revealed date of admission of 2-13-19 and [DIAGNOSES REDACTED]. Review of the resident's undated Physician orders [REDACTED]. Review of the resident's behaviors logs revealed the resident had agitated behaviors of yelling, screaming and/or physically acting out towards staff sometimes on a nearly weekly basis. Review of the resident's Careplan revealed the resident was on psychoactive medication for depression and dementia. The Careplan revealed an AIMS was to be performed on the resident upon admission, quarterly, and PRN (as needed). Review of the medical record revealed absence of an AIMS completed. Interview on 6-26-19 at 3:19 PM with the ADON (Assistant Director of Nursing) confirmed the resident had not had an AIMS completed. C. Review of Progress Notes for Resident 55 revealed an admission date of [DATE]. Review of Resident 55's Care Plan dated 6/3/2019 revealed Resident 55 used psychoactive medications. An AIMS was to be completed when antipsychotic medication was in use initially, quarterly and PRN (as needed). Review of Resident 55's Order Summary Report for (MONTH) 2019 revealed an active order for [MEDICATION NAME] Tablet 25 MG (quetiapine [MEDICATION NAME]) Give 1 tablet by mouth one time a day and [MEDICATION NAME] Tablet 50 MG give 1 tablet by mouth at bedtime. Review of Resident 55's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation that Resident 55 was receiving the [MEDICATION NAME]. Review of Resident 55's assessments and medical record revealed there was no documentation of an AIMS assessment being completed. An interview on 7/01/19 at 1:08 PM with the DON (Director of Nursing) revealed that the AIMS assessments were to be completed for residents on antipsychotic medications and they were not being completed.",2020-09-01
626,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,657,E,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 C1c Based on interview and record review, the facility staff failed to revise the care plan with interventions regarding acute respiratory infection for Resident 20, wandering for Resident 49, and a pressure ulcer for Resident 78. This affected 3 of 24 residents whose care plans were reviewed during the survey process. The facility identified a census of 83 at the time of survey. Findings are: [NAME] Review of Resident 20's SCSA (Significant Change in Status) MDS dated [DATE] revealed an admission date of [DATE]. Resident 20 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated Resident 20 had severe cognitive impairment. Resident 20 had an active [DIAGNOSES REDACTED]. Review of Resident 20's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation Resident 20 received antibiotics for a URI (Upper Respiratory Infection) from 6/13/2019 to 6/23/2019. Review of Resident 20's Care Plan dated 3/29/2018 revealed Resident 20 had received antibiotic therapy for a URI from 6/13/19 to 6/23/19. There were no goals or interventions documented for the URI. Interview with the DON (Director of Nursing) on 7/01/19 at 11:44 AM revealed there should have been goals and interventions for the URI for Resident 20. Review of the facility policy Comprehensive Care Plans dated 11/28/2016 revealed the following: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and as needed. The comprehensive care plan will include measurable goals and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The goals will be utilized to monitor the resident's progress. B. Review of Resident 78's admission MDS dated [DATE] revealed an admission date of [DATE]. No unhealed pressure ulcers were present. Review of Resident 78's Medicare 5 day MDS dated [DATE] revealed Resident 78 had a pressure ulcer (A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) present, stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister), that was not present upon entry/reentry or prior assessment. Review of Resient 78's Medicare 14 day MDS dated [DATE] revealed Resident 78 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Resident 78 had a pressure ulcer present, stage 2, that was not present upon entry/reentry or prior assessment. Review of Resident 78's 30 day MDS dated [DATE] revealed an admission date of [DATE]. No unhealed pressure ulcers was marked. Interview with the DON (Director of Nursing) on 6/26/19 at 10:34 AM revealed Resident 78 had an area behind their left knee that was pinched that resulted in a blister. Interview with the DON on 7/01/19 at 1:13 PM revealed the MDS person felt it was pressure since it was caused by the leg wraps Resident 78 had been wearing at the time. Interview with MDS-C (MDS Coordinator) on 7/01/19 at 3:57 PM revealed the pressure ulcer to Resident 78's left leg was not healed and should have been coded on the MDS. Review of Resident 78's Care Plan dated 5/10/2019 revealed no documentation of interventions for the management and healing of the pressure ulcer. Review of Resident 78's Non-pressure Skin Condition Record dated 6/18/2019 revealed Resident 78 had a scab present 8 cm length by 0.5 cm width to the area behind the left knee. On 6/25/2019 the area measured 0.6 cm length and 1 cm width. There was no documentation the area was healed. Interview with MDS-C (MDS Coordinator) on 7/01/19 at 4:06 PM revealed they had taken the blister off of Resident 78's care plan because they thought it was healed. MDS-C confirmed that the pressure ulcer to Resident 78's leg was not healed and interventions should have been left on the care plan. Interview with NA-K (Nurse Aide) on 6/26/19 at 3:08 PM revealed they got the information they needed to care for the residents from the care plan. C. Review of Resident 49's Admission Record dated 7-1-19 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident 49's PN (Progress Notes) dated 5-3-19 revealed the resident was initially admitted to a room but was moved to room [ROOM NUMBER] on 5/3 due to increased confusion and decreased safety awareness. On 5-4-19 the resident was found wandering during the night shift in the dining room and had to be redirected. On 5-8-19 Resident 49 was again moved from room [ROOM NUMBER] to room [ROOM NUMBER] for closer monitoring due to impulsiveness. The resident was alert but with short-term memory impairment, impaired decision making ability, and increased confusion in the evenings. On 5-13-19 the PN revealed the resident wandered around aimlessly at times. Staff continued to monitor the resident. Review of PN dated 6-14-19 revealed Resident 49 was last seen in the hallway as the resident had refused to go to bed yet. Resident 49's wheelchair was in the room across the room by the window. The staff assisted Resident 49 back to the resident's room and instructed the resident not to go into other residents's room Per the documentation, (gender) did not understand why. Review of the facility investigation report to the State Authority revealed the incident was reported and the new intervention to protect Resident 49 was to move Resident 49 to another unit and dining room which was done on 6-17-19. On 6-15-19 the resident required frequent redirection when the resident became turned around or confused. The resident self-transferred and occasionally used the wheelchair to propel self in the hallways. On 6-16-19 Resident 49 was exit seeking at an outside door to go find the resident's automobile and staff had to redirect away from the exit door. On 6-17-19 Resident 49 was moved to another room, room [ROOM NUMBER] on another unit. The SSD (Social Service Director) discussed with Resident 49's spouse about moving the resident to a Memory Care Unit (which this facility did not provide) and the spouse denied because of another move causing the resident more confusion. Review of PN dated 6-18-19 revealed a Medication Aide observed Resident 49 exiting room [ROOM NUMBER], Resident 30, a dependent female resident. On 6-23-19 at 7:40 PM Resident 49 was observed laying in room [ROOM NUMBER], Resident 8's, a female resident, bed while the dependent resident with dementia sat in a wheelchair in a nightgown and a blanket covering the resident. The staff redirected Resident 49 out of the room. The SSD was informed. On 6-24-19 a nurse observed Resident 49 wander into room [ROOM NUMBER] again and the resident of 404 was laying in bed. Staff went in and redirected the resident back out of the room. On 6/24/19 was the first documented intervention to assist Resident 49 to find the resident's room. The SSD called the spouse to bring in a 'press light to be placed on the outside of the resident's room door. On 6/26/19 Resident 49 attempted to open the door to room [ROOM NUMBER] to enter. Interview on 7-1-19 at 2:11 PM with NA -J (Nurse Aide) revealed Resident 49 wandered into other residents' rooms. The staff were to keep an eye on Resident 49 and redirect the resident as needed. The resident was easy to redirect. NA-J revealed NA-J was not aware of Resident 49 going into any female rooms since being on the 400 unit. Review of Resident 49's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5-22-19 revealed the resident did not wander. Review of Resident 49's Careplan revealed absence of documentation about the resident having any behaviors of wandering and absence of any interventions to protect the other residents from Resident 49's wandering into their rooms. Review of the staff Kardex revealed absence of documentation about Resident 49's wandering or interventions to protect other residents from Resident 49 wandering into their rooms. Review of Resident 49's monthly Behavior Logs for the month of (MONTH) 2019 revealed monitoring did not start until 6-26-19 for Resident attempting to or entering other resident rooms. Review of the (MONTH) 2019 Behavior Logs revealed absence of any monitoring for wandering. Interview on 7-1-19 at 2:24 PM with the ADON (Assistant Director of Nursing) of the 400 unit where Resident 49 moved to, revealed the ADON incident with Resident 49 before the resident moved into room [ROOM NUMBER]. The ADON revealed the suggestion of using STOP signs on other residents' room to prevent Resident 49 from entering those rooms had been discussed, but the IDT (interdisciplinary team) decided against it. Interview on 7-1-19 at 2:24 PM with the DON (Director of Nursing) confirmed Resident 49 started wandering and went into other resident rooms when the resident lived on the 5/6 unit in (MONTH) 2019. After the incident, the facility moved Resident 49 to a different unit, room [ROOM NUMBER]. On this unit 2 interventions had been initiated, a statue was placed outside of Resident 49's door and a small 'spot light' like a porch light, was placed outside the room door to help the resident identify the resident's room. The DON thought the statue was placed after the incident with Resident 49 going into room [ROOM NUMBER]'s room. The DON confirmed the absence of documentation in either of the residents' medical records or an internal investigation to document the interventions. Interview on 7-1-19 at 4:24 PM with the SSD confirmed there was absence of documentation in Resident 49's careplan of the resident behavior of wandering and absence of documentation about the interventions to protect other residents. The SSD confirmed the SSD was aware of the resident having gone into resident's rooms upsetting residents. The SSD also confirmed the monitoring on the Behaviors Logs for the resident's wandering did not start until 6-26-19.",2020-09-01
627,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,686,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record reviews and interviews, the facility failed to consistently monitor pressure ulcers on 2 residents (Resident 57 and 23) out of 2 residents sampled. The facility census was 83 Findings are: [NAME] Record review of Resident 57's Admission Record dated 7-1-19 revealed a date of admission of 6-23-17. The Admission Record revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 5-20-19 revealed the resident had an un unhealed PU (pressure ulcer) staged as a stage 2. (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.) Interview on 06/25/19 at 11:41 AM with Resident 57 revealed the resident had a pressure sore on the resident's bottom, however resident refused observation of the wound. Review of Resident 57's Pressure Ulcer Records revealed documentation on 3 different stage 2 pressure ulcers: on the right heel, on the penis, and on the bottom of the scrotum. However, the documentation on all 3 pressure ulcers was incomplete and inconsistent. Record review of the Pressure Ulcer Record dated 5/30/19 of the right heel revealed the stage 2 pressure ulcer was a FA (facility acquired) PU with an onset date of 3-16-19. It measured at 3 x 3 cm (centimeters). There were no further Pressure Ulcer Records for the right heel documented after 5/30/19. Review of the Pressure Ulcer Records completed prior were completed on the date of discovery on 3/16/19 then weekly on 3/21, 3/28, 4/4, 4/11, 4/18, 5/2, and 5/23. There was absence of documentation the week of 4/21- 4/27 and 2 weeks between 5/5 - 5/18. Review of Pressure Ulcer Record dated 5-30-19 revealed a FA stage 2 PU measured at 5 x 4 cm on the penis with an onset date of 4-28-19. There were no further Pressure Ulcer Records for the right heel documented after 5/30/19. Pressure Ulcer Record completed prior were on the date of discovery on 4/28/19 then the next week on 5/2. The next documentation was not for 2 weeks until 5/23 then the last documentation on 5/30. Review of Pressure Ulcer Record date 5/7/19 revealed the initial documentation of a FA stage 2 PU measured at 3 x 1.5 cm on the bottom of the scrotum and stage 2 FA pressure ulcer under the scrotum measured at 3.0 x 1.5 with 0.1 cm depth. The wound bed was covered in slough (dead tissue). There were no further Pressure Ulcer Records for the right heel documented after 5/7/19. Interview on 06/27/19 at 11:56 AM with RN-D (Registered Nurse) revealed RN-D had just completed a thorough skin check and all of the resident's pressure ulcers were healed and the skin was all intact and without redness. Review of PN dated 6/27/19 revealed the resident's skin was intact and all previous open areas were healed. Interview on 07/01/19 at 11:56 AM with the DON (Director of Nursing) revealed after reviewing the resident's records, the PU documentation stopped on the wounds about the time the resident was placed on hospice. The DON confirmed the documentation and monitoring should have continued by the facility. B. Review of Resident 23's MDS revealed a BIMS (Brief Interview of Mental Status score of 00 which indicates severe cognitive impairment. Section M skin revealed 1 Stage 2 pressure ulcer that was present upon admission; moisture associated damage to skin; had pressure reducing device for chair and device for bed; pressure ulcer/injury care with application of ointments/medications other than to feet; Review of Progress Notes revealed an initial entry dated 4/22/19 Wound bed measures 2.5 x 1 with yellow wound bed. Surrounding skin red, measures 4.5 x 2.5 and nonblanchable. Scant amount of yellow drainage to area. Interview on 6/24/19 at 5:06 PM with ADON-B (Assistant Director of Nursing) revealed and confirmed that there was only one entry dated 4/23/19 as the only assessment noted. ADON-B stated the other entries are in the Progress Notes under the Progress Notes tab. Review of the Progress Notes from 4/22/19 through 6/25/19 revealed no documentation of wound size in the progress notes. Review of Physician order [REDACTED]. four times a day for skin care, -[MEDICATION NAME] Powder Apply to abdominal folds/ groin topically two times a day for yeast Administer until healed. -Apply [MEDICATION NAME] cream to residents coccyx four times a day for skin care -[MEDICATION NAME] Thin - Apply to coccyx for pressure ulcer. Change every 3 days and as needed if soiled as needed for pressure ulcer. Review of the undated Care Plan for Resident 23 revealed intervention is place for caring for a Stage 2 pressure ulcer and the date the care plan interventions were initiated was 4/25/19. The intervention under Pressure Ulcer was - Weekly and PRN (as needed) skin monitoring by professional nurse the Date Initiated: was 5/6/2019 and created on: 5/6/2019 Review of Assessments for skin conditions revealed the following two (2) entries: 1. Pressure Ulcer Record dated 4/23/19 a community acquired pressure ulcer. Wound bed measures 2.5 x 1 with yellow wound bed. Surrounding skin red, measures 4.5 x 2.5 and nonblanchable. Scant amount of yellow drainage to area. Resident denies pain to area. Physician notified and [MEDICATION NAME] applied QID (4 times a day) with cares. 2. Pressure Ulcer Record dated 6/24/19 with date of onset noted as 4/23/19 Stage 2 with measurements of 1.0cm x 0.5 cm depth 0.1 cm. and documented Progress Note Summary: Resident noted to have a moisture slit that was reportedly there upon her admission. Resident's primary care provider advised to apply a thin duoderm to area. Repositioned for pressure relief. Interview on 6/26/19 at 10:55 AM with the DON (Director of Nursing) revealed there was no documentation of the pressure ulcer for this resident since admission. The entry made on 6/24/19 was after ADON-B was asked about the measurements. Review of the Physician Visit/Communication Form dated 6/19/19 revealed documentation of the Coccyx wound as 0.6 x 0.5 cm and a wound on right buttock 0.5 cm x 0.2 cm. This was the only measurement recorded since the initial Pressure ulcer record between 4/23/19 and 6/19/19. Review of the Skin and Wound Management Standard Policy revealed the Pressure Ulcer Record (include deep tissue pressure injuries) is to be used weekly and PRN (as needed) for all pressure ulcers/injuries.",2020-09-01
628,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,755,F,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E6 Based on observation, interviews, and record reviews; the facility failed to maintain documentation the emergency drug box was monitored to ensure it had not been tampered with. This had the potential to affect all of the facility residents. The facility identified a census of 83 at the time of survey. Findings are: Observation of the 400 unit medication room with RN-M (Registered Nurse) on 7/01/19 at 4:49 PM revealed an Emergency Drug Box with a blue unnumbered plastic lock was locked in a cupboard. Interview with RN-M on 7/01/19 at 5:08 PM revealed the nurses were supposed to check the Emergency Drug Box every night. Review of the Emergency Lockbox Log for (MONTH) 2019 revealed no documentation the box was checked on 6/6, and 6/14 through 6/30. Interview with HIM (Health Information Manager) on 7/01/19 at 5:10 PM revealed the nurses were supposed to check the Emergency Drug box every night. HIM confirmed it was not documented on the log on 6/6 and 6/14 through 6/30. Observation of the Emergency Drug Box on 7/01/19 at 5:23 PM revealed these medications were listed as being in the Emergency Drug Box: [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME], quetiapine, silver [MEDICATION NAME], Bactrim DS, and [MEDICATION NAME]. Interview with RN-M on 7/01/19 at 5:33 PM revealed the emergency drug box medications could be used for any of the residents. Review of the Nursing2018 Drug Handbook revealed [MEDICATION NAME] and [MEDICATION NAME] were schedule IV drugs, or controlled substances. Review of the facility policy Emergency Boxes/Emergency Pharmacy Services dated 2/2018 revealed the following: The emergency box will be examined by authorized personnel (LPN or RN) of the facility at least once every twenty-four (24) hours and shall notify the pharmacy upon discovering evidence of tampering. Proof of examination by authorized personnel (LPN or RN) of the facility shall be recorded and maintained at the facility for five years from the date of examination.",2020-09-01
629,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,756,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B(5) Based on interview and record review, the facility staff failed to follow the pharmacist directive to do an AIMS or DISCUS assessment (assessments used to detect the presence of adverse side effects) for Resident 78; the consultant pharmacist failed to identify the irregularity the [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]) was not being given for an approved use to Resident 78; and the facility failed to ensure the Pharmacist's request of labs were followed up with the Physician for one resident, Resident 50. This affected 2 of 5 residents reviewed during the survey process. The facility identified a census of 83 at the time of survey. Findings are: [NAME] Review of Resident 78's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/10/2019 revealed an admission date of [DATE]. Resident 78 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated Resident 78 had moderately impaired cognition. Resident 78 received antipsychotic medication 6 days of the 7 days look back period. Antipsychotics were received on a routine basis only. Review of Resident 78's Care Plan dated 5/10/2019 revealed Resident 78 used antipsychotic medications. An AIMS was to be completed when antipsychotic medication was in use initially, quarterly and PRN. Review of Resident 78's Order Summary Report for (MONTH) 2019 revealed an active order for [MEDICATION NAME] Tablet 25 MG (quetiapine [MEDICATION NAME]) Give 0.5 tablet by mouth at bedtime for dementia with behavioral disturbance. Review of Resident 78's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation that Resident 78 was receiving the [MEDICATION NAME]. Review of Resident 78's Initial Medication Regimen Review dated 5/6/2019 and 5/30/2019 revealed the following recommendations by the consultant pharmacist: AIMS or DISCUS monitoring for tardive dyskinesia was indicated. Review of Resident 78's assessments and medical record revealed no documentation an AIMS or DISCUS assessment had been completed. Interview with the DON (Director of Nursing) on 7/1/2019 at 1:18 PM confirmed there was no documentation an AIMS or DISCUS assessment had been completed for Resident 78. The DON confirmed the facility staff were expected to have completed the assessment. Review of the Nursing2018 Drug Handbook revealed the following information for [MEDICATION NAME]: Medication is indicated for [MEDICAL CONDITION], monotherapy and adjunctive therapy with [MEDICATION NAME] or [MEDICATION NAME] for the short-term treatment of [REDACTED]. Black box warning: drug isn't indicated for use in elderly patients with dementia related [MEDICAL CONDITION] because of increased risk of death from CV disease or infection. Monitor patient for tardive dyskinesia (movement disorder), which may occur after prolonged use. It may not appear until months or years later and may disappear spontaneously or persist for life despite ending drug. Adverse reactions included dizziness and weakness. B. Review of Resident 78's MAR (Medication Administration Record) for (MONTH) 2019 revealed the following: Resident 78 received [MEDICATION NAME] for dementia without behavioral disturbance and was treated for [REDACTED]. Interview with the RP (Registered Pharmacist) on 7/01/19 at 3:23 PM confirmed [MEDICATION NAME] was not FDA (Food and Drug Administration) approved for dementia with behavioral disturbance but it was used for that [DIAGNOSES REDACTED]. Requested documentation that Resident 78 was a risk to themselves or other residents and this was not received. Review of Resident 78's Medical Record including the H&P (History & Physical) from both hospitalization s, the documentation of the hospital admission notes, and progress notes revealed there was no documentation that Resident 78 was a danger themselves or to others. Review of Resident 78's Progress Notes revealed documentation that Resident 78 had a fever on 6/10/2019 and 6/5/2019; Resident 78 was treated with [MEDICATION NAME] 6/1 to 6/24 due to a fracture around internal prosthetic left hip joint. Review of Resident 78's Progress Notes revealed no documentation Resident 78 was a danger to themselves or others. Resident 78 had falls documented resulting in fractures on 6/25/19 and 5/23/2019. Interview with the DON (Director of Nursing) on 7/01/19 at 4:23 PM revealed they could not find any documentation of Resident 78 being a danger to themselves or to others. The DON revealed Resident 78 was admitted to the hospital 7/1/2019 for the femur fracture which resulted from the fall 6/25/2019. C. Review of Resident 50's Admission Record dated 6-26-19 revealed the date of admission of 2-13-19 with [DIAGNOSES REDACTED]. Review of undated Physician orders [REDACTED]. Review of the 'Note to Attending Physician' dated 3-19-19 from the Consulting Registered Pharmacist (RP) sent to the Primary Physician for Resident 50 revealed the RP requested a TSH level ([MEDICAL CONDITION] Stimulating Hormone level which is a blood test used to help monitor the [MEDICAL CONDITION] levels and therefore the effectiveness of the medication [MEDICATION NAME]). The Physician's response was the Physician would address the TSH test the next time the resident was seen by the Physician. Review of the resident's lab tests revealed absence of a TSH test completed. Review of the undated Physician orders [REDACTED].>Review of the Physician Visit sheet dated 5-2-19 revealed the resident was seen by the Physician on 5-2-19 and labs were ordered for a CBC (Complete Blood Count) and a BMP (Basic Metabolic Panel) but not a TSH level. Interview on 6-26-19 at 11:32 AM with the ADON (Assistant Director of Nursing) confirmed the TSH level was not addressed and missed with the Physician at the 5-2-19 visit with the resident.",2020-09-01
630,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,759,D,0,1,TSQB11,"**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 below 5% with 3 errors out of 30 opportunities for an error rate of 10 %. This affected 3 of 15 residents observed during medication administration (Residents 18, 19, and 47). The facility identified a census of 83 at the time of survey. Findings are: Observation of LPN-G (Licensed Practical Nurse) on 11:35 AM on 6/27/2019 revealed LPN-G administered 5 units of [MEDICATION NAME] (rapid acting) insulin (a medication used to treat high blood sugar levels) to Resident 19. LPN-G did not offer Resident 19 any food or juice/milk and Resident 19 did not have any visible food or juice/milk in their room. Observation of LPN-G on 6/27/2019 at 11:44 AM revealed they administered 2 units of [MEDICATION NAME]to Resident 18. LPN-G did not offer Resident 18 any food or juice and Resident 18 did not have any visible food/juice in their room. Observation of LPN-G on 6/27/2019 at 11:50 AM revealed they administered 10 units of [MEDICATION NAME]to Resident 47. LPN-G did not offer Resident 47 any food or juice and Resident 47 did not have any visible food/juice in their room. Observation of Resident 19 on 6/27/2019 at 11:59 AM revealed they were sitting in the hall in their wheelchair. Resident 19 did not have any food or juice. Observation of Resident 19 on 6/27/2019 at 12:00 PM revealed an unidentified staff person wheeled Resident 19 to the dining room table. Resident 19 did not have any food or juice. Resident 18 was observed sitting in the dining room at the table. Resident 18 did not have any food or juice. Observation of the facility dining room on 6/27/2019 at 12:06 PM revealed Resident 47 was walking to the dining room table with their walker. Resident 18 and Resident 19 were in the dining room and did not have any food or juice. Observation of the facility dining room at 12:09 PM, 12:12 PM, and 12:14 PM on 6/27/2019 revealed Resident 18 , Resident 47, and Resident 19 did not have any food or juice/milk. Observation of the facility dining room on 6/27/2019 at 12:19 PM revealed Resident 18 received their meal, 35 minutes after Resident 18 received their insulin. Resident 19 was given a glass of supplement but they did not drink it. Observation of the facility dining room on 6/27/2019 at 12:24 PM revealed Resident 47 received their meal, 34 minutes after receiving their insulin. Observation of the facility dining room on 6/27/2019 at 12:25 PM revealed Resident 19 received their meal, 50 minutes after receiving their insulin . Review of the Nursing2018 Drug Handbook revealed the onset of SQ (subcutaneous) [MEDICATION NAME] ([MEDICATION NAME]) insulin was 15 minutes. Teach patient to give insulin at appropriate time around a meal, depending on product. Interview with the DON (Director of Nursing) on 6/27/19 at 3:24 PM revealed the nurses were to follow the drug hand book for rapid acting insulin; residents should have food within 15 minutes of receiving their rapid acting insulin.",2020-09-01
631,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,804,E,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interview, and record review; the facility staff failed to ensure the milk based house supplement was maintained within a safe and palatable temperature, at or below 41 degrees. This had the potential to affect all 12 of the 12 residents who received the house supplement who resided on the 100 and 400 units: Resident 8, Resident 11, Resident 34, Resident 70, Resident 56, Resident 9, Resident 49, Resident 44, Resident 40, Resident 60, Resident 38, and Resident 17. The facility identified a census of 83 at the time of survey. Findings are: Observation of the 100/400 medication cart on 6/27/19 at 10:40 AM, 11:57 AM, and 12:30 PM revealed a bottle of milk type appearing supplement on the cart that was not on ice. Interview with MA-O (Medication Aide) confirmed it was the facility house supplement that was given to the residents who had an order for [REDACTED].>Observation of MA-O on 6/27/2019 at 10:56 AM revealed MA-O gave 120 ml (milliliters) of house supplement to Resident 34 and Resident 34 drank all of it. Interview with the RD (Registered Dietitian) on 6/27/19 at 1:57 PM revealed the house supplement was their homemade house supplement and was an ice cream base with protein powder. The RD revealed the supplement was not kept on ice during medication pass but the nursing staff were supposed to put it back in the refrigerator when they were done with medication pass. The RD revealed the facility did not have a policy for keeping foods refrigerated. Interview with MA-O on 6/27/19 at 2:05 PM revealed they had just put the supplement back into the refrigerator so they got a glass of the supplement from the refrigerator. The temperature of the glass of supplement was 54.5 F. Observation of the temperature of the supplement on 6/27/19 at 2:08 PM with the RD and interview with the RD at this time revealed the RD confirmed the temperature of the supplement was too high. Review of the facility House Milk Supplement recipe received from the RD revealed it consisted of the following: 1 gallon ice cream mix, 1 gallon whole milk, 2 cups dry milk. Review of the list of residents who had orders for the House Supplement received from the DON (Director of Nursing) on 6/27/19 at 4:15 PM revealed the following residents had an order for [REDACTED]. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: Except during preparation, cooking, or cooling or when time is used as the public health control as specified under Nebraska Pure Food Act, and except as specified under subsection (2) of this section, time/temperature control for safety food shall be maintained: (i) Forty-one degrees Fahrenheit (five degrees Celsius) or less.",2020-09-01
632,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,842,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure documentation of one resident's (Resident 38) medical record was complete and accurate related to skin condition out of 24 residents sampled. Findings are: Record review of Resident 38's Admission Record dated 6-26-19 revealed a date of admission 12-26-12 with [DIAGNOSES REDACTED]. Review of the facility matrix provided by the DON (Director of Nursing) revealed Resident 38 had a pressure ulcer stage 2 (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising). Review of the MDS dated [DATE] revealed the resident has two stage 2 PU (Pressure Ulcers). Review of Resident 38's PN (Progress Notes from 4/17/19 through 6/24/19 revealed documentation on 4/17/19 about the finding of the 2 pressure ulcers and going to request from hospice a special air mattress. After that date there was absence of any documentation about the pressure ulcers. Review of the Pressure Ulcer Record Assessment completed on 4-17-19 of the right buttock revealed a stage 2 pressure ulcer measured at 0.5 cm (centimeter) X 0.5 cm and 2 0.2 cm X 0.2 cm. On the left buttock a stage 2 pressure ulcer measured at 2.2 cm X 0.4 cm abrasion. [MEDICATION NAME] was applied to the areas. There was absence of any further Pressure Ulcer Record Assessments completed after 4-17-19. Review of April, May, and (MONTH) Medication and Treatment records revealed absence of any treatments for the pressure ulcer sheets. Review of the Careplan revealed two stage 2 pressure ulcers to the right buttock and 1 stage 2 to the left buttock initiated on 4-23-19 without any revision dates. Interview on 6/26/19 at 3:01 PM with the ADON (Assistant Director of Nursing) revealed the open areas on the resident's buttocks had been healed for quite some time. The ADON reviewed the chart and confirmed there was absence of any other documentation besides the day the wound was found in the PN. The ADON revealed the wound was not a DU but a maceration and was healed within a few days. We reviewed the documentation present in the chart and the ADON confirmed there was lack of documentation about the DU not being a DU in the chart. The ADON then revealed there might be documentation on the bath sheets. The ADON went to the bath house and returned with 2 'Non-pressure skin condition records' with documentation dated 4-17-19 which revealed location left cheek (with the drawing on the diagram had a circle on the left buttock) and measurements of 2.2 cm x 0.4 cm of partial thickness, reddened, initial evaluation and [MEDICATION NAME], moisture excoriation documented on the form. Documented on the 4/22/19 Non-Pressure Ulcer form was absent of an assessment but was documented to continue with [MEDICATION NAME] moisturizing cream and turn the resident side to side and the wound blanches On 4/29/19 it was documented resolved. Interview with ADON revealed the wound was never a DU but always a macerated wound. ADON revealed the ADON was brand new in (MONTH) to this position as ADON but had been a charge nurse at the facility. The ADON confirmed the documentation did not have an assessment of the wound on 4/22/19 so the lack of documentation could not show if it was improving or declining. The ADON revealed the ADON was not aware the MDS put had entered it as a pressure ulcer or that it was on the Careplan. Interview on 7-1-19 at 7:54 AM with the DON (Director of Nursing) confirmed the wounds on the buttocks were not pressure ulcers but had been reassessed a maceration wounds. The DON confirmed the documentation was poor, the careplan did not match what the wound was, and there was lack of documentation of follow up of the wound and accuracy of the wound.",2020-09-01
633,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,880,F,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17A and D Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during IV (intravenous) medication administration for Resident 80; failed to review the infection control policies annually; failed to comply with Contact Precautions for a resident with a contagious illness, Resident 67; and failed to provide education to the resident and staff about the cause of one resident, Resident 50's UTI (urinary tract infection) culture results and cause of the UTI and therfore potentially prevent future UTI's This had the potential to affect all of the facility residents. The facility identified a census of 83 at the time of survey. Findings are: [NAME] Observation of RN-F (Registered Nurse) on 6/24/19 at 2:17 PM revealed RN-F had Resident 80's IV medication supplies in their left hand including the medication bulb, IV tubing, and a pre-filled saline flush syringe. An unidentified resident approached RN-F with their walker. As RN-F was talking to the unidentified resident, RN-F place their right hand several times on the the handle of the resident's walker. RN-F then handled the IV supplies with the right hand without performing hand hygiene after touching the resident's walker. The resident had been observed holding on to the handle of their walker prior to RN-F touching the handle. RN-F then put Resident 80's IV supplies on the counter and assisted the unidentified resident. After assisting the unidentified resident, RN-F did a 3 second hand scrub with hand sanitizer then retrieved the IV medication supplies and then entered Resident 80's room with them. RN-F touched Resident 80's clothing and PICC (peripherally inserted central catheter-used to administer intravenous medication) line and used a tape measure to measure Resident 80's arm above the PICC line insertion site. RN-F donned gloves then flushed the PICC line before connecting the medication bulb to the PICC line with the tubing. RN-F then removed their gloves, picked up the tape measure, and left Resident 80's room without performing hand hygiene. RN-F then put hand sanitizer in one hand and still had the tape measure in the other hand. Interview with the DON (Director of Nursing) on 06/27/19 at 5:17 PM revealed staff were expected to perform hand hygiene between residents and follow standard precautions all around. Review of the facility policy Infection Control-Hand Hygiene dated (YEAR) revealed hand hygiene must be performed before and after direct patient-contact, before donning gloves, after removing gloves, before and after performing a procedure, e.g. wound care, changing IV tubing, etc. Duration for the entire procedure for the use of the hand sanitizer was 20-30 seconds. B. Review of the facility policy Antimicrobial Stewardship Program with an effective date of 11/2017 revealed no documentation it had been reviewed in the past year. There was also no documentation on the facility policies General Infection Prevention and Control Policies, Policy for Pneumococcal Vaccination of Residents, Policy for Influenza Vaccination of Residents, and Procedure for Influenza Vaccination of Residents they had been reviewed annually. Interview with the DON on 7/01/19 on 4:29 PM confirmed the policies had not been reviewed. C. Record review of Resident 67's Admission Record dated 7-1-19 revealed a date of admission of 5-24-19 with [DIAGNOSES REDACTED]. Review of the undated Physician orders revealed Resident 67 was started on [MEDICATION NAME] (a cephalosporin antibiotic) capsule 300 mg (milligram) for a disorder of the bladder twice a day for 10 days. Review of Resident 67's urine C/S (culture and sensitivity) dated 6-10-19 revealed the urine grew [MEDICATION NAME] cloacae/asburiae which can be a serious cause of nosocomial infections (nosocomial infections, also known as health care-associated infections, were infections acquired in hospitals, nursing homes, or other clinical settings that spread to susceptible patients usually through the health care staff by way of contaminated equipments, bed linens, air droplets, etc.). Observation on 6/25/19 at 1:51 PM of Resident 67's room revealed a TBP (transmission based precaution) bag hanging on the door of the resident's room filled with PPE (personal protective equipment) such as gloves, masks, and gowns. Interview on 6-25-19 at 1:51 with NA-L (Nurse Aide) revealed the resident had infection in the urine and the staff were to use precautions when emptying the catheter or if working with the catheter or urine. If anyone was working with the resident but not working with the urine, staff did not need to utilize the gloves, gowns, or masks except gloves just like we normally do with anyone. Visitors do not need to use any precautions. Interview on 7/01/19 at 10:17 AM with Resident 67 revealed the staff told the resident the TSB bag on the door was because the resident had an infection in the urine that was contagious and the staff wore a gown and gloves and mask when they worked with the urine the staff did not wear gloves, gown, or mask when working with the resident otherwise. While visiting with the resident, observation of the resident revealed the resident took the resident's bare hand and pulled up the bottom of the leg pants to reveal the urinary catheter bag, then rubbed the hand over and over the urinary bag, touching the urinary spout where the urine came out of the bag, explaining when the staff empty the bag and how often and how the resident watches it and at times will put the call light on and ask them to empty it when it gets full. The resident then reached over with the same hand that had been touching the urinary bag, without a cover on it, and touched the overbed table and then turned on the call light. At 10:21 AM, NA-N entered the room without a gown or gloves and turned off the call light with bare hand where the resident had just touched the call light on at. The resident asked NA-N to empty the catheter bag so then NA-N applied a gown, mask and gloves and proceeded to empty the catheter bag following proper procedure. Interview on 7/01/19 at 10:34 AM with the ADON/IC (Assistant Director of Nursing/Infection Control) Nurse revealed the staff only had to follow the Contact Precautions when handing the resident's urine and did not need to put the PPE on when entering the resident room or working with the resident unless working with the urine. The ADON/IC nurse revealed the facility's expectation was for a resident in Contact Precautions and had a catheter bag which needed to be emptied of the urine, the staff were to wear a gown, gloves, and mask with eyeprotection or mask with goggles. If a resident was not in Contact Precautions and had a catheter bag which needed to be emptied of the urine, the staff were to wear gloves and mask but were not required to wear eye splash guard or goggles. Review of the undated facility policy 'Isolation Precautions, Additional Precautions' revealed staff were to wear clean gloves when entering a resident room when in Contact Precautions and to wear a gown if the staff think they may come into contact with soiled material. Interview on 7/01/19 at 10:58 AM with the DON (Director of Nursing) revealed the DON's expectation was when staff were to empty a urinary catheter bag, regardless if the resident was in contact precautions or not, the staff were expected to wear gloves and eyewear either in the form of goggles or a mask with an eyeshield. The DON also revealed when a resident was placed in Contact Precautions, the PPE should be followed everytime staff enter the room, otherwise staff were just following Universal Precautions which were to be used on every resident. D. Review of Resident 50's Admission Record dated 6-26-19 revealed the date of admission of 2-13-19 with [DIAGNOSES REDACTED]. Review of Resident 50's undated Physician orders revealed the resident had been [MEDICATION NAME](an antibiotic) for 10 days for a UTI with the last day on 6-14-19. On 6-20-19 the resident was started on [MEDICATION NAME] (an antibiotic) twice a day [MEDICATION NAME] to prevent UTI's. Review of Resident 50's PN (Progress Notes) dated 6-6-19 revealed the resident's family stopped at the nursing office and requested the nurse request the Physician place Resident 50 on a [MEDICATION NAME] antibiotic medication as a preventative following the current antibiotic regimen being used to treat the UTI because the resident had a history of [REDACTED]. Review of the lab C/S (culture and sensitivity) test of Resident 50's urine dated 6-1-19 revealed [DIAGNOSES REDACTED] Pneumoniae and probable Proteus. [DIAGNOSES REDACTED] Pneumoniae and Proteus were bacteria that were normally found in the human intestines were they do not cause harm. However when introduced into the urinary system, they cause infections. A common transmission from the intestine to the urinary system was by improper technique of the performance of peri-cares such as cleaning a woman after using the toilet from the back to the front. Interview on 06/27/19 at 10:28 AM with the ADON/IC (Assistant Director of Nursing/Infection Control) Nurse confirmed Resident 50 required assistance from staff with transfers and toileting. The ADON/IC also revealed there was absence of education given to the staff or Resident 50 when the facility received the results of the C/S test of the urine in attempt to try and correct the potential cross contamination with peri-cares and therefore possible cause of the UTI's.",2020-09-01
634,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,881,D,0,1,TSQB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review; the facility staff failed to ensure antibiotic stewardship was followed for Resident 20, 50, and 21. This affected 3 of 24 residents reviewed during the survey process. The facility identified a census of 83 at the time of survey. Findings are: [NAME] Review of Resident 20's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 4/11/2019 revealed an admission date of [DATE]. Resident 20 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated Resident 20 had severe cognitive impairment. Resident 20 did not have any active infections. Review of Resident 20's Progress Notes dated 6/2/2019 revealed Resident 20 received an order for [REDACTED]. There was no documentation Resident 20 was seen by the medical provider prior to the antibiotics being ordered. Review of Resident 20's Progress Notes dated 6/13/2019 revealed Resident 20 started taking [MEDICATION NAME], another antibiotic. There was no documentation Resident 20 was seen by the medical provider prior to the antibiotics being ordered. Review of Resident 20's Hospice Physician Order dated 6/14/2019 revealed an order for [REDACTED]. Review of Resident 20's UA report dated 6/5/2019 revealed a C&S was not indicated because the UA was not abnormal. The medical provider wrote a note to finish [MEDICATION NAME] for UTI even though it was not indicated as Resident 20's UA did not show they had a UTI. Review of Resident 20's Physician Visit/Communication forms dated 6/2, 6/3, 6/5, and 6/12 revealed Resident 20 had not been seen by the medical provider. Type of communication was marked fax not visit. The last Physician Visit/Communication form that indicated Resident 20 was seen by the medical provider was dated 4/15/2019. Review of Resident 20's MAR (Medication Administration Record) for (MONTH) 2019 revealed documentation Resident 20 received the [MEDICATION NAME] 6/3 to 6/13/19 and the [MEDICATION NAME] 6/13 to 6/23/19. Interview with ADON/IC (Assistant Director of Nursing/Infection Control) on 6/27/19 at 4:51 PM revealed the nurses were expected to communicate with the medical providers when antibiotics were ordered if the criteria were not met for the residents to receive them. Review of Resident 20's medical record revealed no documentation the facility staff had requested the medical provider to review the need for the [MEDICATION NAME] when the C&S was not indicated and there was no documentation Resident 20 was seen by the medical provider prior to starting the [MEDICATION NAME] for the URI. Review of the facility policy Antimicrobial Stewardship Program with an effective date of 11/2017 revealed the following: The goal of the Antimicrobial Stewardship program is to promote the appropriate use of antimicrobials in order to maximize treatment outcome and minimize unintended consequences of antimicrobial therapy. B. Review of Resident 50's Admission Record dated 6-26-19 revealed the date of admission of 2-13-19 with [DIAGNOSES REDACTED]. Review of Resident 50's undated Physician orders revealed the resident had been [MEDICATION NAME](an antibiotic) for 10 days for a UTI with the last day on 6-14-19. On 6-20-19 the resident was started on [MEDICATION NAME] (an antibiotic) twice a day [MEDICATION NAME] to prevent UTI's. Review of Resident 50's PN (Progress Notes) dated 6-6-19 revealed the resident's family stopped at the nursing office and requested the nurse request from the Physician for Resident 50 be placed on a [MEDICATION NAME] antibiotic medication as a preventative following the current antibiotic regimen being used to treat the UTI because the resident had a history of [REDACTED]. Interview on 6-27-19 at 10:28 AM with ADON/IC (Assistant Director of Nursing/Infection Control Nurse) revealed when the family requested the resident be started on an antibiotic [MEDICATION NAME] on 6-6-19, the nurses should have educated the family about the facility's program of antibiotic stewardship and the risks of long term use of antibiotics so the family could make an informed choice. The ADON/IC revealed if the nurses would have performed the education it would have been documented in the PN and denied the facility had a specific form dedicated to the education about antibiotic stewardship for residents or family. After reviewing the resident's medical record, the ADON/IC confirmed the absence of documentation of education given to the family. C. Review of Physician Orders for Resident 21 revealed an order for [REDACTED].>Review of undated Care plan revealed intervention in place for Antibiotic therapy (Keflex, x 10 days, 6/17/19-6/27/19) related to: Infection (pneumonia) with Date Initiated: 06/17/2019 Review of PN (Progress Notes) revealed testing was not conducted prior to the antibiotic being obtained and chest x-ray results were received after the antibiotic was started. PN dated: 6/17/2019 at 2:29 PM Resident rose this AM for breakfast and C/O (complained of) not feeling well. Resident reports nausea, and does have some mild SOB (shortness of breath) at rest and faint rhonci/crackles to right base. Adventitious (unexpected) sounds did improve some with coughing, and green phlegm was produced. O2 SATS at that time were 86% on R[NAME] O2 at 2 liters applied and resident was able to maintain 90% in room. Resident did maintain 90% on RA (room air) in DR (Dining Room) while awake. Writer did attempt to get resident in to PCP (Primary Care Provider) today, but no appointments available. Physician gives T.O (Telephone Order) for Keflex BID (twice a day) x 10 days, [MEDICATION NAME] BID and PRN (Two times a day and as needed), Cough syrup PRN (as needed), and lab with CXR. (Chest X-ray). CXR was completed today, but labs were attempted with no success. Will encourage fluids and attempt again in AM. PN 6/18/2019 at 4:26 PM Resident continues to have occasional non-productive cough, rhonchi in lungs. Continues to take Keflex for upper respiratory infection with no negative side effects. [MEDICATION NAME] BID (twice a day). Received results to chest x-ray - large left plural effusion with associated atelectasis. Physician notified per fax. Received order per phone from physician to monitor every 4 hours. Interview on 7/01/19 at 11:44 AM with the DON (Director of Nursing) revealed there was no documentation that the physician had seen this resident in regarding to having Upper Respiratory Infection prior to the antibiotic Keflex being started on Keflex. The chest x-ray results were not obtained until the next day. Review of the Antimicrobial Stewardship Program dated 11/2017 revealed, The goal of the ASP (Antimicrobial Stewardship Program) is to promote the appropriate use of antimicrobials in order to maximize treatment outcome and minimize unintended consequences of antimicrobial therapy. The ASP aims to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. The program will promote appropriate use of antibiotics in the facility. the overall goal of ASP (Antimicrobial Stewardship Program) is to prevent undesirable outcomes related to antibiotic misuse by optimizing the selection of drug, dose, rout, and duration of therapy. Antibiotic use protocols and systems to monitor antibiotic use will be implement to achieve ASP goals.",2020-09-01
635,TIFFANY SQUARE,285087,3119 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803,2019-07-01,923,D,0,1,TSQB11,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.18A Based on observation and interview, the facility failed to provide a clean environment related to fuzzy gray debris on bathroom vents which affected 3 residents (Resident 69, Resident 20, Resident 1). The facility census was 83. Findings are: [NAME] Tour of the room occupied by Resident 69 on 6/25/19 at 9:12 AM found the vent in the bathroom ceiling soiled with a fuzzy gray debris. B. Tour of the room occupied by Resident 20 on 6/25/19 at 9:11 AM found the vent in the bathroom ceiling soiled with fuzzy gray debris. C. Tour of the room occupied by Resident 1 on 6/25/19 at 9:13 AM found the vent in the bathroom ceiling heavly soiled with fuzzy gray debris. Interview on 7/1/19 at 5:15 PM with MS (Maintenance Supervisor) revealed that the Rooms occuppied by Resident 69, Resident 20, and Resident 1 had the vent in the bathroom ceiling soiled with a fuzzy gray debris.",2020-09-01
636,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2020-01-06,554,D,0,1,QRS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (16) Based on observation, record review and interviews; the facility failed to assure Resident 23 was safe for the self-administration of medications and to obtain orders for self-administration of medications which had been left at the resident's bedside. The sample size was 1 and the facility census was 24. Findings are: [NAME] Review of the facility policy Self-Administration of Medications (revised 12/12) revealed residents in the facility who wished to self-administer their medications were able to do so, if it was determined they were capable of doing. The policy identified the staff and the physician were to evaluate the resident's mental and physical abilities which included: -decision making capacity; -ability to read and understand medication labels; -comprehension of purpose and proper dosage and administration times; -ability to remove medications from a container, ingest and swallow; and -recognition of risks and adverse consequences of medications. B. Review of a Self-Medication Administration Assessment completed 12/12/19 at 9:07 AM, revealed the resident had expressed an interest in self-administration of medications. The assessment identified the following: -resident unable to state the name, dose, times, strength and frequency of the resident's medications; -resident unable to state if medications required blood pressure or pulse monitoring to determine effectiveness; -resident unable to demonstrate proper storage of medications; and -resident unable to demonstrate ability to properly document the administration of medications. Review of Resident 23's current Care Plan with revision date 12/22/19 revealed the resident had impaired cognition with short term memory loss. In addition, the resident had a history of [REDACTED]. Interventions included education regarding the importance of taking medications, cues, reorientation and supervision as needed and to monitor for changes in cognitive function. An observation of Resident 23's room on 1/2/20 at 9:42 AM revealed a medication cup on the bedside table. The medication cup contained 8 different medications. Resident 23 was seated on the side of the resident's bed with the bedside table in front of the resident. Interview with Resident 23 on 1/2/19 at 10:29 AM revealed the medication cup contained the resident's morning medications. Resident 23 identified the following: -preferred to sleep late and to have a breakfast tray in the resident's room; -staff would frequently leave the resident's morning medications on the resident's bedside table when the resident's blood sugar was tested between 7:00 AM and 7:30 AM; -preferred to take medications after consuming breakfast; and -staff did not observe the resident self-administering the morning medications but would come back to check to make sure the medications were taken or to remind the resident to take if the resident forgot. Review of the resident's Medication Administration Record [REDACTED] -Multivitamin 1 tablet daily; -[MEDICATION NAME] (medication used to treat high blood pressure) 5 milligrams (mg) daily -[MEDICATION NAME] (medication used to treat heartburn) 150 mg daily; -[MEDICATION NAME] (medication for treatment of [REDACTED]. -Vitamin D3 1000 units daily; -Cefdnir (medication used for treatment of [REDACTED]. -[MEDICATION NAME] (medication used for treatment of [REDACTED]. During an interview on 1/2/19 at 10:33 AM, Licensed Practical Nurse (LPN)-C confirmed the resident's 8:00 AM medications had been left in the resident's room for self-administration. Further interview confirmed physician orders for self-administration of these medications had not been obtained.",2020-09-01
637,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2020-01-06,580,D,0,1,QRS211,"**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 failed to notify the attending physician of low blood sugar results for Resident 23 The sample size was 1 and the facility census was 24. Findings are: [NAME] Review of the facility policy for Change in Condition Notification dated 12/14 revealed the facility was to monitor the residents for changes in their condition, to respond appropriately to those changes and to notify the physician of the changes and as directed by the physician. B. Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/12/19 revealed a [DIAGNOSES REDACTED]. Review of a Physician Facsimile (Fax) dated 9/6/19 revealed an order to test the resident's blood sugar 3 times a day and to notify the resident's physician if the resident's blood sugar was less than 60 or greater than 450. Review of the resident's Medication Administration Record [REDACTED] -10/14/19 at 7:30 AM the resident's blood sugar reading was 53; and -10/24/19 at 7:30 AM the resident's blood sugar reading was 54. Review of the Resident's MAR for (MONTH) of 2019 revealed on 11/19/19 at 7:30 AM the resident's blood sugar results were 52. Review of the resident's MAR for (MONTH) of 2019 revealed on 12/27/19 at 5:30 PM the resident's blood sugar reading was 53. There was no evidence Resident 23's attending physician was notified of the low blood sugar results documented on 10/14/19, 10/24/19 and on 11/19/19 at 7:30 AM and on 12/27/19 at 5:30 PM. Interview with the Director of Nurses (DON) on 1/2/20 at 9:02 AM revealed the physician was to be notified any time a blood sugar result was below 60. The DON confirmed Resident 23's low blood sugar results on 10/14/19, 10/24/19 and on 11/19/19 at 7:30 AM and on 12/27/19 at 5:30 PM should have been reported to the attending physician.",2020-09-01
638,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2020-01-06,686,D,0,1,QRS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2a Based on observation, interview, and record review; the facility failed to implement and to revise and/or develop interventions to promote wound healing and to prevent potential recurrence for Resident 15's pressure ulcer. The sample size was 2 and the facility census was 24. Findings are: Review of Resident 15's Care Plan with a review date of 12/2/19 revealed the resident was at risk for pressure ulcer development related to a history of pressure ulcers. Interventions included wound treatment per physician orders [REDACTED]. Further review revealed the resident had a pressure ulcer to the left inner foot started on 8/6/19 that resolved on 8/23/19. A new open area to the left inner foot started on 8/28/19. Review of Resident 15's Weekly Wound Evaluations revealed: - On 8/28/19 and 9/4/19 the resident continued with a stage 2 area to the left inner foot that measured 0.3 centimeter (cm) by 0.3cm, with an intervention to limit the use of the resident's left shoe until healed. - On 9/11/19, 9/18/19, 10/2/19, 10/9/19, and 10/22/19 the resident continued with a stage 2 area to the left inner foot that measured 0.5cm by 0.5cm. The intervention to limit the use of the resident's left shoe until healed remained in place. There was no evidence to indicate any new/revised interventions were implemented. - On 10/24/19 the residents wound care treatment was changed by the physician. - On 11/6/19 the resident continued with a stage 2 area to the left inner foot that measured 0.5cm by 0.5cm. - On 11/13/19, 11/27/19, 12/4/19, 12/12/19, and 1/1/20 the area to the left inner foot measured 0.2cm by 0.2cm. There was no evidence to indicate any new/revised interventions were implemented. Observations of Resident 15 revealed: - 12/31/19 at 10:20 AM, the resident was in the resident's room seated in the resident's wheelchair with shoes on both feet. - 12/31/19 at 2:18 PM, the resident was in the resident's room with shoes on both feet. - 1/2/20 at 8:22 AM, the resident was in the resident's room with shoes on both feet. - 1/2/20 at 11:35 AM, the resident was in the resident's room with shoes on both feet. - 1/6/20 at 8:24 AM, the resident was in the resident's room with shoes on both feet. Interview with Registered Nurse Consultant -E on 1/2/20 at 11:28 AM revealed the facility used a weekly assessment to look at the wounds healing and to identify any interventions being used. Interview with Nursing Assistant (NA)-D on 1/6/19 at 8:03 AM confirmed the only wound intervention for Resident 15's pressure ulcer was to try and have Resident 15 keep the left shoe off in the resident's room, which didn't always work.",2020-09-01
639,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2020-01-06,692,D,0,1,QRS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to implement, evaluate, and/or revise interventions to prevent ongoing weight loss for Resident 4. The sample size was 2 and the facility census was 24. Findings are: Review of the facility Weight Monitoring policy dated 5/2017 revealed the facility would ensure that all residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. Weights should be documented when they are taken and rounded to the nearest whole pound. The newly recorded weight should be compared to the previous recorded weight. Review of Resident 4's Care Plan with a review date of 10/24/19 revealed the resident was at risk for weight loss. Interventions included monitoring weights weekly. Review of Resident 4's Weights and Vitals Summary revealed; - On 11/22/19 the resident's weight was 169 pounds (lbs), - No weight was documented on 11/29/19, - On 12/6/19 the resident's weight was 156 lbs (a 13 pound weight loss in 14 days), - On 12/8/19 the resident's weight was 151 lbs (a 5 pound weight loss in 2 days), - On 12/11/19 the resident's weight was 150 lbs, - On 12/20/19 the resident's weight was 150 lbs, - No weight was documented on 12/27/19. Review of Resident 4's Progress Notes revealed: - No evidence to indicate any interventions were identified after the resident's weight on 12/6/19. - No evidence to indicate any interventions were identified after the resident's weight on 12/8/19. - On 12/9/19 the resident's physician was notified of weight loss, no new interventions were identified. - On 12/12/19 (after a weight loss of 18 lbs) the physician increased the residents [MEDICATION NAME] (a medication used to treat depression) to try and stimulate the resident's appetite. On 1/2/20 at 11:46 AM Resident 4 was brought to the dining room assist table. The residents supplement was provided with lunch. On 1/6/20 at 8:24 AM Resident 4 was in the dining room eating breakfast. The resident's supplement was provided with breakfast. Interview with the Dietary Manager (DM) on 1/6/20 at 8:33 AM confirmed Resident 4 should be weighed weekly. The DM revealed the DM only reviewed weights monthly though. The DM confirmed there was no documentation of the trial protein shake suggested by the Registered Dietitian. The DM confirmed the resident's supplement was provided with the resident's meals, and could be contributing to poor meal intakes.",2020-09-01
640,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2020-01-06,880,D,0,1,QRS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B Based on observations, record review and interview: the facility failed to prevent the potential for cross contamination as respiratory care equipment was not stored in a sanitary manner for Residents 23 and 9. The facility census was 24 and the total sample size was 3. Findings are: [NAME] Review of Resident 23's current Care Plan with revision date 12/30/19 revealed the resident had a history of [REDACTED]. Interventions included the administration of medications/inhalers/oxygen and nebulizer treatments as ordered, monitoring for signs of respiratory distress and monitoring for changes in level of orientation, increased restlessness and anxiety. Review of Resident 23's Medication Administration Record [REDACTED] -[MEDICATION NAME] (used to treat bacterial infections) 500 mg (milligrams) in the morning for cough and wheezes until 11/2/19; and -[MEDICATION NAME] Solution 0.5-2.5 (3) mg/3 milliliters (ml) [MEDICATION NAME]-[MEDICATION NAME] (medications to relax muscles in the airways and increase air flow to the lungs) via a nebulizer (a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) 4 times a day for cough until 11/3/19. Review of Resident 23's MAR for 12/2019 revealed the following: -12/20/19 Cefdnir (medication used to treat bacterial infections) 300 mg twice a day for cough until 12/30/19; -12/20/19 [MEDICATION NAME] (medication used for the treatment of [REDACTED]. -12/26/19 [MEDICATION NAME] 10 mg once a day for cough until 12/29/19. Observation in Resident 23's room on 12/31/19 at 1:56 PM revealed a nebulizer machine positioned on top of the bed linens of a bed in the resident's room. The bed was currently unoccupied and the resident had been using the bed for storage of the resident's craft items. Tubing and a mask were attached to the machine with the tubing coiled on the top of the bed and the mask draped over the nebulizer machine. There were no plastic bag covers observed in the area. During an observation on 01/02/20 at 9:42 AM, the nebulizer machine remained on the top of the bed linens at the foot of the bed next to the resident's bed. The tubing attached to the machine dangled over the foot board of the bed, coiled directly on the floor and then draped across a bedside table next to the resident's bed. The mask attached to the tubing contained moisture droplets. The elastic band used to secure the mask was encircled on a covered plastic mug which contained water and was positioned on the bedside table. B. Review of Resident 9's current Care Plan with revision date 12/31/19 revealed the resident had [DIAGNOSES REDACTED]. Interventions included administration of antibiotics, [MEDICATION NAME] and nebulizer treatments as ordered, prompt treatment of [REDACTED]. Review of the resident's MAR indicated [REDACTED] -12/23/19 [MEDICATION NAME] 30-600 mg 1 tablet twice a day for cough until 12/28/19; -12/23/19 [MEDICATION NAME] Nebulizer Solution 2.5 mg/3 ml inhale 1 vial via a nebulizer 4 times a day for cough until 12/28/19 -12/31/19 [MEDICATION NAME] 30 mg once a day for cough for 5 days; -12/31/19 Cefdnir 250 mg twice a day for [MEDICAL CONDITION] for 10 days; and -12/31/19 Nebulizer treatment reordered due to continued harsh, non-productive cough and lung sounds with wheezes. Observations on 12/30/19 at 12:51 PM and on 12/31/19 at 10:36 AM revealed 2 nebulizer machines stored side-by-side on top of a bedside stand. Tubing and masks were attached to both of the machines with the tubing and masks coiled on the stand and on top of the nebulizer machines. There were no plastic bag covers observed in the area. Also stored on top of the bedside stand and in a cluttered manner were 2 plastic mugs containing water, 2 candy tins, 2 television remotes and a basket filled with individual pieces of candy. During interview on 01/02/20 at 2:35 PM, the Director of Nursing verified the following: -Residents 23 and 9 were at risk for ongoing respiratory infections and were both currently receiving treatment for [REDACTED].>-Resident 9's roommate was also treated for [REDACTED]. -facility policy was to rinse the nebulizer mask after each treatment, allow it to dry, then store the mask and tubing in a plastic bag; and -respiratory care equipment in Resident 9 and Resident 23's room were not stored in accordance with facility policy and placed the residents at risk for potential cross contamination and continued respiratory infections.",2020-09-01
641,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,157,D,0,1,FZQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to notify the physician of Resident 35's low blood sugars. The sample size was 20 and the facility census was 29. Findings are: Review of Resident 35's current undated Care Plan revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 35's Medication Administration Record [REDACTED] - An accucheck (a test used to determine blood sugar levels) was to be completed each morning, and the physician was to be notified if the blood sugar level was less than 60 or greater than 451. - The blood sugar levels on 7/16/17, 7/19/17, 7/20/17, and 7/28/17 were less than 60. During an interview with the Administrator on 8/2/17 at 10:00 AM, the Administrator confirmed the physician had not been notified of Resident 35's blood sugar levels on 7/16/17, 7/19/17, 7/20/17, and 7/28/17.",2020-09-01
642,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,225,D,0,1,FZQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report to the State agency an incident of potential neglect for Resident 19 who sustained a fall during transport by facility staff. The sample size was 20 and the facility census was 29. Findings are: [NAME] Review of the facility policy titled Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property dated 9/7/17 included the following: -neglect means a failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; -it is the responsibility of each individual employee to immediately report any reasonable suspicion of a crime, and all allegations of mistreatment, neglect or abuse; -for purposes of reporting, Immediately means as soon as possible but not to exceed 2 hours in the event of serious injury or death, or 24 hours for all other reports (unless State law/regulations require a shorter timeframe); and -the Administrator shall ensure that alleged violations are reported to State agencies in accordance with existing State and Federal laws. B. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/27/17 indicated the following related to Resident 19: -[DIAGNOSES REDACTED]. -cognitively intact; and -required extensive assistance of 2 for transfers and locomotion on the unit (how the resident moves between locations in his/her room and the adjacent corridor on the same floor; if in a wheelchair, self-sufficiency once in the chair). Review of a Nursing Progress Note dated 6/14/17 at 9:30 AM revealed the following related to Resident 19 was transported to the bath house by a Nursing Assistant (NA) while seated on a whirlpool (bath) chair (a mechanical device used to lower and lift individuals from a whirlpool tub and/or to sit on during a shower; with wheels for transport and maneuverability) and fell forward onto the floor when the bath chair hit ledge of threshold upon entering the bath house. The resident sustained [REDACTED]. Review of an Investigation of Abuse, Neglect or Misappropriation dated 6/20/17 revealed that Adult Protective Services Phone the facility and, during the conversation, advised the facility to send a report to the State Agency related to the incident. During interview on 8/2/17 at 7:10 AM the Administrator verified the State agency was not notified of the violation of potential neglect related to the transfer of Resident 19 until APS appeared to investigate the incident 5 days later.",2020-09-01
643,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,312,D,0,1,FZQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D1c Base on observation, interview, and record review; the facility failed to ensure clothing was dry for Resident 6, who required assistance with Activities of Daily Living (ADL). The sample size was 20 and the facility census was 29. Findings are: Review of Resident 6's current undated Care Plan revealed the resident was at risk for a decline in ADL abilities due to [MEDICAL CONDITION] (a disorder that affects movement, muscle tone, and posture) and required assistance of 1 with dressing and assistance of 1-2 with toileting. An interview with Registered Nurse- C on 8/2/17 at 10:23 AM confirmed Resident 6 required staff assistance with toileting and dressing. On 8/2/17 at 11:45 AM, Resident 6 was transferred to the bathroom by Nursing Assistant (NA) - H and NA -F with the mechanical sit to stand lift (a lift that assists the resident to a standing position for transfers). After using the bathroom, Resident 6 was observed to have a wet area on the back right side of resident's pants on the buttock and upper thigh areas. NA-F stated the wet area was likely from NA-F's hands being wet when helping to adjust the resident's pants. NA-F and NA-H then continued to assist the resident into the resident's wheelchair and take the resident to lunch. A follow-up observation was made on 8/2/17 at 2:10 PM with NA-B and NA-H. Resident 6 was transferred from the wheelchair by NA-B and NA-H with the mechanical sit to stand lift. Resident 6's pants remained visibly wet to the right buttock and upper thigh areas. The cushion of the resident's wheelchair was also observed to be slightly wet. On 8/2/17 at 2:10 PM, NA-H indicated Resident 6's pant were wet and confirmed they needed to be changed.",2020-09-01
644,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,323,E,0,1,FZQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility failed to implement assessed interventions and to revise or develop new fall prevention interventions following falls for 2 residents (Residents 10 and 25) who were assessed at high risk for falls. Furthermore, Resident 19 was not assessed to assure safe transport to and from the bath house, and proper safety equipment was not available to meet the resident's needs. The facility census was 29 and sample size was 20. Findings are: [NAME] Review of Falls Management Policy (revised 4/15) revealed all residents were to be assessed to determine fall risk factors and interventions were then to be developed to reduce the risk of falls or injuries. The following procedures were identified: -All residents were to be assessed on admission, quarterly, with a change in condition and after each fall to determine risk factors. -Development and implementation of fall prevention interventions were to be based on each resident's individual needs. The policy indicated if a resident fell , the resident was to be assessed, causal factors identified and immediate interventions implemented to prevent potential ongoing falls. B. Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 7/7/17 revealed [DIAGNOSES REDACTED]. Review of an Incident Report dated 3/3/17 at 10:10 PM, revealed Resident 10 was observed on the floor of the resident's room. The report indicated the resident was incontinent of urine and had attempted to get to the bathroom. No new interventions were identified to prevent the risk of ongoing falls. Review of an Incident Report dated 6/1/17 at 9:30 PM, revealed the resident was found on the floor of the resident's bathroom. Water was observed on the floor, the resident's toilet would not flush and a plunger was positioned next to the toilet. A new intervention to remove the plunger from the resident's bathroom was identified. Review of Resident 10's current Care Plan with a revision date of 6/13/17 revealed the resident was at risk for falls related to a history of falls. The Care Plan identified the following fall prevention interventions: -Assess the resident for pain if unsteady. -Assist the resident to change into evening clothes and to do cares between 8:00 PM and 9:00 PM. -Encourage the resident to take rest breaks as needed when ambulating. -Ensure the resident is wearing non-slip footwear when up to prevent slipping. -Ensure that assistive devices are within reach at all times. Review of an Incident Report dated 6/16/17 at 9:00 PM, revealed the resident was restless and had been observed walking independently with a walker outside in the facility parking lot and throughout the facility. A visitor who was exiting the facility, alerted the staff that Resident 10 was on the floor in the lounge between the front entrance and the dining room. An intervention to try and assist the resident to go to bed at an earlier time was identified. Review of an Incident Report dated 6/26/17 at 10:20 PM, revealed the resident was found on the floor of the resident's room next to the bed. Further review of the report revealed no causal factors for the resident's fall were identified and no immediate interventions were developed to prevent potential ongoing falls. Review of an Incident Report dated 7/21/17 at 6:32 AM, revealed the resident was found on the floor of the resident's room next to the bed. The resident was involuntary of a bowel movement and indicated a need to use the bathroom. An intervention for the resident to have a TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) for safety was initiated. Observation of Resident 10 on 8/1/17 revealed the following: -From 7:15 AM to 7:25 AM, the resident was seated on the side of the bed in the resident's room. The TABs alarm was hanging from the head rest of a recliner next to the resident's bed but was not attached to the resident. -From 7:25 AM to 8:05 AM, the resident was seated in the recliner in the resident's room. The TABs alarm remained in place to the recliner but was still not attached to the resident. -8:05 AM to 9:00 AM, the resident was seated in a dining room chair at the breakfast table and there was no TABs alarm in place. Observation of Resident 10 on 8/2/17 revealed the following: -From 6:55 AM to 7:15 AM, the resident was lying in bed in the resident's room. The TABs alarm was not attached to the resident. -7:15 AM to 7:32 AM, Nursing Assistant (NA)-F assisted the resident with dressing and with personal hygiene. NA-F seated the resident in a recliner and exited the room without placing the TABs alarm on the resident. -7:48 AM, NA-F assisted the resident with walking out to the dining room for breakfast. The resident was assisted into a chair but no TABs alarm was placed on the resident. -8:30 AM, the resident stood and attempted to ambulate back to the resident's room. The resident's gait was unsteady and balance was poor. NA-F met the resident in the corridor and assisted the resident into a wheelchair. The TABs alarm was in place to the back of the wheelchair however, NA-F failed to attach the alarm to the resident. The resident then self-propelled the wheelchair to the resident's room. During an interview on 8/3/17 from 7:07 AM to 7:20 AM, the Administrator confirmed Resident 10 had a history of [REDACTED]. The Administrator verified the following: -after each individual resident fall, staff should identify causal factors, review and revise fall prevention interventions or develop a new intervention; -the resident had been independent with ambulation but currently required staff assistance for transfers and ambulation; and -the resident was to have the TABs alarm on at all times to alert staff to attempts to self-transfer. C. Review of Resident 25's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident's cognitive ability was moderately intact and the resident had 1 fall with no injury since the last assessment. Review of Resident 25's Progress Notes dated 3/8/17 at 6:00 PM revealed the resident had a history of [REDACTED]. The resident made this comment and staff subsequently lowered the resident to the ground. Documentation indicated the recommendation to prevent further falls was to use 2 staff members to assist with ambulation if 1 of the staff was someone that normally did not walk the resident. This was to ensure the resident felt safe. Documentation further indicated a plan to put the resident in a calm mood before ambulation. Review of a Post Fall Analysis/Plan dated 3/8/17 revealed the recommendations/interventions to prevent a reoccurrence included Education to staff on encouragement, redirection, reassurance during ambulation. Review of Resident 25's Progress Notes dated 3/13/17 at 10:44 AM revealed 1 staff member was assisting the resident from the bathroom to the chair in the resident's room when the resident was lowered to the floor. The intervention to prevent another fall was to have 2 staff members transfer the resident at all times. Review of Resident 25's current undated Care Plan revealed the resident was at risk for falls. The Care Plan indicated the resident was lowered to the floor while being assisted with ambulation and interventions to prevent a reoccurrence following the fall on 3/13/17 were to provide 2 assists with ambulation at all times and non-slip strips were placed on the floor in the bathroom. Further review of the current Care Plan revealed the intervention for the use of 2 assists at all times was discontinued although the specific date this occurred was not recorded. Review of Resident 25's Progress Notes dated 4/16/17 at 6:17 PM revealed 1 staff member was assisting the resident to ambulate out of the bathroom when the resident began calling out help me and I'm going to fall. The staff member lowered the resident to the floor. The intervention to prevent another fall indicated the staff member was instructed to use a slow approach, talk slowly and to tell the resident you can do it (which was the same intervention identified on 3/8/17). Review of a Post Fall Analysis/Plan dated 4/16/17 revealed the recommendations/interventions to prevent a reoccurrence were to encourage the resident to recite a prayer or to count out loud when feeling anxious during ambulation. Review of Progress Notes dated 6/15/17 at 10:26 AM revealed 1 staff member was ambulating Resident 25 to the bathroom when the resident became anxious and the resident bent knees. The staff member lowered the resident to the floor. Documentation indicated education was provided to staff to encourage the resident to keep walking and not to sit on the floor (which was the same intervention identified on 3/8/17). Review of a Verification of Investigation (VOI-a form used to document the investigation following a fall) dated 6/19/17 at 6:40 PM revealed Resident 25 agreed to ambulate with a staff member. After the resident stood up, the resident started yelling, I can't I can't. The staff member assisted in lowering the resident to a kneeling position on the floor. Documentation indicated the recommendation to prevent further falls was New Staff to have 2 assist with (resident) until staff member has been working here for greater than 1 month. Goal is to gain trust of the resident and decrease (resident's) anxiety. Review of a VOI dated 7/15/17 revealed Resident 25 was assisted to and from the bathroom by 1 staff member at 4:30 PM that day. Documentation indicated the resident slid off of the recliner. The staff member assisted in lowering the resident to a kneeling position on the floor. The intervention to prevent a reoccurrence was to place a Dycem ((a non-slip material placed in the seat of a wheelchair/chair to decrease sliding out of chair) in the recliner. Review of a VOI dated 7/16/17 revealed Resident 25 was assisted by 1 staff member from the recliner to bed at 7:46 PM that day. Documentation indicated the resident .took one step back and said 'I'm sitting' then started to sit. The staff member lowered the resident to the floor. The intervention to prevent a reoccurrence was to have 2 staff members assist with all transfers unless a mechanical lift was used. On 8/1/17 at 11:40 AM, NA-A and NA-E were observed to assist Resident 25 out of the recliner in the resident's room. A Dycem was not in place in the seat of the resident's recliner. NA-A and NA-E assisted the resident to ambulate out of the room and half way down the corridor. NA-E pulled the resident's wheelchair behind as they ambulated. Resident 25 then stated That's enough. NA-E immediately placed the wheelchair behind the resident and the resident promptly sat in the wheelchair. Interview with NA-A and NA-E on 8/1/17 at 11:45 AM confirmed there was no Dycem in place in Resident 25's recliner. Interview with NA-A at 12:15 PM on 8/1/17 revealed the Dycem for Resident 25's recliner was found in the side pocket of the recliner and was placed back in the seat of the recliner. Interview with the Director of Nurses (DON) on 8/2/17 at 8:50 AM revealed the fall prevention intervention to have 2 assists at all times when ambulating Resident 25 was most likely discontinued on 4/10/17. The DON indicated the resident completed Physical Therapy on that date and based on a progress note by the Physical Therapist the resident's strength had increased and the resident was able to walk with 1 assist. The DON confirmed Dycem was to be placed in the seat of the recliner when the resident was seated in the recliner. On 8/2/17 at 2:18 PM, Resident 25 was observed seated in the recliner in the resident's room. The Dycem was observed lying on top of the bedside table. D. Review of the MDS dated [DATE] indicated the following related to Resident 19: -[DIAGNOSES REDACTED]. -cognitively intact; and -required extensive assistance of 2 for transfers and locomotion on the unit (how the resident moves between locations in his/her room and the adjacent corridor on the same floor; if in a wheelchair, self-sufficiency once in the chair). Review of the Care Plan dated 5/15/17 indicated Resident 19 was at risk for falls and injury. Nursing interventions included: -call light and personal items available and within reach; -nonskid footwear to prevent slipping; -gait belt (a safety device used to provide support and reduce the risk for falling) with transfers and ambulation; and -keep environment free of clutter. Review of a Nursing Progress Note dated 6/14/17 at 9:30 AM indicated Resident 19 was transported to the bath house on a whirlpool (bath) chair (a mechanical device used to lower and lift individuals from a whirlpool tub and/or to sit on during a shower; with wheels for transport and maneuverability). Upon entering the bath house, the bath chair hit ledge of threshold and the resident fell forward onto the floor. Review of the Post Fall Analysis/Plan dated 6/14/17 revealed the possible causal factors that led to the fall were that the security strap on the bath chair was too small to fit the resident, and the bath chair was akward (sic) to use for transporting. Recommendations/interventions taken to prevent a reoccurrence included ordering a new safety belt for the bath chair, and transporting Resident 19 to the bath house in a wheelchair instead of the bath chair. During interviews on 8/1/17 the following was revealed: -12:57 PM - Resident 19 verified that prior to the fall, transport to and from the bath house was normally accomplished using the bath chair. The resident further verified the safety belt did not fit, and therefore, was not used; -1:20 PM - NA-E verified that prior to the fall, Resident 19 was transported to the bath house on the bath chair and without the safety belt; and -2:01 PM - Licensed Practical Nurse (LPN)-D verified Resident 19 was transported to the bath house on the bath chair and without the safety belt many times prior to the date of the fall. Prior to the fall incident, there was no evidence the facility assessed Resident 19 and the manner of transport to the bath house to assure the safety of the resident. E. Review of the Cascade Patient Transfer Lift System Safe Operation & Daily Maintenance Instructions (the Users Manual for the bath chair used by the facility) dated 10/1/09 included the following: -Before use, residents must be assessed to determine which residents are suitable for transfer, which type of transfer to use, and the number of staff members necessary to transfer each resident; -Although 1 person can perform transfers, certain residents or situations may require the help of one or more additional staff members; -The assessment information must be recorded in the resident's record and must be communicated to the staff; and -Failure to secure the resident properly with the seat (safety) belt could result in injury to the resident or operator.",2020-09-01
645,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,325,D,0,1,FZQN11,"**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 evaluate Resident 35's nutritional needs regarding the resident's fluctuating blood sugar levels. The sample size was 20 and the facility census was 29. Findings are: Review of Resident 35's current undated Care Plan revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 35's Medication Administration Record [REDACTED]. Review of a Progress Note dated 7/11/17 revealed Resident 35's physician was notified of the resident's low blood sugar levels. Further review revealed the physician had requested the dietician review the resident's current diet. During an interview with the Consultant Registered Dietician (CRD) on 8/2/17 at 1:22 PM revealed the most recent dietary review done by the CRD was on 7/26/17. The CRD confirmed Resident 35's blood sugars had not been reviewed by the CRD. Further interview confirmed the CRD was unaware Resident 35 had concerns regarding low and/or fluctuating blood sugar levels.",2020-09-01
646,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,425,D,0,1,FZQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12E7 Based on observation, record review, and interview; the facility failed to ensure that medication labels matched the current physician orders [REDACTED]. The facility census was 29 and the sample size was 20. Findings are: Observation on 8/1/17 revealed the following: -8:15 AM, the label on Resident 35's Novolog (fast acting medication given before meals which helps to lower mealtime blood sugar spikes) Insulin indicated the resident was to receive 10 units subcutaneous (under the skin) at all meals. -8/1/17 at 8:17 AM, Licensed Practical Nurse (LPN)-D administered 12 units of Novolog Insulin to Resident 35. -8/1/17 at 8:20 AM, the label on Resident 35's Tresiba (long acting medication given to control high blood sugar levels) Insulin indicated the resident was to receive 58 units subcutaneous once a day. -8:23 AM, LPN-D administered 52 units of Tresiba Insulin to Resident 35. Review of Resident 35's Medication Administration Record [REDACTED]. Interview with LPN (Licensed Practical Nurse) -D on 8/1/17 at 8:30 AM, confirmed the current physician order [REDACTED]. LPN-D further confirmed that the pharmacy label on the resident's Novolog Insulin and on the Tresiba Insulin did not match the current physician's orders [REDACTED].>",2020-09-01
647,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,431,D,0,1,FZQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].12E4 Based on observation, record review and interview, the facility failed to assure outdated medications were not available for use for Residents 15 and 25. The total sample size was 20 and the facility census was 29. Findings are: Review of the facility policy titled Storage of Medications (revision date ,[DATE]) revealed no discontinued, outdated, or deteriorated medications were to be available for use in the facility. During tour of the Medication Storage areas on [DATE] from 8:50 AM until 9:15 AM, accompanied by the Interim Director of Nursing (DON), the following were found stored in the draws of the medication cart: -an opened container of Miralax Powder (medication used to treat constipation) labeled for use for Resident 15 with an expiration date of ,[DATE]; and -a bubble pack which contained Tylenol 325 milligrams, 2 tablets to be given three times a day labeled for Resident 25 with an expiration date of [DATE]. During interview on [DATE] at 9:15 AM, the DON verified the labels on Resident 15's Miralax and on Resident 25's Tylenol indicated the medications had expired and the medications had been available for resident use.",2020-09-01
648,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2017-08-03,441,D,0,1,FZQN11,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to ensure the mechanical sit to stand lift ( a lift that assists the resident to a standing position for transfers) was disinfected after use, and failed to ensure gloves were worn when there was a potential for contact with bodily fluids. This had the potential to affect Residents 6 and 3. The sample size was 20 and the facility census was 29. Findings are: Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a review date of 11/11/15 indicated durable medical equipment (DME- items that provide a therapeutic benefit to the resident due to a medical condition) must be cleaned and disinfected before reuse by another resident. Observation of resident cares on 8/2/17 from 11:45 AM to 12:05 PM revealed the following: - Resident 6 was assisted to the bathroom by Nursing Assistant (NA)-F with the mechanical sit to stand lift. Resident 6 had been incontinent of bowel. The resident's soiled incontinence product was removed by NA-F and disposed of in the trash. NA-F did not wear gloves while handling the soiled incontinence product. - Resident 6 was then transferred from the bathroom back to the resident's wheelchair. After completion of the transfer NA-H wiped the mechanical sit to stand lift with non-disinfectant wipes. NA-H then took the lift into Resident 3's room. During an interview with the Administrator on 8/3/17 at 7:59 AM, the Administrator confirmed the mechanical sit to stand lift should be cleaned with disinfectant wipes. During an interview with the Director of Nursing (DON) on 8/3/17 at 8:29 AM, the DON confirmed gloves should be worn when handling a soiled incontinence product.",2020-09-01
649,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,550,D,0,1,GJZY11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(21) Based on observation, record review, and interview; the facility failed to maintain Resident 28's dignity related to the use of a gait belt. The sample size was 1 and the facility census was 32. Findings are: Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/17/18 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 (with a score from 0-7 indicating severe cognitive impairment). Review of the facility policy titled Gait Belt dated 8/2015 revealed: - Gait belts were to be used when a resident required assistance with ambulation, - Gait belts should be fastened around the waist/trunk of the resident, - Residents should be transferred with proper body mechanics, and - The gait belt should be removed once the transfer was complete. Observations of Resident 28 from 10/31/18 to 11/5/18 revealed the following: - On 10/31/18 at 10:05 AM, the resident was seated in a recliner in the commons area with a gait belt around the resident's waist. - On 11/1/18 at 10:22 AM, the resident was sleeping in a recliner in the commons area with a gait belt around the resident's waist. - On 11/5/18 from 7:50 AM to 9:02 AM, the resident was seated in a chair at the dining room table. A gait belt remained around the resident's waist the entire time. - On 11/5/18 at 1:10 PM, the resident was seated in a recliner in the commons area, a gait belt remained around the resident's waist. During an interview with the Director of Nursing (DON) on 11/6/18 at 10:00 AM the DON confirmed gait belts should be removed after the transfer was complete.",2020-09-01
650,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,656,E,1,1,GJZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.09C Based on observation, record review and interview; the facility failed to implement care plan interventions for: 1) the prevention of falls/accidents for Residents 6, 21, 22, and 23; 2) the provision of bathing for Residents 21 and 22; 3) the prevention of dehydration for Resident 6; 4) prevention and healing of a pressure ulcer for Resident 32; and 5) provision of Resident 22's walk-to-dine program. The total sample size was 22 and the facility census was 32. Findings are: [NAME] Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident was at risk for a decline in Activities of Daily Living (ADL) and at risk for falls. The following interventions were identified: -assure call light within reach at all times; -bed to be kept in lowest position when resident in bed; and -staff to provide the resident 1-2 assist with transfers to/from the bath chair with 2 whirlpool baths to be provided each week. Review of Bathing Documentation (paper record of baths provided) from 10/5/18 through 11/4/18 revealed Resident 21 did not receive a bath twice every week. Documentation indicated the resident received a bath on (MONTH) 5, 9, 12, 19, 23, 26 and on 30, (YEAR) (a total of 7 out of the 9 baths the resident was to have been provided). Observations of Resident 21 on 11/1/18 revealed the following: -10:57 AM the resident was lying in bed in the resident's room. The resident's bed had not been placed in the low position. -1:34 PM to 2:00 PM the resident was lying on top of the resident's bed with eyes closed. The resident's bed was not in the low position. Interview with the Director of Nursing (DON) 11/1/18 at 2:04 PM confirmed facility staff failed to implement the resident's care plan regarding fall prevention interventions and the number of baths the resident was to receive each week. During an observation of Resident 21 on 11/6/18 at 7:18 AM the resident remained in bed in the resident's room. The resident's bed had not been placed in the low position. B. Review of Resident 22's current Care Plan with revision date 10/7/18 revealed the resident was at risk for a decline in ADL ability and identified the resident was at risk for falls. The following interventions were identified: -TABS alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to be on the resident at all times; -staff to provide the resident with extensive assistance with toileting; -staff to provide the resident assist with a walking program (the resident was to be walked to or from meals for a total of 3 times each day); and -staff to provide the resident 1-2 assist with transfers to/from the bath chair with 2 whirlpool baths to be provided each week. Review of Nursing Rehabilitation Documentation (paper record of the number of times each day the staff assisted the resident with ambulation) from 10/7/18 to 11/4/18 revealed Resident 22 was not assisted to ambulate 3 times each day. Documentation indicated the resident was assisted with walking once a day on (MONTH) 7, 10, 15, 18, 19, 25, 27, 29 and 30, (YEAR) and on (MONTH) 2, 3 and 4, (YEAR). Documentation indicated the resident was assisted with walking twice a day on (MONTH) 8, 9, 13, 14, 16, 17, 22, 24, 26, 28, and 31, (YEAR) and on (MONTH) 1, (YEAR) (a total of 36 out 87 times the resident was to be assisted with ambulation). Review of Bathing Documentation (paper record of baths provided) from 10/8/18 through 11/4/18 revealed Resident 22 did not receive 2 baths weekly. Documentation indicated baths were provided on (MONTH) 11, 18, 25, and 31, (YEAR) and on (MONTH) 4, (YEAR) (a total of 5 out of 9 baths that were to have been provided). Observations of Resident 22 on 11/5/18 revealed the following: -8:00 AM the resident was transferred into a wheelchair and the resident was propelled in the wheelchair by staff out to the dining room for the breakfast meal. Resident 22 was not offered an opportunity to walk out to the breakfast meal. -11:39 AM the resident was seated in a wheelchair in the resident's room. No TABs alarm was in place to the resident. -1:28 PM the resident was in the resident's bathroom with the bathroom door closed. The resident did not have the TABs alarm in place and no staff was in the bathroom or in the resident's room to assure the resident's safety. Interview with the DON on 11/5/18 at 2:00 PM verifed the facility staff failed to implement Resident 22's care plan as the resident did not have the TABs alarm on all times, the resident was left alone in the bathroom, the resident was not provided the number of baths the resident's care plan indicated and staff failed to assist the resident with following the walk-n-dine program. C. Review of Resident 23's current Care Plan with revision date 10/12/18 revealed the resident made attempts to self-transfer despite loss of balance and impaired cognition. In addition, the care plan identified the resident was to have a TABs alarm and pressure sensor alarm on at all times. Observations of Resident 23 on 11/1/18 revealed the following: -10:24 AM the resident was seated in a wheelchair in the resident's room. The resident's pressure sensor alarm was observed lying on the resident's bed. No pressure sensor alarm was noted to the resident's wheelchair. -12:00 PM the resident was seated in a wheelchair and positioned at a table in the dining room. No pressure sensor alarm was observed in the seat of the resident's wheelchair. -1:00 PM to 2:30 PM the resident was seated in the recliner in the resident's room. The pressure sensor alarm remained on the resident's bed and no sensor pressure alarm was observed to the seat of the resident's recliner. Interview with the DON on 11/1/18 at 2:35 PM confirmed Resident 23 was to have both the TABs alarm and the pressure sensor alarm on at all times and staff should have followed the resident's care plan to prevent the potential for falls. D. Review of Resident 6's current undated Care Plan revealed the resident transferred with a full body mechanical lift (a device used to transfer a resident that supports the entire weight of the resident with the use of a sling) with the assistance of 2 staff members. Further review revealed the resident was to wear prevalon boots at all times. Review of an Incident Report dated 7/14/18 revealed Resident 6 was transferred with the full body mechanical lift by 1 staff member from a lounge chair to the resident's wheelchair. After the transfer was completed the staff member noted a 4cm half-moon shaped skin tear to the resident's right hand. There was no evidence to indicate staff members were educated on proper lift techniques according to the resident's plan of care. Review of an Incident Report dated 8/6/18 revealed Resident 6 had a bruise to the left outer knee measuring 6cm by 1cm. The bruise was potentially caused during a transfer with the full body mechanical lift. The resident was not wearing the prevalon boots during the transfer. There was no evidence to indicate staff were re-educated to ensure Resident 6's prevalon boots were worn at all times according to the residents Care Plan. During an interview with the DON on 11/6/18 at 10:00 AM, the DON confirmed the full body mechanical lift should be used with 2 staff members and the resident was to wear the prevalon boots at all times. E. Review of Resident 6's current undated Care Plan revealed the resident required 1 assist with eating. The resident had the potential for fluid deficit related to poor intakes. Staff were to encourage the resident to drink liquids of choice at meals and with cares. The resident required liquids to be thickened to nectar consistency. Further review revealed the staff were to ensure the resident had access to nectar thick liquids whenever possible. Review of Resident 6's Nutrition assessment dated [DATE] revealed the category titled Fluid Needs was not filled out. Observations of Resident 6's room on 11/1/18 revealed: - At 10:01 AM, the resident was seated in the resident's wheelchair, no liquids were available in the room. - At 2:01 PM, the resident was asleep in bed, no liquids were available in the resident's room. During an interview with Licensed Practical Nurse (LPN)-F on 11/5/18 at 2:10 PM revealed the resident was on thickened liquids and staff should keep a cup full of thickened water in the resident's room to offer with cares. F. Review of Resident 32's current undated Care Plan revealed the resident had potential and actual impairment to the resident's skin integrity with an open area to the right buttock. Interventions included keeping the resident's feet slightly elevated to keep the resident from sliding down in bed (as the resident preferred the head of the bed to be elevated). The resident was to be re-positioned at least every 2 hours and as needed. Observations of Resident 32 on 11/1/18 from 7:10 AM until 9:27 AM (2 hours and 17 minutes) revealed the resident was seated upright in the resident's wheelchair. Observation of Resident 32 on 11/1/18 at 10:30 AM revealed the resident was resting in bed. The head of the resident's bed was elevated to 90 degrees (per the resident's preference). The resident's feet were not elevated slightly. Observations of Resident 32 on 11/5/18 from 7:06 AM to 9:15 AM revealed the resident was seated upright in the resident's wheelchair. During an interview with Nursing Assistant (NA)-B on 11/5/18 at 9:35 AM, NA-B revealed Resident 32 had been placed in the resident's wheelchair that morning at 6:30 AM and was not transferred out of the wheelchair until 9:15 AM (2 hours and 45 minutes later).",2020-09-01
651,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,677,D,0,1,GJZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interview, the facility failed to provide: 1) routine bathing assistance, personal hygiene during toileting cares and ambulation assistance for Resident 22 and 2) routine bathing assistance for Resident 21. The sample size was 4 and the facility census was 32. Findings are: [NAME] Review of the facility policy for Perineal Care with revision date 5/2017 revealed the following procedure for completing personal cares when assisting residents with toileting: -wet wash cloth and apply soap or a perineal cleanser. Pre-packaged perineal wipes may also be used; -start at the urethra and cleanse toward the scrotum; -continue to wash the rest of the perineal area, wiping from front to back, alternating from side to side and moving toward the thighs; and -rinse well and dry the urethral and perineal area, working the same direction until the entire area is clean, soap free and dry. B. Review of Resident 22's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/7/18 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident's cognition was moderately impaired, was frequently incontinent of urine and the resident required extensive staff assistance with transfers, ambulation, toileting, personal cares and bathing. Review of Resident 22's current Care Plan with revision date 10/7/18 revealed the resident was at risk for a decline in Activities of Daily Living (ADL) ability and incontinence. The care plan identified the resident required extensive staff assistance with bathing, transfers, toileting, ambulation and personal cares. The resident had a walking program (the resident was to be walked to or from meals for a total of 3 times each day) and a toileting schedule in place and the resident preferred 2 whirlpool baths a week. Review of Bathing Documentation (paper record of baths provided) from 10/8/18 through 11/4/18 revealed Resident 22 did not receive 2 baths weekly. Documentation indicated baths were provided on (MONTH) 11, 18, 25, and 31, (YEAR) and on (MONTH) 4, (YEAR) (a total of 5 out of 9 baths that were to have been provided). Review of Nursing Rehabilitation Documentation (paper record of the number of times each day the staff assisted the resident with ambulation) from 10/7/18 to 11/4/18 revealed Resident 22 was not assisted to ambulate 3 times each day. Documentation indicated the resident was assisted with walking once a day on (MONTH) 7, 10, 15, 18, 19, 25, 27, 29 and 30, (YEAR) and on (MONTH) 2, 3 and 4, (YEAR). Documentation indicated the resident was assisted with walking twice a day on (MONTH) 8, 9, 13, 14, 16, 17, 22, 24, 26, 28, and 31, (YEAR) and on (MONTH) 1, (YEAR) (a total of 36 out 87 times the resident was to be assisted with ambulation). Observation of Resident 22's morning cares on 11/5/18 from 7:31 AM to 7:55 AM by Nursing Assistant (NA)-A revealed the following: -the resident's soiled disposable urinary incontinence brief was removed and the resident was assisted into the bathroom; -without providing perineal cares, a clean disposable urinary incontinence brief was placed on the resident; and -Resident 22 was transferred into a wheelchair, foot pedals were put into place and the resident was propelled in the wheelchair by NA-A out to the dining room for the breakfast meal. Resident 22 was not offered an opportunity to walk out to breakfast. Interview with NA-A on 11/5/18 at 1:00 PM revealed Resident 22 was scheduled to receive 2 baths per week and was to be walked by the staff 3 times a day. NA-A indicated sometimes baths and walking programs did not get completed when staff ran short on time or when not enough staff was available. NA-A further indicated direct care staff had been trained to complete perineal hygiene on residents whenever incontinent or the residents were toileted and verified failure to complete perineal hygiene for Resident 22 with morning cares. C. Review of Resident 21's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS identified the resident's cognition was moderately impaired and the resident required extensive staff assistance with bathing. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident required 1-2 staff assist with transfers to and from the bath chair and further revealed the resident was to receive 2 baths a week. Review of Bathing Documentation from 10/5/18 through 11/4/18 revealed Resident 21 did not receive a bath twice every week. Documentation indicated the resident received a bath on (MONTH) 5, 9, 12, 19, 23, 26 and on 30, (YEAR) (a total of 7 out of the 9 baths the resident was to have been provided).",2020-09-01
652,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,686,D,1,1,GJZY11,"**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 provide care and services for the prevention/treatment of [REDACTED]. The sample size was 1 and the facility census was 32. Findings are: Review of Resident 32's current undated Care Plan revealed the resident had potential and actual impairment to the resident's skin integrity with an open area to the right buttock. Interventions included keeping the resident's feet slightly elevated to keep the resident from sliding down in bed (as the resident preferred the head of the bed to be elevated). The resident was to be re-positioned at least every 2 hours and as needed. Observations of Resident 32 on 11/1/18 from 7:10 AM until 9:27 AM (2 hours and 17 minutes) revealed the resident was seated upright in the resident's wheelchair. Observation of Resident 32 on 11/1/18 at 10:30 AM revealed the resident was resting in bed. The head of the resident's bed was elevated to 90 degrees (per the resident's preference). The resident's feet were not elevated slightly. Observations of Resident 32 on 11/5/18 from 7:06 AM to 9:15 AM revealed the resident was seated upright in the resident's wheelchair. During an interview with Nursing Assistant (NA)-B on 11/5/18 at 9:35 AM, NA-B revealed Resident 32 had been placed in the resident's wheelchair that morning at 6:30 AM and was not transferred out of the wheelchair until 9:15 AM (2 hours and 45 minutes later).",2020-09-01
653,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,689,E,1,1,GJZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observations, record review and interview; the facility failed to implement assessed fall prevention interventions for 3 (Residents 21, 22 and 23) of 5 residents reviewed for falls and to implement interventions to prevent injuries for 2 (Residents 6 and 134) of 2 residents sampled for accident hazards. The facility census was 32. Findings are: [NAME] Review of Resident 21's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 09/30/18 revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was moderately impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -balance was unsteady during transfers and required physical assist to stabilize; and -history of falls. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident was at risk for falls and for injury related to a fall. The care plan further identified the resident had falls in the resident's room on 9/11/18, 10/12/18 and on 10/15/18. Review of a Nursing Progress Note dated 9/11/18 at 9:20 PM revealed Resident 21 was heard calling out for help in the resident's room. The resident was found on the floor with walker collapsed next to the resident. No injuries were identified. The resident's walker was assessed and it was found that a bolt had come out by the left hand brake. The walker was immediately repaired to assure no further falls related to use of the walker. Review of a Nursing Progress Note dated 10/12/18 at 5:50 AM revealed the resident was calling out for help and staff found the resident on the floor next to the resident's bed. Resident 21 had attempted to self-transfer from the bed to a wheelchair. No injuries were identified. New interventions were identified to check the resident for a urinary tract infection and to adjust the current toileting schedule. Review of a Nursing Progress Note dated 10/12/18 at 10:50 PM revealed the resident's pressure sensor alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) was sounding and the resident was found on the floor next to the bed on the resident's knees. The resident identified the need to get to the bathroom. The resident sustained [REDACTED]. A new intervention was developed to place a TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on the resident at all times. Review of a Nursing Progress Note dated 10/15/18 at 11:30 PM revealed the resident was found on the floor next to the resident's bed. No injuries were identified. A new intervention to keep the resident's bed in the lowest position was identified. Observations of Resident 21 on 11/1/18 revealed the following: -10:57 AM the resident was lying in bed in the resident's room. The resident's bed had not been placed in the low position. -1:34 PM to 2:00 PM the resident was lying on top of the resident's bed with eyes closed. The resident's bed was not in the low position. Interview with the Director of Nursing (DON) on 11/1/18 at 2:04 PM confirmed the resident was at risk for falls and had an intervention for the resident's bed to be in the low position whenever the resident was in bed. During an observation of Resident 21 on 11/6/18 at 7:18 AM the resident remained in bed in the resident's room. The resident's bed had not been placed in the low position. B. Review of Resident 22's MDS dated [DATE] revealed the resident's cognition was moderately impaired. The resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive staff assistance with cares, was frequently incontinent and had 1 fall without injury since the previous assessment. Review of Resident 22's current Care Plan (revision date 10/12/18) revealed the resident was at risk for falls due to lower extremity prosthesis with a [MEDICAL CONDITION] to the left leg. A fall prevention intervention was identified for the resident to have a TABs alarm on at all times and for staff to provide the resident assistance with toileting. Observations of Resident 22 on 11/5/18 revealed the following: -11:39 AM the resident was seated in a wheelchair in the resident's room. No TABs alarm was in place to the resident. -1:28 PM the resident was in the resident's bathroom with the bathroom door closed. The resident did not have the TABs alarm in place and no staff was in the bathroom or in the resident's room to assure the resident's safety. During an interview with the DON on 11/5/18 at 1:30 PM, the DON verified the following regarding resident 22: -history of falls with high risk for ongoing falls; -fall prevention intervention for the resident to wear a TABs alarm at all times; and -the resident should not have been left along in the bathroom without staff supervision. C. Review of Resident 23's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS identified the following: -cognition was moderately impaired; -required extensive staff assistance with transfers, bed mobility and toileting; -frequently incontinent of urine; -balance was unsteady during transfers and required physical assist to stabilize; and -history of falls. Review of the resident's current Care Plan with revision date 10/17/18 revealed the resident made attempts to self-transfer despite loss of balance and impaired cognition. In addition, the care plan identified the resident was to have a TABs alarm and pressure sensor alarm on at all times but that the resident had a history of [REDACTED]. The care plan indicated the resident had falls on 10/18/18, 10/22/18 and on 10/23/18. Observations of Resident 23 on 10/31/18 revealed the following: -10:45 AM the resident was in the resident's room and the resident's fall alarms were sounding. The resident had attempted to self-transfer from the resident's recliner. -11:30 AM the resident's fall alarm sounded when the resident attempted to stand from the resident's recliner. -1:45 PM the resident's fall alarms were heard sounding and the resident was observed to be on the floor of the resident's room. Observations of Resident 23 on 11/1/18 revealed the following: -10:24 AM the resident was seated in a wheelchair in the resident's room. The resident's pressure sensor alarm was observed lying on the resident's bed. No pressure sensor alarm was noted to the resident's wheelchair. -12:00 PM the resident was seated in a wheelchair and positioned at a table in the dining room. No pressure sensor alarm was observed in the seat of the resident's wheelchair. -1:00 PM to 2:30 PM the resident was seated in the recliner in the resident's room. The pressure sensor alarm remained on the resident's bed and no sensor pressure alarm was observed to the seat of the resident's recliner. Review of a Nursing Progress Note dated 11/3/18 at 7:45 AM revealed the resident had a fall when the resident was lowered to the floor by staff during a transfer. Review of a Nursing Progress Note dated 11/4/18 at 3:30 PM revealed the resident was found sitting on the floor next to the resident's bed. Interview with the DON on 11/5/18 at 2:35 PM revealed the resident was to have both the TABs alarm and the pressure sensor alarm on at all times. The DON further indicated the resident remained at high risk for falls. D. Review of Resident 134's undated Care Plan revealed the resident was at risk for skin breakdown related to a decrease in overall function. The resident required 1 assist with bathing. Staff were to observe for redness, open areas, scratches, cuts, and bruises, and report any findings to the nurse. Review of a Weekly Wound Evaluation dated 3/8/18 revealed Resident 134 had a skin tear to the resident's right hand measuring 4 centimeters (cm) by 0.1 cm. During an interview on 11/5/18 at 2:10 PM Licensed Practical Nurse (LPN)-F revealed any new skin concern such as a bruise or skin tear should be investigated to determine the cause and then interventions should be implemented to prevent it from happening again. During an interview with the DON on 11/5/18 at 1:20 PM, the DON confirmed an incident report was not completed for Resident 134's skin tear and interventions were not put in place to prevent potential recurrence. E. Review of Resident 6's current undated Care Plan revealed the resident transferred with a full body mechanical lift (a device used to transfer a resident that supports the entire weight of the resident with the use of a sling) with the assistance of 2 staff members. Further review revealed the resident was to wear prevalon boots at all times. Review of an Incident Report dated 7/14/18 revealed Resident 6 was transferred with the full body mechanical lift by 1 staff member from a lounge chair to the resident's wheelchair. After the transfer was completed the staff member noted a 4cm half-moon shaped skin tear to the resident's right hand. There was no evidence to indicate staff members were educated on proper lift techniques. Review of an Incident Report dated 8/6/18 revealed Resident 6 had a bruise to the left outer knee measuring 6cm by 1cm. The bruise was potentially caused during a transfer with the full body mechanical lift. The resident was not wearing the prevalon boots during the transfer. There was no evidence to indicate staff were re-educated to ensure Resident 6's prevalon boots were worn at all times according to the residents Care Plan. During an interview with the DON on 11/6/18 at 10:00 AM, the DON confirmed the full body mechanical lift should be used with 2 staff members and the resident was to wear the prevalon boots at all times. The DON confirmed there was no evidence to indicate training/education was completed with the staff to prevent potential recurrence.",2020-09-01
654,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,690,D,0,1,GJZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1) Based on observations, record review and interviews; the facility failed to provide appropriate care and services for the prevention of urinary tract infections for 1 (Resident 21) of 1 resident sampled who had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). The facility census was 32. Findings are: [NAME] Review of the facility policy titled Infection Control: Urinary Catheters with revision date 5/1/10 indicated the policy was to provide guidance in the preventative measures for controlling infections. The procedure included the following: -eliminate indwelling urinary catheters when possible; -wash hands before and after providing urinary catheter care; -keep the collection bag below the level of the bladder; and -do not allow the catheter tubing, bag or drainage spigot to touch the floor. B. Review of the facility policy Catheter Care (undated) revealed catheter cares were to be performed twice a day and as needed with incontinence or bowel movements to aide in the prevention of infections. The procedure identified the following: -perform hand hygiene; -put on clean gloves; -cleanse from the meatus and up the catheter tubing about six inches with a clean washcloth or a pre-moistened cleansing cloth. Use clean surface for each wipe. -wash perineum well taking care to wash from the front to the back; and -remove gloves and discard then complete hand hygiene. C. Review of Resident 21's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 09/30/18 revealed [DIAGNOSES REDACTED]. The MDS identified the resident's cognition was moderately impaired and the resident required extensive staff assistance with transfers, toileting and personal hygiene. Review of Resident 21's current Care Plan revealed the resident was at increased risk for urinary tract infections due to current [DIAGNOSES REDACTED]. Review of a physician telephone order dated 10/12/18 revealed a new order for [MEDICATION NAME] (medication used to treat infections) 1 gram intramuscularly (IM) for 2 days for treatment of [REDACTED]. During an observation on 11/1/18 from 1:34 PM to 2:00 PM the resident was lying in bed in the resident's room. The resident's indwelling urinary catheter drainage bag was stored inside of a trash receptacle which was positioned next to the resident's bed. The cloth bag which had been in use for covering the drainage bag was now crumpled at the bottom of the trash receptacle. In addition to the cloth bag, a folded newspaper and several soiled Kleenex tissues were inside of the trash receptacle with the urinary catheter drainage bag. During an observation of indwelling urinary catheter care on 11/6/18 from 7:42 AM until 8:00 AM, Resident 21 was positioned on back in bed. Nurse Aide (NA)-E entered the resident's bathroom, washed hands and put on a clean pair of disposable gloves. NA-E brought a wet wash cloth, a towel and an empty clear plastic bag from the bathroom and placed items on the resident's bedside table. NA-E removed the urinary catheter drainage bag from the frame of the resident's bed and placed the drainage bag directly on top of the resident's bed linens. The urinary catheter drainage bag was not kept below the level of the resident's bladder. While Resident 21 remained lying in bed, NA-E dressed the resident's lower extremities and removed the resident's disposable urinary incontinence brief. NA-E used the wash cloth and towel to complete indwelling urinary catheter cares. NA-E removed soiled gloves and without washing hands or completing hand hygiene, NA-E assisted the resident to sit on the side of the resident's bed. While assisting the resident with swinging legs out of bed, the resident's urinary catheter drainage bag fell to the floor. NA-E proceeded to assist the resident with dressing upper extremities and with transferring the resident into a wheelchair before assuring the catheter drainage bag was removed from the floor and before returning to the resident's bathroom to wash hands. During interview on 11/6/18 at 11:54 AM, the Director of Nursing (DON) confirmed the following regarding Resident 21's indwelling urinary catheter: -the resident was recently started on [MEDICATION NAME] to treat a urinary tract infection; -NE-E should have followed the facility policy regarding completion of catheter cares and hand-washing; and -the resident's indwelling urinary catheter drainage bag and/or tubing should never be stored directly on the floor or on the resident's bed linens and the drainage bag should always be kept below the level of the resident's bladder.",2020-09-01
655,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,692,D,0,1,GJZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observation, interview, and record review; the facility failed to provide adequate hydration to meet the needs of Residents 6 and 32. The sample size was 2 and the facility census was 32. Findings are: [NAME] Review of Resident 6's current undated Care Plan revealed the resident required 1 assist with eating. The resident had the potential for fluid deficit related to poor intakes. Staff were to encourage the resident to drink liquids of choice at meals and with cares. The resident required liquids to be thickened to nectar consistency. Further review revealed the staff were to ensure the resident had access to nectar thick liquids whenever possible. Review of Resident 6's Nutrition assessment dated [DATE] revealed the category titled Fluid Needs was not filled out. Observations of Resident 6's room on 11/1/18 revealed: - At 10:01 AM, the resident was seated in the resident's wheelchair, no liquids were available in the room. - At 2:01 PM, the resident was asleep in bed, no liquids were available in the resident's room. During an interview with Licensed Practical Nurse (LPN)-F on 11/5/18 at 2:10 PM revealed the resident was on thickened liquids and staff should keep a cup full of thickened water in the resident's room to offer with cares. B. Review of Resident 32's current undated Care Plan revealed the resident needed staff to continue to offer food and fluids as long as the resident was still able to consume them. On 11/5/18 at 7:30 AM Resident 32 was seated in the resident's wheelchair in the commons area of the facility. The resident called out water, water. LPN-F responded and asked the resident what the resident needed. The resident repeated water, water. LPN-F then called to Nursing Assistant (NA)-G to bring Resident 32 a drink. At 7:35 AM NA-G brought Resident 32 a glass of thickened apple juice and gave the resident 2 drinks. Resident 32 coughed and stated it was too sour and didn't want any more apple juice. NA-G stated it was apple juice and shouldn't be sour. No other liquids or water were provided. At 7:54 AM Resident 32 was seated in the dining room and complained of being thirsty. The resident had thickened juice and thickened water in front of the resident. There were no staff members in the area. NA-G then entered the dining room at 7:55 AM (25 minutes after the initial request for water) and assisted Resident 32 with a drink of water. Interview with LPN-F on 11/5/18 at 2:10 PM revealed Resident 32 was on hospice and had been declining. Resident 32 now required staff assistance with drinking. Interview with the Director of Nursing on 11/5/18 at 11:26 AM confirmed liquid intakes were not recorded or monitored.",2020-09-01
656,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,725,E,0,1,GJZY11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review and interview, the facility failed to provide nursing staff to provide ambulation assistance for Resident 22 and provision of baths for Residents 21 and 22. 2 of 6 confidential resident interviews and 3 of 6 confidential family interview voiced concerns that there was not enough nursing staff available to meet the resident's needs. The total sample size was 22 and the facility census was 32. Findings are: [NAME] 2 of 6 confidential resident interviews and 3 confidential family interviews conducted on 10/31/18 through 11/6/18 from 09:30 AM until 3:00 PM voiced concerns that there was not enough nursing staff available to meet the needs of the facility residents. Comments regarding staffing included: -residents were not provided baths as often as the residents preferred; -call light response times were frequently 20-30 minutes depending on the day of the week and the time of day; and -difficult to find any staff available in the evenings if need help or just have a question. B. Review of Resident 22's current Care Plan (revised on 10/7/18) revealed the resident was at risk for a decline in Activities of Daily Living (ADL) ability and incontinence. The care plan identified the resident required extensive staff assistance with bathing, transfers, toileting, ambulation and personal cares. The resident had a walking program (the resident was to be walked to or from meals for a total of 3 times each day) and a toileting schedule in place and the resident preferred 2 whirlpool baths a week. Review of Bathing Documentation (paper record of baths provided) from 10/8/18 through 11/4/18 revealed Resident 22 did not receive 2 baths weekly. Documentation indicated baths were provided on (MONTH) 11, 18, 25, and 31, (YEAR) and on (MONTH) 4, (YEAR) (a total of 5 out of 9 baths that were to have been provided). Review of Nursing Rehabilitation Documentation (paper record of the number of times each day the staff assisted the resident with ambulation) from 10/7/18 to 11/4/18 revealed Resident 22 was not assisted to ambulate 3 times each day. Documentation indicated the resident was assisted with walking once a day on (MONTH) 7, 10, 15, 18, 19, 25, 27, 29 and 30, (YEAR) and on (MONTH) 2, 3 and 4, (YEAR). Documentation indicated the resident was assisted with walking twice a day on (MONTH) 8, 9, 13, 14, 16, 17, 22, 24, 26, 28, and 31, (YEAR) and on (MONTH) 1, (YEAR) (a total of 36 out 87 times the resident was to be assisted with ambulation). Observation of Resident 22's morning cares on 11/5/18 from 7:31 AM to 7:55 AM revealed the resident was transferred into a wheelchair, foot pedals were put into place and the resident was propelled in the wheelchair by NA-A out to the dining room for the breakfast meal. Resident 22 was not offered an opportunity to walk out to breakfast. Interview with NA-A on 11/5/18 at 1:00 PM revealed Resident 22 was scheduled to receive 2 baths per week and was to be walked by the staff 3 times a day. NA-A indicated sometimes baths and walking programs did not get completed when staff ran short on time or when not enough staff was available. C. Review of Resident 21's current Care Plan (revision date 9/4/18) revealed the resident required 1-2 staff assist with transfers to and from the bath chair and further revealed the resident was to receive 2 baths a week. Review of Bathing Documentation from 10/5/18 through 11/4/18 revealed Resident 21 did not receive a bath twice every week. Documentation indicated the resident received a bath on (MONTH) 5, 9, 12, 19, 23, 26 and on 30, (YEAR) (a total of 7 out of the 9 baths the resident was to have been provided).",2020-09-01
657,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,761,E,0,1,GJZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, interview, and record review; the facility failed to ensure insulin (a medication used to treat diabetes mellitus) was stored within the temperature range recommended by the manufacturer for 4 residents (Residents 1, 30, 25, and 17 ) and failed to ensure insulin pens were dated when opened for 2 residents (Residents 1 and 30). The sample size was 4 and the facility census was 32. Findings are: [NAME] On 11/6/18 at 10:19 AM an observation of the medication refrigerator revealed the thermometer read 22 degrees Fahrenheit (F). Review of the Record of Refrigeration Temperatures dated 4/2018 to 11/2018 revealed frequent temperature readings below 36 degrees F. Review of a document provided by the facility on 11/6/18 titled Insulin in Fridge revealed 4 residents (Residents 1, 30, 25, and 17) had insulin stored in the refrigerator. Interviews with the Director of Nursing (DON) on 11/6/18 from 10:05 AM to 10:15 AM revealed the refrigerator was used to store insulin and various other medications. Further interview confirmed the thermometer read 22 degrees F and insulin should be refrigerated at temperatures between 36 and 46 degrees F. B. Observation of the medication cart on 11/6/18 at 10:10 AM with Licensed Practical Nurse-D revealed 2 of 5 insulin pens were not dated when opened. This included Resident 1's [MEDICATION NAME]and Resident 30's Tresiba insulin. During an interview with LPN-D on 11/6/18 at 10:10 AM, LPN-D confirmed the insulin pens were not dated when opened for Residents 1 and 30. Further interview confirmed the medications should be dated when opened.",2020-09-01
658,ARBOR CARE CENTERS-HARTINGTON LLC,285088,"PO BOX 107, 401 DARLENE STREET",HARTINGTON,NE,68739,2018-11-06,880,D,0,1,GJZY11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview: the facility failed to prevent potential cross contamination between residents as hands were not washed at appropriate intervals during the provision of catheter cares for Resident 21. The total sample size was 22 and current census was 32. Findings are: [NAME] Review of the facility policy titled Infection Control: Urinary Catheters with revision date 5/1/10 indicated the policy was to provide guidance in the preventative measures for controlling infections. The procedure included the following: -eliminate indwelling urinary catheters when possible; -wash hands before and after providing urinary catheter care; -keep the collection bag below the level of the bladder; and -do not allow the catheter tubing, bag or drainage spigot to touch the floor. B. During an observation of indwelling urinary catheter care on 11/6/18 from 7:42 AM until 8:00 AM, Resident 21 was positioned on back in bed. Nurse Aide (NA)-E entered the resident's bathroom, washed hands and put on a clean pair of disposable gloves. NA-E brought a wet wash cloth, a towel and an empty clear plastic bag from the bathroom and placed items on the resident's bedside table. While Resident 21 remained lying in bed, NA-E dressed the resident's lower extremities and removed the resident's disposable urinary incontinence brief. NA-E used the wash cloth and towel to complete indwelling urinary catheter cares. NA-E removed soiled gloves and without washing hands or completing hand hygiene, NA-E assisted the resident to sit on the side of the resident's bed. NA-E proceeded to assist the resident with dressing upper extremities and with transferring the resident into a wheelchair before returning to the resident's bathroom to wash hands. Interview with the Director of Nursing on 11/6/18/16/18 at 11:48 AM, confirmed NA-E was expected to remove gloves and wash/sanitize hands following provision of urinary catheter cares and removal of soiled gloves.",2020-09-01
659,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2017-02-28,325,D,0,1,6R9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and interviews; the facility failed to implement weight loss interventions to maintain nutritional parameters and to prevent ongoing weight loss for 2 (Residents 12 and 131) of 28 sampled residents. The facility census was 85. Findings are: [NAME] Review of facility Fortified Meal Policy (undated) revealed the following weight loss interventions which were to be implemented for residents with an unplanned weight loss: - For the breakfast meal the resident was to be offered Super Cereal (hot cereal made with additional sugar, butter and whole milk/cream to provide additional calories) or 1 fortified meal option (peanut butter, cheese, butter and/or sour cream). - Fortified (added nutrients and calories) snack at 10:00 AM. - For the noon meal the resident is to be provided 1 fortified food item at the discretion of the cook. - Fortified shake or snack at 3:00 PM. - For the evening meal the resident is to be provided 1 fortified food item at the discretion of the cook. B. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/6/17 revealed the resident's cognition was moderately impaired and had current [DIAGNOSES REDACTED]. The assessment indicated the resident required supervision with eating and the resident's weight was 172 lbs. (pounds). Review of Resident 12's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed the resident's weight on 12/30/16 was 179 lbs. Further review revealed the resident's weight on 1/3/17 was 172 lbs. (3.9% weight loss in 4 days). Review of Dietary Progress Note dated 1/6/17 at 11:32 AM, revealed a recommendation by the Registered Dietician (RD) to start the resident on 2cal (supplemental drink with added calories to prevent weight loss) 90 cc (cubic centimeters) twice a day. Review of Resident 12's current Care Plan dated 1/6/16 revealed the resident had the potential for altered nutrition related to confusion and poor meal intakes. Interventions included the following: - 2cal supplement 90 cc twice a day - liberalized geriatric diet - assist as needed with intakes and offer cues and reminders at meals and snack times Review of Nursing Progress Note dated 1/13/17 (7 days after the RD's recommendation) at 6:54 AM revealed a new physician order [REDACTED]. Review of Resident 12's Medication Administration Record (MAR) dated 1/2017 revealed from 1/13/17 through 1/17/17 the resident received 2cal supplement twice a day, however there was no documentation to indicate the amount of supplement the resident consumed. Review of Resident 12's Weights and Vitals Summary Sheet revealed the resident's weight on 1/17/17 was 169 lbs. (5.6% loss in 3 weeks). Review of Dietary Progress Note dated 1/23/17 at 1:02 PM, revealed a recommendation to start the resident on the facility Fortified Meal Policy. Review of Resident 12's medical record from 1/23/17 to 2/27/17 revealed no documentation regarding the amount of fortified snack the resident consumed when offered each day at 10:00 AM and 3:00 PM. Observation of Resident 12 on 2/27/17 from 10:30 AM to 12:00 PM, revealed the resident was positioned in a recliner in the resident's room with the resident's eyes closed. The resident's fortified snack had been placed on a bedside table next to the resident's recliner. The fortified snack was not opened and the resident made no attempt to consume the fortified snack. During an interview on 2/27/17 at 12:00 PM, Resident 12 confirmed the resident had not eaten the fortified snack and indicated the staff had removed the snack when the resident refused to eat. During an interview on 2/27/17 at 2:00 PM, the RD identified Resident 12 was to receive 2cal supplement 90 cc twice a day, fortified foods at each meal and a fortified snack twice a day for ongoing weight loss. The RD confirmed the 2cal supplement was not initiated until 7 days after the RD had made the recommendation. On 2/28/17 at 9:45 AM, Resident 12 was observed seated in a wheelchair at a table in the facility main dining room. Resident 12 was independently eating a bowl of hot cereal. Resident 12 held a spoon containing a bite of hot cereal and the resident was attempting to place the spoon into the resident's mouth. Nursing Assistant (NA)-N approached the resident, removed the spoon from the resident's hand and placed the spoon back into the bowl of hot cereal. NA-N removed the brake from Resident 12's wheelchair and propelled the resident out of the dining room and into the Bath House. A dietary staff member immediately approached the resident's table, removed the remaining hot cereal and the resident's fluids and placed the items in a trash receptacle. Observation of Resident 12's room on 2/28/17 at 10:00 AM revealed a snack in a covered container had been placed on a bedside table. The snack was labeled with the resident's name and the current date. Resident 12 was not observed in the resident's room. Observation of Resident 12 on 2/28/17 at 11:00 AM revealed the resident was propelled into the resident's room by the resident's husband. The fortified snack remained unopened on the bedside table. During an interview on 2/28/17 at 11:30 AM, Resident 12 indicated the resident's husband had consumed the snack. During interview on 2/28/17 from 1:30 PM to 1:45 PM, the Director of Nursing (DON) confirmed the following: -Staff were to monitor residents to ensure fortified snacks which were provided as a weight loss intervention were being consumed. -Fortified snacks were to be identified on the resident's MAR. -Charge Nurses were responsible for documenting the amount of fortified snack the resident consumed on the resident's MAR. -Staff should not have removed the resident from the dining room table, until the resident had finished eating the resident's meal. C. Review of Resident 131's MDS dated [DATE] revealed the resident was admitted with [DIAGNOSES REDACTED]. The MDS further indicated the resident was severely cognitively impaired, required supervision with eating, and experienced a significant weight loss. Review of Resident 131's Weights and Vitals Summary revealed the following record of weights: -12/22/16 - 150.5 pounds, -12/23/16 - 145 pounds, and -12/26/16 - 143.5 pounds. Review of Resident 131's Care Plan dated 12/27/16 revealed the resident had the potential for altered nutrition related to dementia, [MEDICAL CONDITION], diabetes, and weight loss, with a goal for no significant weight loss from 143 pounds. Interventions included to offer finger foods as needed, and to fortify (add extra ingredients to increase caloric intake) meals and follow supplements as ordered for snacks. Review of Dietary Progress Notes by the RD dated 12/27/16 at 10:24 AM revealed Resident 131 required cuing and supervision at meals due to confusion, and eats finger foods the best. Documentation indicated the admission weight of 150.5 pounds on 12/22/16 was questionable, and no recommendations were made for dietary interventions at this time. Review of the Weights and Vitals Summary dated 12/28/16 revealed Resident 131 weighed 143 pounds. Review of Dietary Progress Notes by the Dietary Manager (DM) dated 12/29/16 at 3:16 PM revealed Resident 131's usual body weight over the last few months had been around 155 pounds. Documentation revealed average meal intakes were fair to good, and a recommendation was made to fortify meals and offer a fortified snack. Review of Resident 131's medical record, including the MAR dated 12/30/16 through 1/22/17, indicated there was no evidence the resident was offered a fortified snack as recommended by the DM. Review of Dietary Progress Notes by the RD dated 1/23/17 at 12:30 PM indicated Resident 131's current body weight was 143 pounds, and weight is down from usual weight of 155# (pounds). Documentation indicated the resident was started on fortified meals and snacks per policy, and the resident's weight still remains down from usual. The RD recommended discontinuing the fortified snacks and replacing them with Mighty Shake (a nutritional supplement) 6 ounces 2 times daily (BID) at snack times. Review of Resident 131's MAR dated 1/2017 and 2/2017 revealed the following: -an order dated 1/24/17 for Mighty Shake 6 ounces BID; -documentation that the Mighty Shake was administered at 10:00 AM and 3:00 PM from 1/24/17 through 2/5/17; and -no evidence the Mighty Shakes were accepted by the resident, including the percentage of each dose consumed. During interviews on 2/28/17 the following was revealed: -at 8:33 AM the DM verified the administration and consumption of fortified snacks was supposed to be documented on the MAR; -at 9:25 AM Registered Nurse (RN)-J verified the administration and consumption of fortified snacks was documented on the MAR; and -at 1:20 PM the DON indicated the expectation was that documentation of the administration of supplements include the amount consumed by the resident.",2020-09-01
660,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2017-02-28,371,F,0,1,6R9C11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to ensure food was prepared and stored in a manner to prevent cross contamination as there was a dusty soil residue on the covers of 3 ceiling light fixtures and the filter of the automatic juice dispenser, and the painted surface of the ceiling next to the air vent in the food storage area was chipped and peeling This had the potential to affect all of the residents who ate food prepared in the facility kitchens. The facility census was 85. Findings are: [NAME] Observations conducted during the kitchen sanitation tour on 2/27/17 from 10:30 AM until 11:00 AM revealed the following: -there was a dusty soil residue in the ceiling light fixture covers located above the clean pots and pan storage unit, above the puree food preparation table and adjacent to the floor mounted commercial mixer of the main kitchen; -paint was chipped and peeling on the surface of the ceiling by the air vent in the food storage area of the main kitchen; and -there was a dusty soil residue on the filter screen of the automatic juice dispenser in the kitchen located between the 600 and 700 wings. B. Interview with the Dietary Manager (DM) on 2/27/17 at 12:10 PM confirmed the ceiling light fixture covers were in need of cleaning and indicated they were cleaned by the maintenance department on a monthly basis. The DM verified the painted surface of the ceiling by the air vent in the food storage area was chipped, peeling and in need of repair. C. Interview with the DM on 2/28/17 at 8:42 AM revealed cleaning of the ceiling light fixture covers and the filter screen of the automatic juice dispenser were not listed on the routine kitchen cleaning schedules. The DM was not sure of the date they were last cleaned. D. Interview with the Maintenance Director on 2/28/17 at 10:10 AM confirmed the cleaning of the ceiling light fixture covers and the filter of the automatic juice machine were not listed on a routine maintenance cleaning schedule and was not sure of the date they were last cleaned. E. Review of the 7/2016 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service and sanitation practices revealed the following: -3-305.14-During preparation, unpackaged food shall be protected from environmental sources of contamination. -4-601.11(C)-Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. -6-201.16(A)-Wall and ceiling covering materials shall be attached so that they are easily cleanable.",2020-09-01
661,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2017-02-28,431,D,0,1,6R9C11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observations, interview and record review; the facility failed to assure medications were stored and secured at all times to prevent access from unauthorized persons for 1 (Resident 12) out of 28 sampled residents. The facility census was 85. Findings are: Review of the facility policy for Medication Provision (undated) identified medications were to be kept secured at all times. The medication room or cart was to be kept locked each time they were not in view (out of sight) of a nurse. The individual administering medications was to remain with the resident to assure medications were consumed before documenting administration. Review of Resident 12's Medication Administration Record [REDACTED]. Observations on 2/28/17 revealed the following: - 9:10 AM, Resident 12 was positioned in a wheelchair at the resident's table in the main dining room. Licensed Practical Nurse (LPN) - O was observed dispensing medications from a medication cart at the entrance of the dining room. Resident 12 was eating breakfast independently. - 9:45 AM, the medication cart and LPN-O were no longer visible in the dining room. Resident 12 remained at the table finishing breakfast. No other residents were observed in the dining room. Nursing Assistant (NA)-N and NA-F approached the resident's table. NA-N assisted Resident 12 from the table and out of the dining room. NA-F proceeded to remove a paper cup from the resident's table, which contained 25 cc of an orange liquid. NA-F exited the dining room with the cup and then placed the cup on a bedside table in the resident's room. Resident 12 was not observed in the resident's room. Interview with NA-F at 2/28/17 at 10:00 AM, revealed the orange liquid in the paper cup left at the resident's table was medication the resident was to have taken. NA-F identified the resident had been removed from the table and assisted to the bath house, before the resident had consumed the medication. Interview with LPN-O on 2/28/17 at 10:30 AM, revealed the orange liquid in the paper cup was the resident's Potassium Chloride. LPN-O confirmed the medication had been left at the resident's table and LPN-O had not waited until the medication was consumed before walking away from the resident. LPN-O verified staff had been trained not to leave medications unsecured and staff were to witness the resident actually taking the medication before documenting administration of the medication.",2020-09-01
662,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2019-06-24,580,D,0,1,2H0G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.04C3a (6) Based on interview and record review, the facility failed to notify the attending physician of a change in condition for 2 of 2 sampled residents. This involved weight changes for Resident 64 and 79. The facility census was 84. Findings are: [NAME] Review of Resident 64's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/10/19 revealed a [DIAGNOSES REDACTED]. Review of an Order Summary Report dated 6/2019 revealed an order dated 5/31/19 to report to the resident's physician if the resident has a weight gain of 2-4 pounds in 1-3 days. Review of a Weights and Vitals Summary Report revealed the resident's weight on 6/11/19 was 242 pounds. Further review revealed the resident's weight on 6/18/19 was 245 pounds (a weight gain of 3 pounds). review of the resident's medical record revealed [REDACTED]. B. Review of Resident 79's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 79's admission orders [REDACTED]. Review of the resident's Weights and Vitals Summary Report revealed the following regarding the resident's daily weights: -6/9/19 weight was 200 pounds; -6/10/19 weight was 204 pounds (up 4 pounds in 1 day); and -6/12/19 weight was 205 pounds (up 5 pounds in 3 days). review of the resident's medical record revealed [REDACTED]. Review of the Weights and Vitals Summary Report revealed the resident's weight on 6/14/19 was 209 pounds (up 9 pounds in 5 days). Interview with the Director of Nurses (DON) on 6/20/19 at 3:24 PM confirmed the following: -Resident 64 had an order to notify the resident's physician if the resident had a weight gain of 2-4 pounds in 1-3 days; -Resident 64 had a 3 pound weight gain from 6/11/19 to 6/18/19; -Resident 64's physician was not notified of the resident's weight gain; -Resident 79 was admitted on [DATE] with an order for [REDACTED].>-Resident 79 had a 4 pound weight gain from 6/9/19 to 6/10/19 and a 5 pound weight gain from 6/9/19 to 6/12/19; and -Resident 79's physician was not notified of the resident's continued weight gain until 6/14/19 when the resident had gained 9 pounds in 5 days.",2020-09-01
663,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2019-06-24,684,D,0,1,2H0G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview, the facility failed to provide ongoing assessment and monitoring of Resident 79's areas of bruising to assure healing. The sample size was 1 and the facility census was 84. Findings are: [NAME] Review of the facility policy for Skin and Wound Management Standard with revision date 4/2019 revealed staff were to perform routine skin inspections with bathing and with cares as well as a weekly skin check. Any identified concerns were to be assessed with [REDACTED]. Non-pressure skin conditions were to be assessed and measured every 7 days or more frequently if indicated until the areas were resolved. B. Review of Resident 79's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/10/19 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was identified as needing extensive staff assistance with transfers, bed mobility, toilet use and personal hygiene. In addition, the resident was assessed as having occasional bladder and frequent bowel incontinence. Review of Resident 79's Admission/Re-admission Nursing Review dated 6/3/19 at 1:34 PM revealed the following was identified: -front of right lower leg with scattered bruising in various stages of healing; -front of left lower leg with scattered bruising; and -scattered bruising to both upper extremities. Review of a Non-Pressure Skin Condition Record dated 6/6/19 at 1:33 PM revealed the resident was identified as having a dark purple bruise from an IV. The assessment did not indicate the location of the bruising or identify any measurements for the bruise. Review of a Non-Pressure Skin Condition Record dated 6/6/19 at 1:38 PM revealed the resident had several, dark purple bruises which were first observed on 6/3/19 when the resident was admitted . Further review of the assessment revealed no identification as to how many bruises the resident had, where the bruising was located on the resident and there was no evidence the bruises had been measured. Review of a Non-Pressure Skin Condition Report dated 6/13/19 at 12:45 PM revealed the resident continued to have areas of scattered bruising in various stages of healing to the resident's upper left extremity. Bruising was first identified 6/3/19 when the resident was admitted . Further review of the assessment revealed no documentation to indicate measurements of the areas of bruising had been completed. Review of a Non-Pressure Skin Condition Report dated 6/13/19 at 2:46 PM revealed the resident continued to have areas of scattered bruising in various stages of healing on the resident's right upper arm. Bruising was first identified 6/3/19 when the resident was admitted . Further review of the assessment revealed no documentation to indicate how many areas of bruising the resident had or that the bruising had been measured to help with the identification of healing. Review of a Non-Pressure Skin Condition Report dated 6/13/19 at 3:05 PM revealed the resident continued to have areas of scattered bruising. Bruising was first identified 6/3/19 when the resident was admitted . Further review of the assessment revealed no documentation to indicate where the bruising was located, how many bruises the resident had and there was no evidence any of the areas of bruising had been measured to determine healing of the areas. During an interview on 6/20/19 at 3:24 PM, the Director of Nursing (DON) verified the following: -Resident 79 was admitted on [DATE] with a skin assessment completed at 1:34 PM; -the admission skin assessment identified the resident had scattered areas of bruising to bilateral upper extremities and bilateral lower extremities; -the exact location of the areas of bruising were not identified and there were no measurements completed on the areas of bruising; and -staff should have followed the facility policy and identified the location and the measurements of each area of bruising with every completed assessment in order to be able to provide ongoing assessment of the areas to determine healing.",2020-09-01
664,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2019-06-24,689,G,0,1,2H0G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to implement interventions to prevent potential choking episodes for Resident 41. The sample size was 1 and the facility census was 84. Findings are: Review of a Progress Note dated 5/12/19 revealed at 12:50 PM Resident 41 began coughing during lunch. The resident had increased difficulty breathing and talking. The resident shook no when asked if the resident could talk. Back blows were performed with no improvement. The resident became unresponsive and cyanotic (bluish discoloration usually caused by low oxygen levels) with fixed pupils. The resident's chin was lifted, to obtain optimal airway, and the resident then coughed and was able to take breaths at that time. The resident's physician and Power of Attorney (POA) were notified per telephone. The resident's POA requested the resident's current diet remain unchanged. Review of a ST (Speech Therapy) Daily Treatment Note dated 5/14/19 revealed ST recommended a mechanical soft diet with extra sauces/gravies and no raw fruits or vegetables. Review of a Progress Note dated 5/14/19 at 10:30 PM, revealed Resident 41 was offered a ground meat sandwich. The resident coughed and had strider (high-pitched, wheezing sound caused by disrupted airflow) type respirations. The nurse attempted the [MEDICATION NAME] maneuver and performed back blows with no change. The resident began to have cyanosis to the lips, ears, and nail beds. The resident became unresponsive to tactile (sensory stimulation involving touch) and verbal stimulation. The resident was transferred out of the wheel chair, to the floor, rolled on side, and back blows were performed again. Oxygen was started and the resident started coughing. Review of a Progress Note dated 5/17/19 at 8:50 AM revealed Resident 41 had another choking/wheezing episode at the breakfast table. The wheezing lasted for a few seconds and then the resident stopped wheezing and took a drink of water. The resident did this a few times at the breakfast table, and then had more wheezing when seated in the recliner in the day area. The resident became cyanotic in the face. Oxygen was applied and a breathing treatment was completed. Review of a Progress Note dated 5/20/19 at 10:00 AM revealed Resident 41 choked on Cream of Wheat cereal. The Cream of Wheat cereal was stuck to the resident's throat. The resident was encouraged to drink more fluids and was able to drink the fluids. The staff were educated to add some milk to the Cream of Wheat cereal to help with swallowing. Review of Resident 41's current Care Plan revealed the Care Plan was updated on 5/20/19 to include the following interventions related to the resident's choking episodes: - Monitor for signs and symptoms of aspiration (sucking food into the airway), - All staff were informed of special dietary and safety needs, - Check the resident's mouth after meal for pocketed food and debris, - Follow the diet as prescribed with no raw fruits and vegetable, - Monitor for shortness of breath, choking, labored respiration, and lung congestion, and - Refer to speech therapist for swallowing screen/evaluation as needed. Review of a Progress Note dated 5/24/19 at 12:21 PM revealed Resident 41 was seated at the dining room table and had an extreme episode of wheezing/food stuck in the resident's throat. Back blows and [MEDICATION NAME] maneuver were performed with no change. Sips of water were given to clear the throat with no relief. The resident went unresponsive and turned blue/grey. The resident was transferred to bed and oxygen was started. Once the resident was laid down, color came back slowly and the resident coughed numerous times. Review of a ST Daily Treatment Note dated 5/27/19 revealed it was reported that Resident 41 had an extreme choking episode over the past weekend where the resident's airway was blocked for several minutes. The nurse stated that the meal provided during the incident did not have extra sauces/gravies. Resident 41's Therapist Progress and Updated Plan of Care dated 5/28/19 identified a list of foods to avoid to prevent potential choking while on the mechanical soft diet. Food items to avoid included rice, corn, cheese, bread, pie crusts, cookies, raw fruits, raw vegetables, potato chips, pineapple, sticky foods (such as chewy candies), lettuce, and dry cereal. Review of a ST Daily Treatment Note dated 5/30/19 revealed Resident 41 had oral residue post swallow of ground meats. On 6/20/19 at 12:20 PM Resident 41 was seated in the dining room for lunch. The resident was served a lettuce salad with dressing, which was placed in front of the resident ready for consumption. Interview with the Assistant Dietary Manager on 6/20/19 at 12:20 PM confirmed Resident 41 had dietary restrictions which included no raw fruits or vegetables. The Assistant Dietary Manager confirmed the resident should not have been served a lettuce salad. Resident 41 was observed on 6/24/19 from 9:20 AM to 9:37 AM. The resident was seated in the dining room eating breakfast. The resident was served hot cereal with milk, ground meat, and scrambled eggs with a variety of drinks. The resident ate independently. After eating, the resident was transferred from the dining room table to a recliner in the day area by Nursing Assistant (NA)-C and NA-L. The resident's mouth was not checked to ensure no food items were pocketed. Interviews with NA-B, NA-L, and Registered Nurse-M on 6/24/19 from 9:32 AM to 9:37 AM, confirmed Resident 41's mouth was not checked after breakfast on 6/24/19. Further interview confirmed the staff did not check Resident 41's mouth after meals. Review of Resident 41's Medical Record on 6/24/19 revealed no evidence to indicate oral inspections were completed after meals to check for pocketed food items.",2020-09-01
665,HERITAGE OF BEL AIR,285089,1203 NORTH 13TH STREET,NORFOLK,NE,68702,2019-06-24,880,D,0,1,2H0G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B Based on observations, record review and interview; the facility failed to assure respiratory care equipment was cleaned and stored in a sanitary manner to prevent ongoing respiratory infections for 1 (Resident 83) of 1 sampled residents. The facility census was 84. Findings are: Review of Resident 83's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/27/19 revealed [DIAGNOSES REDACTED]. Review of Resident 83's current Care Plan with revision date 6/17/19 revealed the resident was at risk for altered respiratory function related to wearing [MEDICAL CONDITION] (continuous positive airway pressure- treatment that uses mild air pressure to keep breathing airways open) at night. Interventions included the following: -assess respiratory status as needed; depth, rate. Presence of breath sounds, shortness of breath and cough; -[MEDICATION NAME] (sterile inhalation solution containing [MEDICATION NAME] and [MEDICATION NAME] (medication which relaxes muscles in the airways and increases air flow to the lungs) treatments per orders; -[MEDICAL CONDITION] with oxygen per home settings; and -percussion treatments (clapping on the chest and/or back to loosen mucus in the lungs). Review of the resident's Medication Administration Record [REDACTED] -5/24/19 [MEDICATION NAME] solution 0.5-2.5 milligrams (mg)/3 milliliters (ml) inhale via nebulizer three times a day; -5/24/19 [MEDICATION NAME] (medication used to loosen chest congestion) 1200 mg two times a day; and -5/30/19 for [MEDICATION NAME] (medication used to treat bacterial infections) 750 milligrams (mg) once a day for 7 days for [DIAGNOSES REDACTED]. Review of Resident 83's Treatment Administration Record (TAR) dated 6/2019 revealed a nursing order for the staff to change the black plastic bag covers every month. The resident was to have 3 plastic bag covers in the resident's room; 1 for storage of the oxygen equipment, 1 for the storage of the nebulizer equipment and 1 for the storage of the [MEDICAL CONDITION] equipment. Observation in Resident 83's room on 6/18/19 at 10:27 AM revealed a [MEDICAL CONDITION] machine and a nebulizer machine side-by-side on top of a small dresser. The mouth piece of the nebulizer was connected to the machine and there were droplets of moisture visible on the inside surface. The mask for the [MEDICAL CONDITION] was positioned uncovered on a paper towel barrier next to the [MEDICAL CONDITION] machine. There were 3 black plastic bag covers observed in the area, but the respiratory equipment had not been placed inside of the covers. On 6/19/19 at 8:17 AM, the resident's [MEDICAL CONDITION] mask was observed uncovered and lying on a paper towel barrier on the back of the toilet tank of the resident's bathroom. The hand washing sink was next to where the mask was stored. During interview on 6/24/19 at 7:20 AM, the Director of Nursing verified the staff should rinse the nebulizer mouth piece after each treatment, allow it to dry, then store it in a black plastic bag covers provided. In addition, the [MEDICAL CONDITION] mask should not have been left uncovered next to the hand washing sink and on the back of the toilet tank.",2020-09-01
666,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-02-21,580,D,1,0,X1OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C3a (6) Based on record reviews and interview, the facility failed to ensure that the physician was notified to determine the need for further medical care after 1) a fall with a head injury and a change in vital signs for one closed record resident (Resident 1) and 2) ongoing nausea and weakness for one closed record resident (Resident 2). The facility census was 35 with three sampled closed resident records and two current sampled residents reviewed. Findings are: [NAME] Review of Resident 1's Progress Notes revealed that on 2/9/19 at 10:34 PM the resident attempted to ambulate to the bathroom and fell backwards and hit the back of the head and sustained a golf ball sized protuberance (swelling). Further review revealed that on 2/10/19 at 1:20 AM, staff reported that the resident complained of pain all over. The nurse noted that the resident had labored breathing, pupils were dilated and not reacting to light and the resident was unresponsive. At 2:20 AM the resident was transported by ambulance to the hospital where the resident was diagnosed with [REDACTED]. Review of the Vital Signs Flow Sheet revealed that on 2/10/19 at 12:30 AM and at 1:30 AM the resident's blood pressure increased and at 2:00 AM the resident's breathing rate increased. Review of the facility FAX Cover Sheet, dated 2/9/19 at 11:42 PM, revealed that the resident's physician was notified of the resident's fall and swelling at the back of the head Interview with the DON (Director of Nursing) on 2/21/19 at 10:30 AM confirmed that the nurse should have called the physician to report the fall and the swelling rather than send a facsimile. Further interview confirmed that the nurse should have notified the physician of the resident's changes in vital signs. It was noted that the resident was on routine blood thinning medication which increased the risk for complications and abnormal bleeding. B. Review of Resident 2's Progress Notes revealed that on 2/16/19 at 6:46 AM the night nurse reported that the resident complained of not feeling well and had not eaten because of nausea. Further review revealed that at 9:00 AM the resident complained of nausea with emesis and at 10:45 AM the resident was found on the bathroom floor and could not sit up or help with the transfer from the floor. At 1:30 PM the resident passed away. Interview with the DON on 2/21/19 at 10:45 AM confirmed that the nurse should have notified the physician of the resident's change in condition, including ongoing nausea and weakness, which was not the resident's usual behaviors.",2020-09-01
667,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,558,D,0,1,06US11,"Licensure Reference Number: 175 NAC 12-006.18B1 Based on observations and interviews, the facility failed to ensure that a call bell was available for one sampled resident (Resident 7). Facility census was 35. Sample size was 16. Findings are: On 4/17/19 at 2:12 PM, Resident 7 was observed resting in bed. There was no call light visible on the bed or connected to the wall plug for the resident's use. A desk call style bell which could be tapped on top to ring was located on the dresser but was not within reach of the resident. On 4/18/19 at 10:13 AM, a thorough check of the room revealed no call light was availble anywhere in the room. The bell on remained on the dresser. On 4/18/19 at 10:21 AM, an interview with the facility's Administrator and DON (Director of Nursing) revealed that this resident had been provided with a cordless call light due to tangling self in the cord of a regular call light. A check of the room by both the Administrator and the DON could not find the cordless call light they had described. MA(Medication Aid)-A who was in the room caring for Resident 7 revealed that the cordless call light had broken some time ago, and a bell to ring had been provided instead. MA-A could not say how long ago this happened. The Administrator, DON, and MA-A all verified that Resident 7 could not reach the bell from the bed and that there was nowhere to position the bell for the resident's use while in bed at that time.",2020-09-01
668,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,584,E,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.18A (1) Based on observations and interviews, the facility failed to 1) Clean and replace stained and damaged flooring located by the coffee machines and ice machines in the dining room. This could affect some residents in the dining room, 2) The facility failed to repair a damaged wall for one sampled resident (Resident 2). Sample size was 16 current residents. Facility census was 35. Findings are: [NAME] Observation on 04/17/19 at 12:00 p.m. Floor located in the dining room by the ice machine and under the coffee pots was stained and damaged. Observation on 04/22/19 at 1:59 p.m. Floor located in the dining room by the ice machine and under the coffee pots was stained and damaged. Staff interview on 04/22/19 at 1:59 p.m. Dietary Consultant/ Contracted provider for House Keeping verified the flooring in the dining room located under the coffee pots and next to the ice machine was damaged and stained to the point it was not cleanable. Staff interview on 04/22/19 at 2:15 p.m. Administrator and Consultant of Operations verified the flooring in the dining room located under the coffee pots and next to the ice machine was damaged and stained to the point it was not cleanable. Consultant of Operations reported the flooring would be repaired and cleaned immediately. B. On 4/22/19 at 2:55 PM, observed multiple cuts and scrapes in the wall behind the recliner in Resident 2's room (room [ROOM NUMBER]) where the paint had been removed from wall. On 4/23/19 at 10:16 AM, the facility's Administrator also observed the wall in room [ROOM NUMBER] and verified that the wall behind Resident 2's recliner was damaged and needed to be repaired.",2020-09-01
669,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,623,D,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide written notification for 2 sampled residents (Resident #184 and Resident #233) or their personal representatives regarding discharge to the hospital. Facility census: 35 residents. Sample size: 16 current residents. Findings are: [NAME] On 4/23/19 at 07:58 AM a review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) for Resident #184 revealed the resident was admitted to the facility 10/12/18. The review also revealed Resident #184 was discharged [DATE] and returned to the facility 3/11/19. The resident was again discharged [DATE] and returned to the facility 4/15/19. On 4/23/19 at 10:10 AM during an interview, the Administrator confirmed there was no written notification made to the family representative of Resident #184 regarding the hospital discharges. Regarding written notification, the Administer stated, It's not being done. It's not being sent. . On 4/23/19 at 11:00 AM an interview with the Director of Nursing confirmed that written notification was not being done regarding discharges. B. On 4/18/19 at 8:25 AM, Resident 233 revealed a recent hospitalization after a fall in the facility. On 4/22/19 at 1:30 PM, Resident 233's family member verified that the facility had contacted the family about the need to send the resident to the hospital by phone. The family member was unaware of receiving any form of written communication about this. On 4/22/19 at 2:00 PM, NA (Nursing Assistant)-B who served as the facility's Social Service coordinator verified that Resident 233 was sent to the hospital on [DATE] following a fall and returned on 4/16/19. NA-B revealed that no written notice was provided to the family about this and that there was no policy requiring written notification of a facility initiated discharge. On 4/22/19 at 5:51 PM, the facility's MDS (Minimum Data Set, a federally mandated assessment and tracking tool) coordinator verified that Resident 233 was discharged from the facility on 4/15/19 and was readmitted on [DATE] based on the MDS record. On 4/23/19 at 1:28 PM, the DON (Director of Nursing) verified that the facility did not have a procedure in place to provide written notification of a facility initiated transfer for hospitalization .",2020-09-01
670,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,625,D,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the resident or their personal representative of the bed hold policy within 24 hours of transfers to the hospital for 2 sampled residents (Resident #184 and Resident #233). Facility census: 35 residents. Sample size: 16 current residents. Findings are: [NAME] On 4/23/19 at 07:58 AM a review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) for Resident #184 revealed the resident was admitted to the facility 10/12/18. The review also revealed Resident #184 was discharged [DATE] and returned to the facility 3/11/19. The resident was again discharged [DATE] and returned to the facility 4/15/19. On 4/23/19 at 9:00 AM a review of the facility Bed Hold Policy revealed This Bed Hold Notice Form is to be signed by you or your legal representative and returned to Indian [NAME]s Manor within 24 hours. On 4/23/19 at 10:10 AM during an interview, the Administrator confirmed the facility bed hold policy was not being followed, that the resident or their personal representative were not informed of the bed hold policy, and that a bed hold was not being sent or signed by the resident or their personal representative, It's not being done. On 4/23/19 at 11:00 AM an interview with the Director of nursing confirmed that the facility bed hold policy was not being followed, that the resident or their personal representative were not informed of the bed hold policy, and that a bed hold was not being sent or signed by the resident or their personal representative. B. On 4/18/19 at 8:25 AM during an interview, Resident 233 revealed a recent hospitalization after a fall in the facility. On 4/22/19 at 1:30 PM, Resident 233's family member verified that the facility had contacted the family about the need to send the resident to the hospital by phone. The family member was unaware of receiving any form of written communication about this. On 4/22/19 at 5:51 PM, the facility's MDS (Minimum Data Set, a federally mandated assessment and tracking tool) coordinator verified that Resident 233 was discharged from the facility on 4/15/19 and was readmitted on [DATE] based on the MDS record. On 4/23/19 at 7:48 AM, NA(Nursing Assistant)-B who served as the facility's Social Service coordinator verified that there was no policy or procedure in place to provide bed hold notification when residents were discharged to the hospital. On 4/23/19 at 1:28 PM, the DON (Director of Nursing) verified that the facility did not have a procedure in place to provide bed hold notification when the facility inititiated a transfer for hospitalization .",2020-09-01
671,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,641,E,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to accurately code MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment items to reflect the resident's status during the assessment reference date for 1 closed record sampled resident (Resident 33) and 2 current sampled residents (Residents 2 and 26). Sample size was 16 current residents and 3 closed records. Facility census was 35. Findings are: [NAME] Record review of Resident 33's Admission MDS assessment completed on 3/19/19 revealed the resident was admitted to the facility on [DATE]. Review of the Medications section of this MDS revealed the facility had assessed the resident and determined the resident had not received any insulin injections during the reference period (3/12/19-3/19/19) of the assessment. Record review of Resident 33's Medication Review Report dated 3/21/19 and signed by the resident's physician on 3/24/19 revealed the resident had an order for [REDACTED]. Record review of Resident 33's Medication Administration Record [REDACTED]. Interview with the MDS Coordinator, RN (Registered Nurse)-C on 4/23/19 at 10:21 a.m. confirmed Resident 33 received [MEDICATION NAME] injections every day of the reference period of the resident's Admission MDS concluded on 3/19/19 and that the insulin injections were not recorded on the resident's MDS assessment. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (an manual with instructions on how to accurately assess and code MDS assessments) Version 1.16 revised (MONTH) (YEAR). - In the section for coding resident Medications, the facility is instructed to review the resident's medication administration records for the 7-day look--back period (or since admission/entry or re-entry if less than 7 days). - For insulin the facility is instructed to determine if the resident received insulin injections during the look back period . count the number of days insulin injections were received . enter in Item N0350A (the coding item for number of days insulin was received during the look-back period). B. Record review on 4-18-19 revealed that Resident 2's Level 2 PASARR (Pre-Admission Screening and Resident Review) was completed on 7-31-19 and the findings were The evaluation conducted to determine eligibility for placement/continued stay in a nursing facility indicates that the above named individual is eligible for admission/continued residence in a Medicaid certified nursing facility and does not require specialized services as defined in 42 CFR 483.134. Record review 4-18-19 revealed MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 1-25-19 identified the resident as not having had Level 2 PASARR completed. This is a MDS discrepancy as information on the completed Level 2 PASARR was not transferred to Resident 2's MDS. Staff interview on 04/18/19 at 02:19 p.m. MDS Coordinator verified that an error had been made on the MDS dated [DATE] as Resident 2 did have a Level 2 PASARR completed on 7-31-15 and this information was not placed in the MDS assessment. C. Record review of the MDS Quarterly Review Assessment for Resident 26 which was completed on 3/29/19 showed that this resident received an Antipsychotic (a class of medication primarily used to manage symptoms of [MEDICAL CONDITION] such as delusions, hallucinations, paranoia, or confused thoughts) for all 7 days of the look back period. However, the section for Antipsychotic Medication Review was marked No - Antipsychotics were not received. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (an authoritative instruction manual on how to accurately code assessment items on the MDS) Version 1.16 revised in (MONTH) of (YEAR) revealed the following instructions for the section entitled Medications Received under Coding Instructions for Antipsychotic record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period . Instructions for the section entitled Antipsychotic Medication Review under Coding Instructions instructed the facility to code no if antipsychotics were not received. On 4/23/19 at 2:13 PM, the facility's MDS coordinator verified that Resident 26 did receive [MEDICATION NAME] (an antipsychotic medication) on all 7 days of the look back period in March. The MDS coordinator also verified that this was not documented correctly in section entitled Antipsychotic Medication Review, and the DON (Director of Nursing) acknowledged the MDS coordinator's information. The Medication Administration Record [REDACTED].",2020-09-01
672,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,656,D,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12.006.09C Based on observation, interviews, and record reviews, the facility failed to develop a comprehensive care plan 1) for a new pressure area for one sampled resident (Resident 4) and 2) for medications being administered to one sampled resident (Resident 26). Facility census was 35. Sample size was 16. Finding are: [NAME] On 4/22/19 at 11:59 AM during an interview, RN(Registered Nurse)-D revealed that a pressure area was noted on Resident 4's left gluteal fold (the horizontal crease between the upper leg and the buttocks) during a routine skin check last week. RN-D stated that treatment for [REDACTED]. RN-D also revealed that this dressing was changed every other day by the night shift. On 4/22/19 at 1:46 PM, care provided to Resident 4 by MA(Medication Aide)-E and MA-F revealed a total of three duoderm dressings on the resident's buttocks area all of which were clean and intact and dated 4/21/19. Both MAs revealed they did not know why this resident had duoderm dressings on her buttocks. MA-E verified that this resident was totally dependent on staff for all care and could not have applied or moved the dressings independently. On 4/22/19 at 5:15 PM, MA-E and MA-F assisted RN-D to check and change the dressings on Resident 4. RN-D removed all three duoderm dressings and verified that there was no redness or open area under two of the dressings. RN-D also verified that the third dressing was applied appropriately over the open area which had been found during last week's skin check. RN-D also revealed that the area had improved since that time as this nurse had done the initial observation and had obtained treatment orders. RN-D could not explain why three duoderm dressing were on the resident but stated that it was possible that the night shift nurse had seen redness or other concerns which had healed since the duoderm dressings were applied. RN-D then applied a new dressing to the open area. Review of the Care Plan for Resident 4 did not show any information related to the pressure area on the resident's left gluteal fold. The Care Plan did have a Focus for Skin which revealed that the resident's skin was fragile and might tear and bruise easily. This Focus also indicated that Resident 4 was at risk for skin breakdown due to a decreased level of functioning and incontinence (the inability to control bowel and/or bladder function). Updates had been made to the Interventions for this Focus but the last update was 3/30/17 and did not reflect the current skin concern. On 4/22/19 at 5:48 PM during an interview, RN-C who served as the facility's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used to develop resident care plans) coordinator verified that the Care Plan for Resident 4 had not been developed or updated to reflect the pressure area on the resident's left gluteal fold. B. Review of the Medication Administration Record [REDACTED]. Review of the Admission Record for Resident 26 revealed medical [DIAGNOSES REDACTED]. Review of the Treatment Administration Record for 4/1/19 to 4/30/19 for Resident 26 revealed monitoring for side effects related to the use of antipsychotic medication, diuretic medication, insulin, and sedative/hypnotic medication. The MDS Quarterly Assessment which was completed on 3/29/19 revealed that Resident 26 had received insulin injections on 7 days, antipsychotic medication on 7 days, antidepressant medication on 7 days, and diuretic medication on 7 days. The MDS Assessment is a federally mandated comprehensive assessment tool which should be used to develop resident care plans. Review of the Care Plan for Resident 26 revealed it did not address any specific medications or diagnoses. On 4/22/19 at 5:48 PM during and interview, RN-C who served as the facility's MDS coordinator verified that the Care Plan for Resident 26 had not been developed to reflect the resident's medication use and the related diagnoses. On 4/23/19 at 1:30 PM, the DON (Director of Nursing) verified that RN-C was responsible to develop and update Care Plans and agreed that information provided by RN-C about resident Care Plans was accurate.",2020-09-01
673,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,755,E,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12.006.12A Based on observation, interviews, and record review, the facility failed to provide a medication that was ordered for one sampled resident (Resident 2). Facility census was 35. Medication Administration observation included 3 sampled residents and 2 non-sampled residents. Findings are: On 4/18/19 at 9:06 AM LPN (Licensed Practical Nurse)-G was administering medications to Resident 2. The electronic Medication Administration Record [REDACTED]. LPN-G revealed that this medication was not available and could not be administered. LPN-G documented this medication as not administered on the medication administration record. A Progress Note on 4/18/19 at 9:19 AM indicated [MEDICATION NAME] was not available from pharmacy. Progress Notes from 4/17/19 at 8:32 AM, 4/16/19 at 8:05 PM, and 4/15/19 at 8:37 AM indicated [MEDICATION NAME] was not available. On 4/18/19 at 9:27 AM during an interview, LPN-G and RN(Registered Nurse)-H both verified that [MEDICATION NAME] for Resident 2 was not available from the pharmacy although neither nurse knew why the medication was not available or how long it had been missing. Review of MD orders showed med was ordered on [DATE]. On 4/18/19 at 2:00 PM, the DON (Director of Nursing) revealed that when medication is not available staff should notify the physician who ordered it. The DON reviewed Resident 2's electronic record and verified that [MEDICATION NAME] had been ordered on [DATE] but had not been delivered by by the pharmacy and was not being administered to the resident. The DON verified there was no documentation to show that a phsyian had been notified that the medication was not being administered. On 4/18/19 at 2:40 PM, LPN-G revealed the physician had not been notified that [MEDICATION NAME] was not available for Resident 2 that morning as LPN-G believed the medication had been ordered and would come in the afternoon pharmacy delivery. On 4/23/19 at 8:50 AM, another interview with the DON revealed that [MEDICATION NAME] for Resident 2 was still not available but a fax had been sent to notify the physician who had ordered the medication. Licensure Number: 175 NAC 12-006.12E1b Based on observation, interviews, and record review, the facility failed to ensure that the narcotic count was completed and signed by two nurses including the nurse going off duty and the nurse coming on duty who will take control of the keys to secure the medication for one medication cart. Finding are: On 4/18/19 at 9:49 AM after administering medications to Resident 2, LPN(Licensed Practical Nurse)-G was unable to locate a count sheet for [MEDICATION NAME] for Resident 2. When asked if the count sheet was present when the narcotic count was made at the start of the shift, LPN-G revealed that the cart had been counted by another nurse, RN(Registered Nurse)-H at the start of the shift. RN-H verified that the narcotic count had been completed at the start of the shift and the Narcotic Count Sheet was signed by RN-H as the nurse coming on duty. Both LPN-G and RN-H verified that LPN-G was the nurse on duty for the cart that shift and that they had not recounted the narcotics when the keys to the cart were passed from RN-H to LPN-[NAME] On 4/22/19 at 6:06 PM, LPN-I administered [MEDICATION NAME] to Resident 12. When LPN-I signed the count sheet for Resident 12's [MEDICATION NAME], review of the book showed that theNarcotic Count Sheet had not been signed at the start of the shift by the nurse going off duty or by LPN-I who was coming on duty. After administering the medications, LPN-I signed the Narcotic Count Sheet at 6:15 PM and wrote in initials for the off duty nurse to sign later. The facility policy entitiled Narcotics-Counting and Destruction Policy revealed that the nurse going off duty and the nurse coming on duty should sign together in the unit narcotic book. On 4/23/19 at 8:05 AM, the DON (Director of Nursing) verified that the facility policy required the nurse coming on duty and the nurse going off duty to count all narcotics in the cart together and to sign the narcotic count sheet together to verify that the narcotic count was correct when exchanging the keys to the cart.",2020-09-01
674,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,758,D,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the order for prn (as needed) [MEDICATION NAME] (a [MEDICAL CONDITION] medication used to treat anxiety) was limited to 14 days without a rationale from the physican for extending its use for one sampled resident (Resident 7). Facility census was 35. Sample size was 16. Findings are: The Medication Administration Record [REDACTED]. The start date for the order was 3/29/19. The medication was administered on 4/4/19 and 4/9/19. No documentation could be found to indicate that this order had been reviewed by the physician or that the physician had been notified regarding how often the medication was being administered. On 4/23/19 at 9:05 AM, the DON (Director of Nursing) verified that the order for prn [MEDICATION NAME] for Resident 7 was not reviewed by a physician within 2 weeks to document a rationale for its continued use.",2020-09-01
675,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,761,D,0,1,06US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Number: 175 NAC 12-006.12E1 Based on observation and interviews the facility failed to ensure that medications were stored securely at all times for one sampled resident (Resident 2). Facility census was 35. Sample size was 16. Findings are: On 4/18/19 at 9:20 AM after removing medications from cards and bottles for Resident 2, LPN(Licensed Practical Nurse)-G turned cards containing unused pills upside down and set them on top of the medication cart. LPN-G took care to set the card containing [MEDICATION NAME] to one side under the computer monitor stating that this was done to ensure that card was returned to the locked narcotic drawer after the medication administration was completed. LPN-G then entered the resident's room leaving all of the medications on top of the cart. The cart was left outside the door facing into the hallway. Cart was not locked while the nurse was away from it. RN(Registered Nurse)-H approached the cart at 9:25 AM and verified that the cart should not be left unlocked and unattended with medications on top. LPN-G returned to the cart at 9:27 AM. On 4/23/19 at 8:50 AM, the DON(Director of Nursing) revealed that Resident 31 and Resident 133 both wander and could potentially have taken medications or other things left unattended on the cart.",2020-09-01
676,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2019-04-23,812,F,0,1,06US11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interviews the facility failed to: 1) Date and label open bag of breaded chicken patties, and a loaf of raisin bread and, 2) Facility failed to clean the exhaust hood located over the stove of dirt and debris. These failures hat the potential to affect all residents. Facility census was 35. Findings are: [NAME] Observation on 04/17/18 at 10:05 a.m. revealed an open bag of chicken patties in the walk in freezer and an open loaf of raisin bread in the walk in refrigerator that had not been labeled or dated. Observation on 04/18/19 at 7:38 a.m. revealed an open bag of chicken patties in the walk in freezer and an open loaf of raisin bread in the walk in refrigerator that had not been labeled or dated. Observation on 04/22/19 at 1:36 p.m. revealed an open bag of chicken patties in the walk in freezer and an open loaf of raisin bread in the walk in refrigerator that had not been labeled or dated. Staff interview 04/22/19 at 2:22 p.m. Administrator and Consultant for operations verified that any food items that were open should have been labeled and dated. Review of the 07/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 3-201.11(C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 Labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.17 and 3-202.18. B. Observation on 04/18/19 at 7:38 a.m. revealed the exhaust hood over the stove located in the kitchen had a build up of dirt and debris located on it. Observation on 04/22/19 at 1:36 p.m. revealed the exhaust hood over the stove located in the kitchen had a build up of dirt and debris located on it. Staff interview on 04/22/19 at 1:36 p.m. Dietary Consultant Verified the exhaust hood over the stove located in the kitchen had a build up of dirt and debris on it. Dietary Consultant reported it would be cleaned immediately. Staff interview on 04/22/19 at 2:25 p.m. Administrator and Consultant of operations verified the exhaust hood over the stove had not been cleaned as there was dirt and debris located on it. Administrator reported this would be taken care of immediately. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Authoritive reference for the food service sanitation practices, revealed the following: 6-5-1.14(A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt and other materials.",2020-09-01
677,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,550,D,0,1,9I0Q11,"Licensure Reference Number 175 NAC 12-006.05(21) Based on record reviews, observations and interviews; the facility failed to ensure that a dependent resident, sleeping in public areas for extended periods of time, was assisted to their room to sleep to promote dignity for one current sampled resident (Resident 4). The facility census was 39 with 19 current sampled residents. Findings are: Review of Resident 4's Care Plan, goal date 5/5/18, revealed that the resident was dependent on staff for transfers with a mechanical lift and ambulation with a wheelchair. Observations on 4/24/18 at 3:00 PM revealed the resident sleeping in the wheelchair in the front lobby. Observations on 4/25/18 at 9:00 AM and 11:00 AM revealed the resident sleeping in the wheelchair in the dining room lounge area. Further observations at 1:00 PM revealed the resident sleeping in the wheelchair in the front lobby. Observations on 4/30/18 at 9:15 AM revealed the resident sleeping in the wheelchair in the dining room lounge area. Further observations at 10:30 AM revealed the resident sleeping in the wheelchair during the exercise class and at 10:55 AM in the dining room lounge area. Interview with the Director of Nursing on 4/30/18 at 12:15 PM confirmed that the resident should be taken to the room to sleep, rather than public areas, to promote the resident's dignity.",2020-09-01
678,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,565,E,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.06 Based on interviews and record reviews, the facility failed to respond to the Resident Council to review past concerns, facility action toward the concerns, and determination if the issues brought to the facility by the council were resolved. Facility Census was 39 with 11-13 residents attending Council meetings in (MONTH) and (MONTH) of (YEAR). Findings are: Record review of Resident Council minutes from the (MONTH) (YEAR) meeting, attended by 11 residents (Residents 13, 26, 30, 14, 11, 9, 18, 22, 16, 23, and 33), revealed the following concerns brought up by residents: - From old business- beds were still not being made in the morning and laundry still not being picked up from the rooms. One resident stated bathroom is still not being cleaned well enough. New business concerns brought up included: - One resident stated call light is not always in reach. - some residents expressed they are not getting the number of baths they want. - A couple of residents stated sometimes it takes a long time to get call lights answered. - One resident stated not getting celery. - One resident stated would like sausage once in a while. - One resident stated clothes come back from laundry a different color. - One resident stated sometimes gets the wrong clothes back. Record review of Grievance Tracking Logs revealed grievance forms were filed based on the council meeting included the following: - 2/28/18, Resident 22 expressed laundry not being picked up. The Follow Up for this grievances was recorded as Will f/u (follow up) at (MONTH) Res (Resident) Council. The section on whether the residents were satisfied with resolution was not completed. - 2/28/18, Resident 16 expressed call light not in place. The Follow Up for this grievances was recorded as Will f/u (follow up) at (MONTH) Res (Resident) Council. The section on whether the residents were satisfied with resolution was not completed. - 2/28/18 Resident 33 expressed bathroom not cleaned good enough. The Follow Up for this grievances was recorded as Will f/u (follow up) at (MONTH) Res (Resident) Council. The section on whether the residents were satisfied with resolution was not completed. - 1/30/18 Resident 22 expressed laundry not being picked up during the day. There was no Follow up documented and the section on Satisfied with resolution was not completed. - 1/30/18 Resident 33 expressed bed not getting made until late in day. There was no Follow up documented and the section on Satisfied with resolution was not completed. -2 /28/18 Resident 33 expressed clothes coming back from laundry different color and not getting number of baths wanted. The Follow Up for this grievances was recorded as Will f/u (follow up) at (MONTH) Res (Resident) Council. The section on whether the residents were satisfied with resolution was not completed. - 2/28/18 Residents 22, 16, 26, expressed call lights not being answered timely. The Follow Up for this grievances was recorded as Will f/u (follow up) at (MONTH) Res (Resident) Council. The section on whether the residents were satisfied with resolution was not completed. - 2/28/18 Residents 22 and 33 expressed beds not getting made in the morning. The Follow Up for this grievances was recorded as Will f/u (follow up) at (MONTH) Res (Resident) Council. The section on whether the residents were satisfied with resolution was not completed. Record review of the (MONTH) (YEAR) Resident Council meeting minutes with 13 residents present (Residents 33, 26, 28, 30, 14, 10, 11, 7, 22, 24, 23, 20, and 16) revealed the following: - Old business- went over concerns from last meeting. Laundry is still not getting picked up from their rooms. It is still taking a long time to get call lights answered. There was nothing in the minutes documenting the residents were informed of what had been done to resolve prior grievances from the meeting and formal grievances filed in which the follow up was recorded to be done at this meeting. There was nothing in the minutes to identify if resolutions of these concerns/grievances had been accomplished for the residents. Interview on 4/30/18 at 11:30 a.m. with the Social Services Director, who was present at the (MONTH) and (MONTH) (YEAR) Resident Council meetings, verified the concerns brought up at the (MONTH) (YEAR) meeting and the formal grievances filed with concerns to be followed up at the (MONTH) meeting were not recorded explaining facility interventions to address the concerns and grievances, nor was follow up and resolution documentation recorded for those concerns/grievances.",2020-09-01
679,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,576,E,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.05 (12) Based on interviews and record review, the facility failed to ensure residents received mail on Saturdays affecting any residents who could potentially receive mail on the weekend. Facility census was 39. Findings are: Interview with Resident Council members (Residents 13, 30, 10, 7, 22, 24, 33, 23, 139, and 28) during a meeting with the council on 4/24/18 at 11:01 p.m. revealed from the members that mail was not always received on Saturdays. Interview with the city Post Office worker on 4/30/18 at 12:40 p.m. revealed the city Post Office is open on Saturdays and does deliver mail to the facility. Interview with the facility AD (Activity Director) on 4/30/18 at 3/10 p.m. revealed the AD is responsible for delivering mail to the residents once the Post Office brings the mail to the facility. The AD confirmed not working on all Saturdays and when asked who delivers mail when the AD is absent, the AD stated no one is designated. Record Review of the facility's Resident Rights information provided to residents revealed the nursing facility must Respect the Resident's right to personal privacy . including the right to send and promptly receive unopened mail .",2020-09-01
680,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,580,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on interviews and record reviews, the facility failed to: 1) notify family of newly developed pressure sores and notify the physician of elevated blood sugar readings for one sampled resident (Resident 32). Sample size was 19 current residents. Facility census was 39. Findings are: [NAME] Record review of Resident 32's Admission Record printed on 4/24/18 revealed the resident was admitted to the facility on [DATE], The form listed FM (Family Member)-A as the Responsible Party and Power of Attorney for the residents Care. Further examination of the form revealed among the resident medical [DIAGNOSES REDACTED]. Interview with FM-A on 4/24/18 at 11:54 a.m. revealed the facility staff had not notified FM-A of the discovery of newly developed pressure sores on the resident's bottom when they occurred. Record review of Resident 32's electronic Progress Notes revealed an entry on 4/16/18at 12:47 p.m. that FM-A was upset of not notified about resident's wound to left buttocks that was found last night. Explained to FM-A that this nurse did not realize that the previous shift had not notified (FM-A) and that this nurse had not seen the area yet as the resident was already in (the resident's) wheelchair .FM-A verbalized understanding but wants to be notified of any changes in the resident status. Record review of Initial Weekly Wound Documentation Forms completed on 4/17/18 revealed pressure wounds were discovered to Resident 32's Coccyx identified as a Stage 2 (Partial Thickness loss of dermis (outer layer of skin) presenting as a shallow open ulcer) pressure ulcer measuring 1.8 by 1 centimeter. A second wound was also identified in the resident's left gluteal fold recorded as a Stage 2 pressure ulcer measuring 3 by 2 centimeters with 0.1 centimeter in depth. The section on the form for family notified was not checked nor was a family member identified as being notified of the wounds. B. Record review of Resident 32's Medication Administration Record [REDACTED] - 4/10/18 recorded at 563 mg/dl (milligrams per deciliter of blood). - 4/13/18 recorded at 545 mg/dl. - 4/21/18 recorded at 413 mg/dl Record review of Resident 32's electronic progress notes and documents in the resident's medical record chart revealed no documentation that the physician was notified of these elevated readings. Source: Diabetes Self Management What is a Normal Blood Sugar Level updated 3/27/2018. For Fasting the Official ADA (American Diabetes Association) for someone with diabetes: 80-130 mg/dl. Interview with the interim-DON (Director of Nursing) and Corporate Nurse Consultant on 4/30/18 at 4:15 p.m. confirmed that facility staff were to notify resident representatives and/or family members of changes in condition immediately or as directed by the resident or family. The DON and Consultant also verified that the facility staff should notify physicians of significant elevations in blood sugar readings unless otherwise directed by the physician.",2020-09-01
681,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,583,D,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.05 (21) Based on record reviews, observations and interview; the facility failed to ensure that residents were draped during personal cares to prevent unnecessary over exposure of the resident's body and promote privacy for one current sampled resident (Resident 36). The facility census was 39 with 19 current sampled residents. Findings are: Observations on 4/25/18 at 9:15 AM revealed MA (Medication Aide) - B and MA - D transferred Resident 36 to bed with a full mechanical lift. Further observations revealed MA - B and MA - D positioned the resident on the bed, pulled down the resident's slacks below the knees and removed the disposable brief. The resident was incontinent of urine and MA - B and MA - D provided personal cares to clean the resident without any attempts to cover or drape the resident during the care. Review of the facility policy Perineal Care, dated (MONTH) (YEAR), revealed The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Further review revealed the procedure which included the following: . 6. Provide privacy. 7. Fold the bedspread or blanket toward the foot of the bed. 8. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 9. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. Interview with the Nurse Consultant on 4/30/18 at 12:20 PM confirmed that the staff were to cover or drape the residents during personal cares to prevent unnecessary exposure of the resident's body and to promote the resident's privacy and comfort.",2020-09-01
682,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,584,E,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep equipment, fixtures, and furnishings clean, safe, and in good repair for six sampled rooms (room [ROOM NUMBER], 7, 9, #0, 34, and 44). Licensure Reference Number 175 NAC 12-006.18B Observations on 04/25/18 at 09:16 AM revealed that Rooms 4, 7, 9, #4, and 44 had dusty bathroom vents, room [ROOM NUMBER] had a porcelain sink with broken porcelain on the front, and room [ROOM NUMBER] had holes in the wall tiles in the bathroom. Interviews on 04/25/18 at 09:16 AM with the Administrator and Maintenance supervisor confirmed that room [ROOM NUMBER], 7, 9, 34, and 44 had dusty bathroom vents, confirmed that room [ROOM NUMBER] had a porcelain sink with visibly broken porcelain, and confirmed that room [ROOM NUMBER] had holes in the wall tiles in the bathroom. Licensure Reference Number: 175 NAC 12-006.18C Observations of Resident 4's room on 4/24/18 at 11:40 AM revealed a stained and soiled pillow case on the resident's bed. Further observations on 4/25/18 at 7:15 AM revealed the resident's bed made with the same soiled and stained pillow case. Interview with Medication Aide - D on 4/25/18 at 10:10 AM confirmed that the pillow case needed to be changed. Interview with the Director of Nursing on 4/25/18 at 10:55 AM confirmed that soiled linens were to be changed to promote the resident's comfort.",2020-09-01
683,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,637,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to identify changes from MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) comparison assessments to identify or determine if a Significant Change in Status assessment should be completed for one sampled resident (Resident 32). Sample size was 19 current residents. Facility census was 39. Findings are: Record review of Resident 32's Admission Record printed on 4/24/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 32's MDS records revealed a Quarterly review assessment was completed on 3/30/18 and a Quarterly review assessment was completed on 12/29/18. Comparison of these two MDS records revealed the following declines in the resident's condition: - Transfer ability (moving between surfaces such as bed to chair, chair to wheelchair) declined from Extensive assistance (Resident involved in activity, staff provide weight bearing support) in (MONTH) to total dependence (full staff performance of the activity) in March. - Eating (how much help the resident needed to consume foods) declined from Supervision (oversight and encouragement provided) in (MONTH) to Extensive assistance in March. - The resident's Functional Range of Motion (how the resident moves joints) declined from no impairments in (MONTH) to Impairment on both sides of the lower extremities in March. - The resident was assessed with [REDACTED]. - The resident's weight declined from 121 pounds in (MONTH) to 105 pounds in (MONTH) and was recorded as a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The weight loss was documented on the assessment as not having lost weight due to a physician prescribed weight loss regiment indicating the weight change was significant. - The resident developed an Unstageable (known but not stageable ulcer due to coverage of the wound bed by slough and/or eschar (scabbing) in (MONTH) and had no ulcers in December. Observation of Resident 32's meals and intakes on 4/24/18 at noon and supper, 4/25/18 at breakfast and noon, and 4/30/18 at breakfast and noon revealed the resident was assisted with meal intake from staff and family members and made no attempts to feed self. Interviews with MA-B and MA-D prior to the provision of care for Resident 32 on 4/25/18 at 9:40 a.m. revealed the resident is dependent on staff with a mechanical lift for all transfers between surfaces. MA-B and MA-D stated the resident wears a pressure relief heel protector due to a pressure ulcer on the right heel and required positioning help from staff due to contracted (fixed range of motion) to both knees. Both MA-B and MA-D stated the resident needed assistance with meals due to declines in condition and inability or resistance to feeding self and losing weight. MA-B and MA-D described the resident has ongoing pain with transfers and the wound care and is on routine narcotic pain medication patches for relief. Observations of Resident 32's transfer from the wheelchair to bed on 4/25/18 from 9:45 a.m. to 10:00 a.m. revealed the resident was dependent on staff with the use of a mechanical lift and two staff members, MA (Medication Aide)-B and MA-D to assist the resident. Further observation revealed the resident had a heel pressure relieving device on the left heel, and had contractures (fixed range of motion) to both knees. The resident was observed with a narcotic [MEDICATION NAME] on the left shoulder. Interview with RN (Registered Nurse)-B, the MDS Coordinator, on 4/30/18 at 3:30 p.m. confirmed Resident 32 experienced declines in transfer ability, eating ability, range of motion, increased pain, weight loss, and the development of a pressure ulcer between the 12/29/18 Quarterly review MDS and the 3/30/18 Quarterly review MDS assessments. RN-B verified there was no documentation that the interdisciplinary team acknowledged the changes and considered completing a Significant Change in Status MDS rather than a Quarterly abbreviated assessment. Source: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (a manual with regulatory requirements on how to complete and transmit MDS assessments) Version 1.14 (MONTH) (YEAR). Instructions include: The SCSA (Significant Change in Status Assessment) is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either improvement or decline . A 'significant change is a decline or improvement in a resident's status that will not normally resolve itself without intervention by staff . impacts more than one area of the resident's health . and requires interdisciplinary review and/or revision of the care plan. Other instructions in the manual identify A SCSA is appropriate when there is a determination that a significant change in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and the resident's condition is not expected to return to baseline within two weeks . The final decision regarding what constitutes a significant change in status must be based upon the judgment of the IDT . However staff must note these transient changes in the resident's status in the resident's record . Guidelines in the manual for determining a significant decline instructs staff to observe for Decline in two or more of the following . Any decline in ADL (Activities of Daily Living) physical functioning area where a resident is newly coded as Extensive assistance, Total Dependence . Emergence of unplanned weight loss problem . Emergence of a new pressure ulcer . overall deterioration of resident's condition.",2020-09-01
684,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,656,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1 175 NAC 12-006.09C1b Based on record reviews, observations and interviews; the facility failed to ensure that 1) a care plan was developed to address contractures (shortening of muscle that prevents normal mobility) and limitations in range of motion for one current sampled resident (Resident 24) and 2) fluids were offered with cares as directed on the care plan for one current sampled resident (Resident 4). The facility census was 39 with 19 current sampled residents. Findings are: [NAME] Review of Resident 24's Admission Record, printed 4/24/18, revealed that the resident had [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/9/18, revealed that the resident had limitations in range of motion at bilateral lower extremities. Review of the Care Plan, goal date 6/23/18, revealed no care plan to address the resident's contractures or limitations in range of motion. Interview with the Director of Nursing on 4/30/18 at 11:30 AM confirmed that the care plan should have been developed to address the resident's contractures and limitations in range of motion. B. Review of Resident 4's Care Plan, goal date 5/5/18, revealed that the resident was dependent on staff for assistance eating and drinking and drank nectar thickened liquids in sippy cups at meals. Further review revealed interventions including to encourage the resident to drink all fluids at meals and offer drinks during waking hours to promote adequate hydration. Observations on 4/24/18 at 5:20 PM revealed MA (Medication Aide) - B and MA - C transferred the resident from the bed to the bathroom and then to the wheelchair to prepare for supper. Further observations revealed a full glass of thickened water on the resident's dresser. MA - B and MA - C did not offer the resident a drink of water and transported the resident to the dining room. Further observations revealed that the resident was not offered a drink of thickened water or juice until the supper tray was served at 6:40 PM. The resident did accept the thickened juice with the meal. Observations on 4/25/18 at 7:15 AM and 12:00 PM revealed the resident seated at the assistance table in the dining room with no fluids on the table. Observations of the resident's room on 4/25/18 at 7:30 AM and 11:00 AM revealed the same full glass of thickened water on the resident's dresser. Interview with the Director of Nursing on 4/20/18 at 12:00 PM confirmed that the nursing staff were to encourage and offer fluids as directed on the care plan to ensure that the resident's hydration needs were met.",2020-09-01
685,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,657,B,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference number: 175 NAC 12-006.09C1c Based on record reviews and interview, the facility failed to include Nursing Assistant input into revision of Resident care plans for 3 sampled residents (Residents 19, 32, and 34). Sample size was 19 current residents. Facility census was 39. Findings are: [NAME] Record review of Resident 19's Admission Record printed on 4/24/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 19's Baseline Care Plan document signed on 1/29/18 by staff, the resident, and the resident's family members reviewing and contributing to the resident's plan of care development revealed staff included in the process were RN (Registered Nurse)-E, the Social Services Director, and a Physical Therapy Assistant. There was no documentation that a Nurse Aide was included in the care planning process for Resident 19. B. Record review of Resident 32's Admission Record printed on 4/24/18 revealed the resident was admitted on [DATE]. Record review of Resident 32's Baseline Care Plan document signed on 4/5/18 by staff, the resident, and the resident's family members reviewing and contributing to the resident's plan of care development revealed staff included in the process were RN (Registered Nurse)-E, the Social Services Director, the Activities Director, and a Physical Therapy Assistant. There was no documentation that a Nurse Aide was included in the care planning process for Resident 32. C. Record review of Resident 34's Admission Record printed on 4/24/18 revealed the resident was admitted on [DATE]. Record review of Resident 34's Baseline Care Plan document signed on 4/12/18 by staff, the resident, and the resident's family members reviewing and contributing to the resident's plan of care development revealed staff included in the process were RN (Registered Nurse)-E, the Kitchen Manager, Social Services Director, the Activities Director, and a Physical Therapy Assistant. There was no documentation that a Nurse Aide was included in the care planning process for Resident 34. Interview with the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator, RN-E, confirmed that Nurse Aides were not included among the interdisciplinary team developing or revising care plans for Residents 19, 32, and 34.",2020-09-01
686,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,676,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D1b Based on record reviews, observations and interviews; the facility failed to evaluate a decline in activities of daily living and develop a plan to restore abilities for one current sampled resident (Resident 4). The facility census was 39 with 19 current sampled residents. Findings are: Review of Resident 4's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 10/20/17, revealed that the resident required extensive assistance with two plus persons physical assistance for bed mobility and extensive assistance with one person physical assistance with dressing, eating and toilet use. Review of the MDS, dated [DATE], revealed that the resident was totally dependent with two plus persons physical assistance with bed mobility and totally dependent with one person physical assistance with dressing, eating and toilet use. Interview with the MDS Coordinator on 4/25/18 at 11:00 AM confirmed that the resident had a decline in activities of daily living as stated above. Further interview revealed that there was no documentation that the declines were evaluated to determine potential causal factors or that care plan changes were not developed to potentially restore the resident's ability to participate in activities of daily living. Observations on 4/24/18 at 5:20 PM revealed MA (Medication Aide) - B and MA - C transferred the resident from the bed, bathroom and then the wheelchair with a mechanical lift. Further observations on 4/24/18 at 6:15 PM revealed that staff fed the resident at the evening meal. Interview with MA - B on 4/24/18 at 5:30 PM confirmed that the resident was dependent on staff for transfers, dressing, eating and toileting.",2020-09-01
687,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,684,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D2c Based on record reviews and interviews, the facility failed to ensure follow up assessment of the resident's condition and any interventions and/or responses were completed for one sampled resident (Resident 32) with abnormal elevated fasting blood pressure readings. Sample size was 19 current residents. Facility census was 39. Findings are: Record review of Resident 32's Admission Record printed on 4/24/18 revealed the resident's admitted to the facility was on 5/3/2015. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 32's Medication Administration Record [REDACTED] - 4/10/18 recorded at 563 mg/dl (milligrams per deciliter of blood). - 4/13/18 recorded at 545 mg/dl. - 4/21/18 recorded at 413 mg/dl Record review of Resident 32's electronic progress notes for (MONTH) of (YEAR) and documents in the resident's medical record chart revealed no documentation that there were any descriptions of the resident's condition at the time of the elevated fasting blood sugar readings on 4/10; 4/13; and 4/21/18. There was no documentation describing any nursing interventions or response to interventions, or follow up blood sugar tests to determine if the resident's blood sugars improved. Source: Diabetes Self Management What is a Normal Blood Sugar Level updated 3/27/2018. For Fasting the Official ADA (American Diabetes Association) for someone with diabetes: 80-130 mg/dl. Interview with the interim-DON (Director of Nursing) and Corporate Nurse Consultant on 4/30/18 at 4:15 p.m. confirmed Resident 32's fasting blood sugar readings were significantly high on 4/10/18; 4/13/18; and 4/21/18 and there was no documentation the facility nursing staff described the condition of the resident at the time of the readings or any interventions or responses to interventions, or follow up blood sugar testing to determine if the resident's blood sugars improved.",2020-09-01
688,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,688,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D4 Based on record review and interview, the facility failed to develop a plan to restore, maintain or prevent further decline for one current sampled resident (Resident 24) with contractures (shortening of muscle that prevents normal mobility) and functional limitations in range of motion. The facility census was 39 with 19 current sampled residents. Findings are: Review of Resident 24's Admission Record, printed 4/24/18, revealed that the resident had [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/9/18, revealed that the resident had limitations in range of motion at bilateral lower extremities. Interview with the Director of Nursing on 4/30/18 at 11:30 AM confirmed that the resident was not on a restorative nursing program to address the resident's contractures or limitations in range of motion to potentially restore, maintain or prevent further declines.",2020-09-01
689,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,689,E,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews; the facility failed to 1) follow safety plan for smoking for one current sampled resident (Resident 26) and 2) ensure that water temperatures at the hand sink did not exceed 120 degrees F (Fahrenheit) for four current sampled residents (Residents 4, 24, 36 and 32) The facility census was 39 with 19 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006. 09D7a [NAME] Observations on 4/24/18 at 9:30 AM revealed Resident 26 smoking on the front porch of the facility. Interview with the resident on 4/24/18 at 2:00 PM revealed that the resident smokes independently outside on the front porch. Further interview revealed that the resident kept cigarettes and lighters in room in the top drawer of the bedside dresser, Review of the facility Smoking or E-cigarette Assessment, signed 1/5/18, revealed that the resident needed the facility to store lighter and cigarettes. Interview with the Director of Nursing on 4/25/18 at 11:15 AM confirmed that there was a discrepancy with the smoking assessment and current smoking routine for the resident. Further interview on 4/30/18 at 11:30 AM revealed that the resident's cigarettes and lighters are kept at the nurse's station for safety. Interview with DON on 4/30/18 at 11:30 AM - keeping cigarettes and lighter at the nurse's station for safety. Licensure Reference Number: 175 NAC 12-006.18E3a(2) B. Observations of Residents 4 and 24's shared bathroom (room [ROOM NUMBER] and 12) on 4/24/18 at 11:40 AM revealed that the water temperature at the hand sink was 128 degrees F (Fahrenheit). Further observations on 4/25/18 at 12:15 PM revealed that the water temperature was 127.9 degrees F and on 4/30/18 at 2:20 PM 126.8 degrees F. C. Observations of Resident 36's bathroom (room [ROOM NUMBER]) on 4/24/18 at 12:30 PM revealed that the water temperature at the hand sink was 125.2 degrees F and on 4/30/18 at 2:20 PM 127.4 degrees and 2:30 PM 124 degrees F. D. Observations of Resident 32's bathroom (room [ROOM NUMBER]) on 4/30/18 at 2:20 PM revealed that the water temperature at the hand sink was 125 degrees F. Interview with the Administrator on 4/30/18 at 2:30 PM confirmed that the water temperatures were too hot in the resident's bathroom hand sinks to reduce the risk for accidental burns.",2020-09-01
690,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,690,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D3(2) Based on record reviews and interview, the facility failed to assess potential causal factors and develop a plan to restore bowel continence for one current sampled resident (Resident 4). The facility census was 39 with 19 current sampled residents. Findings are: Review of Resident 4's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 10/20/17, revealed that the resident was frequently incontinent of bowel. Review of the MDS, dated [DATE], revealed that the resident was always incontinent of bowel. Interview with the MDS Coordinator on 4/25/18 at 11:00 AM confirmed that the resident had a decline in bowel incontinence. Further interview revealed that there was no documentation that the decline was evaluated to determine potential causal factors or that care plan changes were developed to potentially restore the resident's bowel continence.",2020-09-01
691,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,698,D,0,1,9I0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure one sampled resident's (Resident 141) [MEDICAL TREATMENT] access port was monitored for abnormalities. The resident was the only resident in the facility receiving [MEDICAL TREATMENT]. Sample size was 19 current residents. Facility census was 39. Findings are: Record review of Resident 141's Admission Record printed on 4/24/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Observation of Resident 141 on 4/24/18 at 10:00 a.m. revealed the resident had a [MEDICAL TREATMENT] port on the left arm. Interview with the Resident 141 on 4/24/18 at 10:00 a.m. revealed the resident received long-term [MEDICAL TREATMENT] treatments for several years and was currently transported for [MEDICAL TREATMENT] treatments three times a week. Record review of Resident 141's Care Plan initiated on 4/18/18 revealed a Focus problem documenting the resident had end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] treatments three times a week with the potential for complications secondary to [MEDICAL TREATMENT]. Interventions for the problem included directions to check for bruit (pulsating sound through an artery or vein heard with a stethoscope) and thrill (pulse) in the resident's [MEDICAL TREATMENT] access (LEFT UPPER ARM) every shift and further evaluate changes. Record review of Resident 141's Medication Administration Record [REDACTED]. Interview with RN (Registered Nurse)-E on 4/30/18 at 3:30 p m. and charge nurse, RN-A on 4/30/18 at 3:50 p.m. confirmed Resident 141's [MEDICAL TREATMENT] access port on the Left Arm should be monitored daily for abnormal symptoms. RN-E and RN-A verified there was no treatment record or daily assessment documentation that the resident's access port was being monitored a minimum of daily. Source: National Institutes of Health/U.S. National Library of Medicine: Taking Care of Your Vascular Access for [MEDICAL TREATMENT]. (MONTH) (YEAR). Regarding Day to day care of your vascular access the instructions included: Check the pulse (also called thrill) in your access every day and Call your provider right away if you notice any of these problems: Bleeding from your vascular access site, signs of infection such as redness, swelling, soreness, pain, warmth, or pus around the site, a fever of 100.3 or higher, the pulse (thrill) in your graft or fistula slows down or you do not feel it at all, the arm or hand feels cold, numb, or weak.",2020-09-01
692,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,755,D,0,1,9I0Q11,"**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 ensure a resident received medication in accordance with prevailing professional standards for 1 resident sampled (Resident #21). Census: 39 residents. Sample size: 19 residents. Observation on 4/24/18 at 11:30 AM RN-A administered medications to Resident #21. RN-A opened a capsule of [MEDICATION NAME] (a medication used for pain control, to help prevent or control [MEDICAL CONDITION], or as a mood stabilizer) and poured the contents into a medication administration cup. RN-A then took 2 Tylenol tablets (a medication to help relieve minor pain), crushed them and put them in the same cup with the [MEDICATION NAME]; mixed the medication in pudding, and administered it to Resident #21. Record review revealed there was no order to crush medications for Resident #21. Interview on 4/25/18 at 01:45 PM with DON (Director of Nursing) confirmed there was no order to crush medications for Resident #21. Classification and Indications.",2020-09-01
693,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,801,F,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.04D2a Based on record review and interviews, the facility failed to provide a qualified Dietary Manager as evidenced by the Dietary Manager not having credentials or continuing education that was required for the position. All residents could be affected. Facility census was 39. Findings are: Record Review of the files for the Dietary Manager revealed there were no educational or certification records identifying the Dietary Manager successfully completed a course in food service management. Interview on 04/24/18 at 12:42 p.m. with the Registered Dietician verified the Dietary Manager who was hired 3 weeks ago did not have the education, credentialing or certification required for the position of Dietary Manger. Interview on 04/25/18 at 10:52 a.m. with the Dietary Manager verified this person did not have the education, credentialing or certification required for the position of the Dietary Manager.",2020-09-01
694,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,803,F,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.11A1 Based on record reviews and interviews, the facility failed to follow the breakfast menu. This failure had the potential to affect all residents. Facility census was 39 Findings are: Record review of the HCSG - Breakfast Menu titled N Super Division Week-At-AGlance, hcsg1NSuperBase2018 Week 2, revealed that residents should have had biscuits, sausage gravy, oatmeal, hashbrowns, orange juice, milk, coffee, or hot cereal and cold cereal of choice. Items that were served for breakfast were the biscuits and hashbrowns with choice of drinks and hot or cold cereal. Sausage gravy was not served. Interview on 04/24/18 at 12:02 p.m. with Resident 9, identified there had been no meat products served at breakfast the last two days and that breakfast consisted of hashbrowns and a muffin. There was no sausage gravy served at the breakfast meal. Interview on 04/24/18 at 12:31 p.m. with Resident 23, identified there had been no meat products served at breakfast the last two mornings, there had only been a muffin or biscuit served with hashbrowns and no sausage gravy provided as identified on the menu. Interview on 04/24/18 at 12:42 p.m. with the Registered Dietician verified there was no sausage gravy provided as outlined in the menu for 4-24-18 and that the menu should have been followed. Interview on 04/24/18 at 12:45 p.m. with the Dietary Manager and Kitchen Consultant verified the breakfast Menu on 4-24-18 was not followed as no sausage gravy was prepared or provided to residents.",2020-09-01
695,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,812,F,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interviews the facility failed to: 1) Prevent buildup of condensation and ice where frozen foods were stored inside of the walk in freezer, 2) to provide proper hand hygiene while preparing meals, 3) to keep frozen foods off the freezer floor, and 4) clean the dirt and lent off the ceiling vent located over the center counter in the kitchen. These failures had the potential to affect all residents. Facility census was 39 Findings are: [NAME] 04/24/18 at 11:51a.m. Kitchen observation revealed the walk in freezer was leaking water causing ice built up and condensation on the ceiling, floor and on walls on the inside of the walk in freezer. Chunks of ice were located on the floor making the floor slippery. 04/24/18 at 5:35 p.m. Kitchen observation revealed the walk in freezer was leaking water causing ice built up and condensation on the ceiling, floor and on walls inside of the walk in freezer. Chunks of ice were located on the floor making the floor slippery. 04/25/18 at 8:00 a.m. Kitchen observation revealed the walk in freezer was leaking water causing ice built up and condensation on the ceiling, floor and on walls inside of the walk in freezer. Chunks of ice were located on the floor making the floor slippery. 04/25/18 at 11:00 a.m. Interview with the Administrator, Dietary Manager, and Dietary Consultant verified the walk in freezer was leaking water and causing ice buildup and condensation on the ceiling, floor and walls inside the walk in freezer. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-303.12-(A) Packaged food may not be stored in direct contact with undrained ice. Source: Quality Assurance & Food Safety, (MONTH) (YEAR) quotes the Food and Drug Administration and the United States Department of Agriculture/Food and Safety Inspection Service Related to Condensation in guidance documents with the most recent a draft guidance from the Food Safety Modernization Act. The preventive rule discusses condensation buildup as a hazard for listeria, salmonella, and molds that produce mycotoxins (substances produced by mold growing in food that cause illness or death when ingested by man). B. 04/24/18 at 11:51 a.m. Kitchen observation revealed a box of fish located in the far left side corner of the floor of the walk in freezer. 04/24/18 at 5:35 p.m. Kitchen observation revealed a box of fish located in the far left side corner of the floor of the walk in freezer. 04/25/18 at 8:00 a.m. Kitchen observation revealed a box of fish located in the far left side corner of the floor of the walk in freezer. 04/25/18 at 11:00 a.m. Interview with the Administrator, Dietary Manager, and Dietary Consultant verified a box of fish had been placed on the left side corner of the freezer floor. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Authoritive reference for the food service sanitation practices, revealed the following: 305.11(B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling Equipment as specified under 4-204.122. C. 04/24/18 at 11:51 a.m. Kitchen observation revealed buildup of lent and dirt in the exhaust fan located above the counter top located next to the small kitchen sink island. 04/24/18 at 5:35 p.m. Kitchen observation revealed buildup of lent and dirt in the exhaust fan located above the counter top located next to the small kitchen sink island. 04/25/18 at 8:00 p.m. Kitchen observation revealed buildup of lent and dirt in the exhaust fan located above the counter top located next to the small kitchen sink island. 04/25/18 at 11:00 a.m. Interview with the Administrator, Dietary Manager, and Dietary Consultant verified the exhaust vent located over the sink and counter top had not been cleaned as there was dirt and lent located on it. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Authorities reference for the food service sanitation practices, revealed the following:6-5-1.14(A) Intake and exhaust air ducts shall be cleaned and tilters changed so they are not a source of contamination by dust, dirt and other materials. D. 04/24/18 at 5:35 p.m. Kitchen observation revealed (Cook)-F did not wash hands, use hand sanitizer or wear gloves prior to separating the bread rolls and placing then on resident plates. 04/24/18 at 5:35 p.m. Kitchen observation revealed (Cook)-F did not wash hands, use hand sanitizer or wear gloves prior to taking food temperatures of meat balls, noodles, broccoli, Pizza, and puree foods. (Cook)-F used the same food thermometer and used the same sanitation wipe for the food thermometer on all foods. 04/24/18 at 5:45 p.m. Kitchen observation revealed (Cook)-F did not wash hands, use hand sanitizer or wear gloves prior to separating the brownies and placing them on individual plates. At one point (Cool)-F used thumb on left hand to push brownies onto the plates and then (Cook)-F licked her left thumb off and continued to place brownies on the individual plates. 04/24/18 at 6:15 p.m. Kitchen observation revealed (Cook)-F did not wash hands, or use hand sanitizer prior to placing gloves on her hands. (Cook)-F used the same gloves to serve all foods even after wiping off counter top with them on and handling a dirty dish towel. 04/25/18 at 11:00 a.m. Interview with Administrator, Dietary Manager, and Dietary Consultant verified that (Cook)-F did not follow proper hand hygiene while working in the kitchen in order to prevent cross contamination. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an Authorities reference for the food service sanitation practices, revealed the following: 2-301.14 When to Wash (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.",2020-09-01
696,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,908,D,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.18B1 Based on observation, record review, and interview, the facility failed to provide equipment to meet the needs as specified in the care plan for 1 sampled resident (Resident #23). Census: 39 residents. Sample size: 19 residents. Observation on 04/24/18 01:51 PM revealed the right side adaptive arm rest/cradle was unsecured and not functional for use or positioning for the right arm of Residents #23. The covering was frayed, the zipper was broken and dangling, and the cloth around the zipper area was torn and hanging down and off the rest. Resident #23 had arm covered with blanket, not resting on adaptive arm rest/cradle. On 04/24/18 at 02:00 PM record review of the care plan for Resident #23 revealed that the staff ensure that (Resident #23) wheelchair is in good repair and available at all times Interview on 04/24/18 at 01:51 PM with Resident #23 confirmed that the right side adaptive arm rest wasn't of use to resident for positioning. Resident reported that the arm rest had been that way for quite a while, that it's really quite frustrating because I can't use it right like this. Interview with the Administrator confirmed that the right side adaptive arm rest/cradle for the wheelchair for Resident #23 is not functional for resident to utilize properly as arm rest, that it isn't secured, and that the covering to arm rest is frayed, torn and in disrepair.",2020-09-01
697,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2018-04-30,925,F,0,1,9I0Q11,"Licensure Reference Number: 175 NAC 12-006.18A(4) Based on observations and interviews the facility failed to prevent the entrance of rodents into the food pantry. This failure had the potential to affect all residents. Facility census was 39. Findings Are: [NAME] Observation on 04/24/18 at 5:30 p.m. mouse droppings and nesting materials were located in the corner of the pantry next to the mouse trap as well as across the room under some shelving close to the Kitchen door. Observation on 04/25/18 at 8:00 a.m. mouse droppings and nesting materials were located in the corner of the pantry next to the mouse trap as well as across the room under some shelving close to the Kitchen door. Interview on 4/25/18 at 11:00 a.m. with the Administrator, Dietary Manager and Dietary Consultant Verified the mouse droppings located in the food pantry in two different areas. B. Observation on 04/25/18 at 10:52 AM revealed there were bugs in the lighting covers throughout the facility's east and west halls, on both the north and south wings, and in the main dining area. Interview on 04/25/18 at 10:52 AM with the Administrator and Maintenance supervisor confirmed that there were bugs in the lighting covers throughout the facility's east and west halls, on both the north and south wings, and in the main dining area.",2020-09-01
698,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,253,E,0,1,NVXB11,"Licensure Reference Number: 175 NAC 12-006.18B Based on observation and interview, the facility failed to 1) repair damaged to walls in rooms occupied by Residents 37, 13, 10, 39, 5, 48, 33, 40, and 32; 2) clean or replace rusty sink drains for bathrooms occupied by Residents 3, 19, 33, and 48; 3) clean or replace stained floor tile in the bathroom occupied by resident 12; and 4) replace cracked floor tiling in the room occupied by Residents 3 and 19. Facility census was 40 with 30 resident room sampled. Findings are: Observation of resident rooms on 5/30/17 between10 AM and 4 PM, on 5/31/17 from 7AM to 11AM, and 6/1/17 at 10 AM revealed the following: - Rooms occupied by Residents 37, 13, 10, 39, 5, 48, 33, 40, and 32 revealed the walls to the rooms were scraped and gouged exposing underlying surfaces. - Bathroom sinks in rooms occupied by Residents 3, 19, 33, and 48 contained rust around the rims of the drains. - The bathroom floor tiles were stained around the base of the toilet in the room occupied by Resident 12. -That the floor tile in the room occupied by Residents 3 and 19 was cracked and gouged. Interview with the Maintenance Director on 6/1/17 at 1-AM confirmed the following: - The walls the rooms occupied by Residents 37, 13, 10, 39, 5, 48, 33, 40, and 32 were scraped and gouged exposing underlying surfaces. - The bathroom sinks in the rooms occupied by Residents 3, 19, 33, and 48 contained rust around the rims of the drains. - The bathroom floor tiles were stained around the base of the toilet in the room occupied by Resident 12. - The floor tile in the room occupied by Residents 3 and 19 was cracked and gouged.",2020-09-01
699,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,279,D,0,1,NVXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C1b Based on record reviews and interview, the facility failed to ensure that care plans were developed to address anxiety and depression for one sampled resident (Resident 48). The facility census was 40 with five residents sampled for medication review. Findings are: Review of the Admission Record, printed 5/31/17, revealed that Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed an order, dated 11/8/16, for [MEDICATION NAME] (antidepressant medication) daily. Review of the care plan, target date 4/29/17, revealed no care plan to address anxiety or depression. Interview with the Director of Nursing on 6/1/17 at 9:00 AM confirmed that care plans should have been developed to address the resident's anxiety and depression.",2020-09-01
700,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,329,D,0,1,NVXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interview, the facility failed to identify and monitor symptoms of anxiety and depression for one sampled resident (Resident 48) on routine antianxiety and antidepressant medications to ensure that the resident received the therapeutic benefits of the medications. The facility census was 40 with five residents sampled for medication reviews. Findings are: Review of the Admission Record, printed 5/31/17, revealed that Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed an order, dated 11/8/16, for [MEDICATION NAME] (antidepressant medication) daily. Review of the electronic medical record, including progress notes, revealed no evidence that the resident's specific symptoms of anxiety or depression were identified or monitored. Interview with the Director of Nursing on 6/1/17 at 9:00 AM confirmed that the resident's symptoms of anxiety and depression were not identified or monitored to ensure the therapeutic benefits of the medications.",2020-09-01
701,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,371,F,0,1,NVXB11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observations, record review, and interviews, the facility failed to: 1) keep the kitchen floor free from dirt and food particles; 2) clean the vent hoods above the stove to prevent buildup materials; 3) repair a cracked ceiling in the kitchen; 4) prevent the walk-in freezer from buildup of rust; and 5) ensure the snack refrigerator for one of two halls (Front Hall) was cleaned. These failures could potentially affect all residents of the facility. Census was 40. Findings: [NAME] Observations on 5/30/17 at 10:00 a.m. and 6/1/17 at 6:30 a.m. revealed the following: - Dirt and food particles on the kitchen floor, A buildup of dirt, food particles, and debris across the kitchen floor; A buildup of gray fuzzy material on the vent hood above the stove; - The ceiling of the kitchen with cracks, discolored paint, and chips of peeling paint, and - A rust buildup surrounding the outside door of the walk-in freezer. Interview with the Dietary Manager and Facility Consultant on 6/1/17 at 9 a.m. confirmed that the floors in the kitchen were not clean, there was gray fuzzy build up on the vents above the stove, the ceiling had cracks and it was discolored, and the freezer walk-in door had rust on the outside of it. Review of the 7/21/2016 version of the Food Code, based on the United States Food Code and used as an authoritative reference for the food service sanitation practices, revealed the following: -6-501.12 Cleaning, Frequency and Restrictions. (A) Physical facilities shall be cleaned as often as necessary to keep them clean. -6-101.11 Indoor Areas, Surface Characteristics: (A) materials for indoor floor, wall and ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and easily cleanable for areas where FOOD ESTABLISHMENT operations are conducted. B. Observations of the front hall medication room on 5/31/17 at 10:15 AM revealed a snack refrigerator with multiple spills and stains on the floor of the refrigerator and on the storage sections on the door. Interview with RN (Registered Nurse) - A on 5/31/17 at 10:15 AM confirmed that the refrigerator was used for snacks and nourishments for more than two residents on the front hall. RN - A confirmed that the refrigerator needed to be cleaned. Interview with the Director of Nursing (Infection Control Nurse) on 6/1/17 at 8:45 AM confirmed that the snack refrigerator needed to be cleaned routinely to reduce the risk of cross contamination. Reference: Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-305.11 Food Storage. (A) Food shall be protected from contamination by storing the food in a clean, dry location.",2020-09-01
702,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,425,E,0,1,NVXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.10A2 Based on observations and interviews, the facility failed to ensure that the medication nurses compared the prescription labels on the medication cards to the physician orders [REDACTED]. The facility census was 40 with five residents sampled for medication administration. Findings are: Observations of the medication pass on 5/31/17 at 8:35 AM - 8:50 AM revealed LPN (Licensed Practical Nurse) - B prepared to administer medications for Resident 44. Further observations revealed LPN - B removed the medication cards from the medication cart, compared the prescription label one time with the physician orders [REDACTED]. LPN-B administered the medications, returned to the medication cart, placed the medication cards back to the drawer and signed off on the MAR indicated [REDACTED]. Observations of the medication pass on 6/1/17 at 8:15 AM revealed RN (Registered Nurse) - C administered medications for Resident 48. RN - C removed the medication cards from the medication cart, compared the prescription label with the physician orders [REDACTED]. RN-C administered the medications and returned to the medication cart to document that the medications were administered. Interview with LPN - B on 5/31/17 at 3:30 PM confirmed that the medication orders on the prescription label should be compared to the physician's orders [REDACTED]. Interview with the Director of Nursing on 6/1/17 at 8:45 AM confirmed that the nurses were to compare the medication order on the prescription label with the physician's orders [REDACTED].",2020-09-01
703,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,431,E,0,1,NVXB11,"Licensure Reference Number: 175 NAC 12-006.12E1 Based on observations, record review and interviews; the facility failed to ensure that the refrigerator, used for medication storage in the medication room, temperatures were monitored and documented at least daily to ensure the integrity of the medications stored in the refrigerator. The facility census was 40 with more than two residents' medications stored in the refrigerator. The facility census was 40 residents. Findings are: Observations of the medication room on the back hall on 5/31/17 at 10:15 AM revealed a Refrigerator Temps (Temperatures) log posted on the medication storage refrigerator. Further observations revealed individual prescribed medications and stock medications stored in the refrigerator. Review of the Refrigerator Temps log revealed no temperature recorded on 5/4/17, 5/5/17, 5/11/17, 5/12/17, 5/18/17, 5/18/17, 5/20/17, 5/21/17 and 5/2317 - 5/30/17. Interview with LPN (Licensed Practical Nurse) - B, Charge Nurse, on 5/31/17 at 10:15 AM revealed that the temperature of the medication storage refrigerator was to be monitored and recorded on the temperature log at least daily. Interview with the Director of Nursing (Infection Control Nurse) on 6/1/17 at 8:50 AM confirmed that the nurses were to obtain and record the temperature of the medication storage refrigerator at least daily to ensure the integrity of the medications stored in the refrigerator.",2020-09-01
704,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,441,E,0,1,NVXB11,"Based on observations and interviews, the facility failed to ensure that 1) hand washing was done after disposable gloves were removed and before continuing with other tasks for one sampled resident (Resident 21), 2) opened distilled water containers located in the back hall medication room were dated when opened and 3) respiratory equipment was cleaned and covered after use for one sampled resident (Resident 53) to reduce the risk of cross contamination. The facility census was 40 with 21 residents currently residing on the back hall and 30 sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.17D [NAME] Observations on 5/30/17 at 12:00 PM revealed RN (Registered Nurse) - A donned disposable gloves for blood sugar testing for Resident 21. Further observations revealed RN - A removed the disposable gloves, returned to the medication cart and prepared an insulin injection without washing hands or using an alcohol based gel. Interview with the Director of Nursing (Infection Control Nurse) on 6/1/17 at 8:40 AM confirmed that the nurses were to wash hands after disposable gloves were removed and before continuing with another task to reduce the risk of cross contamination. Licensure Reference Number 175 NAC 12-006.17B B. Observations of the back hall medication room on 5/31/17 at 10:15 AM revealed two opened, undated gallon containers of distilled water on the counter. Interview with LPN (Licensed Practical Nurse) - B, Charge Nurse, on 5/31/17 at 10:15 AM revealed that the distilled water was probably used to fill the humidifier containers on the oxygen concentrators for unidentified residents on the back hall. Interview with the Director of Nursing (Infection Control Nurse) on 6/1/17 at 8:40 AM confirmed that the containers of distilled water were to be dated when opened and any water not used after 30 days was to be discarded to reduce the risk of cross contamination. C. Observation on 5/30/17 at 10:30 a.m. revealed Resident 53's Nebulizer was left sitting on the dresser intact (not taken apart), cleaned or covered. Observation on 5/31/17 between 7:45 a.m. and 9:45 a.m. revealed Resident 53''s nebulizer was left on the dresser without being cleaned. Observation on 6/1/17 at 7:45 a.m. revealed Resident 53's nebulizer was not cleaned or covered after use. On 6/1/17 at 11:43 a.m., an interviewed the Director of Nursing and facility Nursing consultant confirmed that the nebulizer wasn't cleaned or covered after use for Resident 53.",2020-09-01
705,INDIAN HILLS MANOR,285091,1720 NORTH SPRUCE,OGALLALA,NE,69153,2017-06-01,469,F,0,1,NVXB11,"Licensure Reference Number: 175 NAC 12-006.18A(4) Based on observation and interview, the facility failed to prevent the entrance of mice in the dry storage of the kitchen. This failure could affect food storage for all residents. Facility census was 40. Findings are: Observation of the kitchen on 5/30/17 at 10:30 a.m. revealed there were mouse traps on the bottom shelf and in the corner of the dry storage. Observation of the kitchen on 6/1/17 at 6:30 a.m. revealed there was evidence of mouse traps in the back pantry and in the corner of the dry storage area where there were also mouse droppings -Interview 6/1/17 at 9:00 a.m. with the dietary manager and facility consultant confirmed that there were mouse droppings in the corner of the dry storage area of the kitchen.",2020-09-01
706,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,166,E,0,1,FF7611,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.06B Based on observation, record review and interview; the facility failed to resolve grievances regarding call light response. The sample size was 46 and the facility census was 87. Findings are: [NAME] Review of the facility Grievance Tracking Logs from 1/13/17 through 6/16/17 revealed the following concerns regarding call light response: -1/13/17-Resident 51 reported staff answered the call light and stated they would return in 5 minutes but did not come back and the resident had to put the call light on again; -3/17/17-Resident 125's family member voiced a concern regarding the timeliness of call light response in the evening; -4/15/17-Resident 132's family member reported the call light was on for 20 minutes at 4:00 PM and for 30 minutes at 9:00 PM that day; -4/26/17-Resident 98's family member reported the call light was not being answered; -5/12/17-Resident 37 reported the call light was on at night for a long time; -5/22/17-Resident 49's family member reported the resident stated the call light was not answered for 20 minutes; and -5/24/17-Resident 62's family member reported a staff member turned off the call light and left the room without assisting the resident. B. Review of Resident Council Minutes dated 3/27/17 revealed 10 residents voiced concerns that call lights were not being answered and/or needs were not being met when the call light was answered. Review of Resident Council Minutes dated 4/27/17 (with 12 residents in attendance) revealed the call light response issues were not resolved. Documentation indicated When call lights are answered needs are not met. Staff say they will be back, turn off light and never return. Review of Resident Council Minutes dated 5/30/17 revealed the concerns with call light response were not addressed. C. 7 of 20 confidential resident interviews conducted between 10:45 AM on 6/14/17 and 1:15 PM on 6/15/17 voiced concerns regarding call light response. Comments included the following: -Put call light on and had to wait 30 minutes. They don't always take time to meet your needs; -Wait a long time to get staff to assist and last night it took 2 hours. Staff came in and shut off the light and stated they would be right back but did not come back. The resident made repeated attempts until they provided assistance; and -Call light response takes 30 minutes. D. 2 confidential family interviews conducted between 1:13 PM on 6/14/17 and 6/20/17 at 1:40 PM revealed the following: -1 family member reported they had filed a number of grievances with the facility which were not resolved; and -Another family member reported it took at least 45 minutes before the call light was answered. The family member indicated they had complained about this to the facility. E. Observations and interview with Resident 140 on 6/20/17 revealed the following: -Resident 140's call light was on from 7:15 AM until 7:33 AM (18 minutes); -Resident 140's call light was on at 9:05 AM. The call light was turned off at 9:10 AM but the resident turned the call light on again at 9:11 AM. Nursing Assistant (NA)-N then entered the resident's room, turned off the call light and exited the room; -At 9:13 AM Resident 140 reported using the call light to ask for assistance to the toilet. Resident 140 indicated NA-N turned off the call light and stated (NA-N) would be right back. Resident 140 stated staff frequently enter the room, turn off the call light, state they will be right back and then leave the room. Resident 140 further indicated staff don't come back right away which caused the resident to have urine incontinence. Resident 140 proceeded to turn the call light back on; -Resident 140's call light was on from 9:13 AM until 9:17 AM when NA-I entered the room. Resident 140 requested assistance to the toilet. NA-I stated they needed to help another resident and would be back to assist Resident 140. NA-I turned off the call light and exited the room; -Resident 140 turned the call light back on at 9:24 AM; -At 9:34 AM the call light was off and NA-I and NA-N provided toileting assistance (29 minutes after the resident first called for assistance to the toilet); -At 9:46 AM the resident turned on the call light for assistance off of the toilet; -At 10:06 AM Registered Nurse P entered Resident 140's room, turned off the call light and exited the room; and -At 10:19 AM NA-I and NA-N entered Resident 140's room to assist the resident off of the toilet (33 minutes after the resident called for assistance to transfer off of the toilet).",2020-09-01
707,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,176,D,0,1,FF7611,"LICENSURE REFERNCE NUMBER 175 NAC 12-006.10A2 Based on observation, record review, and interview; the facility failed to assess Resident 46 to determine if the resident could safely self-administer insulin. The sample size was 46 and the facility census was 87. Findings are: Review of Resident 46's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/28/17 revealed the resident had a Brief interview for Mental Status score of 12 ( BIMS is a test used to determine cognitive status with a score of 8-12 indicating moderately impaired cognition). Review of Resident 46's Medication Administration Record [REDACTED] -V-Go 30 Kit (disposable insulin pump) apply to abdomen topically in the morning; -Remind the resident to give the bolus dose (sliding scale amount- amount of insulin given varies based on the blood sugar reading) of insulin by pump prior to meals; and -Check blood sugars before each meal and at bed time. Inform the resident what the reading was and the resident would give the bolus dose of insulin using the insulin pump. On 6/19/17 at 11:16 AM, Licensed Practical Nurse (LPN)-W was observed to enter Resident 46's room and informed the resident of a blood sugar reading of 210 and indicated that the resident would need to administer 6 units of insulin per the physician's sliding scale orders. Resident 46 then pushed the bolus ready button which caused the bolus delivery button to pop out. The bolus delivery button was then pushed in to inject the insulin, and then repeated the process. The resident did lose count and needed to be reminded of the number of units by LPN-W. Resident 46 also was unable to tell if the bolus ready button had been pushed far enough to get the bolus delivery button to pop out. If the bolus delivery button did not pop back out, it would not deliver any more insulin when pushed. In addition as the insulin pump was attached to the resident, the resident could administer insulin at any time. Review of the facility policy titled Self-Administration of Medications dated 06/2015 revealed if a resident desired to self-administer medications, an assessment was conducted by an interdisciplinary team to assess the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility. This assessment needed to be done at least quarterly and anytime there was a significant change in the resident's condition. The determination also needed to address the bedside storage of the medication. During interviews with the Assistant Director of Nursing (ADON) on 6/20/17 at 2:30 PM and 6/21/17 at 8:15 AM, the ADON confirmed a self-administration assessment had not been completed for Resident 46.",2020-09-01
708,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,223,E,1,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observations, record review and interview, the facility failed to ensure Residents 29, 96, 115, and 74 were protected from abuse. The sample size was 46 and the facility census was 87. Findings are: [NAME] Review of the facility policy titled Abuse Prohibition Policy and Procedure (undated) revealed it was the policy of the facility to take appropriate steps to prevent occurrence of abuse and to assure all alleged allegations of abuse were reported immediately to the Administrator of the facility. In addition, the allegations were to be reported to state agencies in accordance with existing state law. The Administrator or designee would complete a thorough investigation of each allegation and report all investigations to the state agency as required by state and federal law. If circumstances required it, a resident suspected of being the subject of abuse would be removed to a safe environment where the resident would be protected. If the suspected perpetrator was another resident, the residents would be kept separated so they had no access to each other, until the incident was investigated. If the suspected perpetrator was an employee, the employee was to be placed on immediate suspension while the investigation was being completed. B. Review of Resident 29's Nursing Progress Notes dated 6/14/17 at 8:35 PM, revealed the resident was involved in a physical altercation with Resident 96. The note indicated Resident 29 was aware of the resident's personal space and surroundings and reacted negatively when Resident 96 entered Resident 29's space. Resident 29 was assessed with [REDACTED]. Review of Resident 29's current Care Plan (undated) revealed the resident had a [DIAGNOSES REDACTED]. The Care Plan identified a resident to resident altercation on 6/14/17 with a new intervention for a Stop sign to be placed across the door of the resident's room. Review of Resident 96's Nursing Progress Notes dated 6/14/17 at 8:35 PM, revealed the resident had been involved in a physical altercation with Resident 29. The note further indicated the resident had a [DIAGNOSES REDACTED]. The resident was a wanderer and ambulated freely throughout the unit. Resident 96 was assessed with [REDACTED]. Review of Resident 96's current Care Plan (undated) revealed the resident had a [DIAGNOSES REDACTED]. The resident had behaviors which included wandering and occasional agitation. The Care Plan identified a resident to resident altercation on 6/14/17 with new interventions to complete every 15 minute checks on the resident for 24 hours and to place a large sign on the resident's door to help the resident identify own room. Observations on 6/15/17 from 7:30 AM to 9:30 AM, revealed the following: -No sign with Resident 96's name was noted on Resident 96's room door to indicate placement of the resident's room. -No Stop sign was observed across the entrance of Resident 29's room. Review of Resident 29's medical record revealed no evidence that 15 minute checks had been completed after the resident to resident altercation with Resident 96 to assure the resident's location. Review of Resident 96's medical record revealed no evidence the staff had completed visual checks every 15 minutes of the resident to assure no further altercations with Resident 29 occurred. Interview with the Alzheimer's Unit Coordinator on 6/15/17 from 9:30 AM to 10:00 AM, revealed the Coordinator had not been notified of the resident to resident altercation between Resident 29 and Resident 96 and indicated the incident had not been acknowledged during morning report. The Coordinator was also unaware of the intervention for every 15 minute visual checks of the residents and verified there was no evidence to indicate the checks were completed. C. Review of Resident 115's Nursing Progress Note dated 6/8/17 at 2:52 AM, revealed the resident had pushed the call light to seek assistance with toileting. The resident started to cry and indicated was going to report staff for coming in here and jumping all over me. Review of a facility investigation of a potential allegation of staff to resident abuse dated 6/8/17 revealed at 2:52 AM, Resident 115 indicated Nursing Assistant (NA)-Y came into the resident's room and had jumped all over the resident. Documentation revealed NA-Y continued to attempt to provide cares for the resident but the resident became verbally abusive to staff. NA-Y exited the resident's room and NA-Z then assisted the resident. Resident 115 reported to NA-Z that NA-Y was verbally abusive to the resident. Further review of the investigation revealed Resident 115 had a [DIAGNOSES REDACTED]. The report indicated NA-Y was not to work on the Alzheimer's Care Unit (ACU) until after the investigation was completed. During an interview on 6/19/17 from 9:05 AM to 9:20 AM, Resident 115 identified NA-Y had been rude to the resident. Resident 115 further identified NA-Y made the resident feel the resident was a lot of trouble and it was apparent staff did not want to help the resident. Resident 115 indicated NA-Y continued to work on the ACU for about a week after Resident 115 reported the staff's behavior but Resident 115 had not seen the staff since that time. During an interview on 6/20/17 from 9:00 AM to 9:20 AM, the Director of Nursing (DON) verified NA-Y remained on the nursing schedule after the allegation of potential staff to resident abuse. NA-Y was not allowed to work with Resident 115 but continued to provide cares for other residents. D. Review of a facility investigation of a potential allegation of staff to resident abuse dated 6/16/17 revealed Resident 74 reported an incident which occurred at 5:30 AM on 6/12/17 involving NA-Y (4 days after Resident 115 had complained of verbal abuse by NA-Y). Documentation indicated the resident reported NA-Y told the resident .You're worse than my children. Resident 74 further reported NA-Y got close to the resident's face and NA-Y made a hand gesture by holding fingers an inch apart. NA-Y told the resident, I'm this close . The resident denied feeling threatened and stated .I wasn't afraid or anything because I can handle myself. Interview with the Administrator on 6/21/17 from 7:25 AM to 7:45 AM confirmed NA-Y had been allowed to work following Resident 115's report of verbal abuse on 6/8/17. The Administrator confirmed NA-Y was not suspended until after a complaint was received from Resident 74 regarding mistreatment by NA-Y.",2020-09-01
709,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,225,D,1,1,FF7611,"**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 report and investigate an incident of potential abuse/neglect for 1 resident (Resident 115) out of 46 sampled residents. The facility census was 87. Findings are: [NAME] Review of the facility policy titled Abuse Prohibition Policy and Procedure (undated) revealed it was the policy of the facility to take appropriate steps to prevent occurrence of abuse and to assure all alleged allegations of abuse were reported immediately to the Administrator of the facility. In addition, the allegations were to be reported to state agencies in accordance with existing state law. The Administrator or designee would then complete a thorough investigation of each allegation and report all investigations to the state agency as required by state and federal law. If circumstances require it, a resident suspected of being the subject of abuse shall be removed to a safe environment where the resident would be protected. If the suspected perpetrator is another resident, the residents will be kept separated so they have no access to each other, until the incident is investigated. If the suspected perpetrator is an employee, the employee will be placed on immediate investigatory suspension while investigation is completed. B. Review of Resident 115's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/3/17 identified the resident's cognition was moderately impaired with [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive staff assistance with toileting and transfers and had behaviors which included verbal behaviors directed at others. Review of Resident 115's Nursing Progress Notes dated 6/8/17 at 11:36 PM, revealed the resident had pulled the call light and when Nursing Assistant (NA)-Z responded, the resident was upset. Further review of the Progress Note revealed the resident had told NA-Z to get out. NA-Z then left the resident's room. NA-Z returned to assist the resident, but the resident remained agitated. NA-Y went into the resident's room to try and provide assist. Resident 115 told NA-Y to leave the room as well. NA-Z returned to the resident's room after several minutes and the resident indicated staff were picking on me. Resident 115 stated, She is going to kill me and I don't want her in my room anymore. Resident 115 did not become calm until NA-Z reassured the resident that NA-Y would not return to the resident's room. Review of the facility investigations of potential abuse/neglect from 1/1/17 through 6/20/17 revealed no evidence Resident 115's allegation of potential staff to resident abuse was reported to the State agency and there was no evidence an investigation was completed. Interview with the Administrator on 6/21/17 at 9:30 AM, confirmed the State agency was not informed of Resident 115's allegation of potential staff to resident abuse and an investigation had not been completed.",2020-09-01
710,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,248,D,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5b Based on observation, record review and interview; the facility failed to provide individualized activities for 1 (Resident 44) of 46 sampled residents. The facility census was 87. Findings are: Review of Resident 44's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 5/9/17 identified [DIAGNOSES REDACTED]. The assessment further indicated the resident had severe cognitive impairment, displayed behaviors which included physical behaviors directed at others and episodes of wandering which occurred on a daily basis and required extensive staff assistance with activities of daily living. Review of Resident 44's current Care Plan dated 3/27/17 revealed the resident had the potential for impaired socialization related to the resident's dependence on staff for emotional, intellectual, physical and social stimulation. The resident had a cognitive deficit related to dementia with a short attention span. Interventions included: -All staff to converse with resident while providing cares; -Encourage family involvement and invite family to events, activities and meals; and -Resident enjoys music, holding baby dolls and stuffed animals, 1:1 (one to one) grooming such as nail-care, massages and back rubs. Observations on 6/19/17 revealed from 10:00 AM to 10:30 AM, a group exercise activity was held in the Alzheimer's Care Unit (ACU) dining room. Observations of Resident 44 on 6/19/17 from 10:00 AM to 10:30 AM, revealed the resident was propelling the resident's wheelchair up and down the ACU corridor. Observations on 6/20/17 at 9:00 AM, revealed a group of residents were assisted with a group exercise activity in the ACU dining room. Observations on 6/20/17 revealed from 10:00 AM to 11:00 AM, residents on the ACU were assisted with playing games, coloring and/or working on puzzles in the dining room. Observations of Resident 44 on 6/20/17 from 9:00 AM to 11:00 AM, revealed the resident was seated in a wheelchair in the corridor of the ACU. The resident propelled the wheelchair up and down the corridor. The resident would intermittently stop and close eyes for a few minutes, before resuming repetitive movement up and down the corridor. Record review of the activity calendar for (MONTH) of (YEAR) revealed on 6/20/17 at 3:00 PM, Bingo was offered. Observation of Resident 44 on 6/20/17 at 3:00 PM, revealed Resident 44 remained seated in a wheelchair. The wheelchair was parked in the ACU corridor. The resident's eyes were closed and the resident was leaning forward as if the resident was asleep. Review of Resident 44's individual activity participation for (MONTH) of (YEAR) revealed no documentation to indicate the resident attended any of the offered activities on the ACU. On 6/21/17 at 9:00 AM, an interview was conducted with the ACU Coordinator. The Coordinator identified no assessment had been completed for Resident 44 to determine the resident's activity preferences and confirmed the resident's current activity program did not address the resident's behaviors and psychosocial needs.",2020-09-01
711,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,253,E,0,1,FF7611,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A (1) Based on observation and interview, the facility failed to ensure: 1) Bathroom vents were free from dust; 2) Bathroom flooring was in good repair and; 3) A bathroom door and wall were in good repair. This affected 5 residents (Residents 115, 11, 68, 100, and 82). The sample size was 46 and the facility census was 87. Findings are: Observations of residents' rooms during the environmental tour on 6/20/17 from 10:30 AM to 11:15 AM with the Housekeeping Supervisor, Maintenance Director, and the Interim Administrator revealed the following: -Resident 115's bathroom vent was covered with dust. -Resident 11's bathroom vent was covered with dust. -Resident 68's bathroom vent was covered with dust. -Resident 100's bathroom vinyl flooring had a crack in it measuring 3-4 foot long. -Resident 82's bathroom door was missing a large piece of exterior finish and the dry wall at the base of the wall was falling off with pieces of drywall on the floor. Interviews with the Housekeeping Supervisor and the Interim Administrator on 6/20/17 from 10:30 AM to 11:15 AM confirmed the bathroom vents were dusty and needed cleaned, the vinyl flooring in Resident 100's room needed repaired, and the bathroom wall and bathroom door in Resident 82's room needed repaired/replaced.",2020-09-01
712,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,280,E,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1C Based on observation, interview, and record review; the facility failed to ensure Care Plans were revised to address: 1) Resident 35's incontinence management: 2) Resident 82's oral cares: 3) Resident 53's positioning preferences; 4) Resident 10's problems with bruises and skin tears; and 5) Resident 140's use of a mechanical lift with transfers. The sample size was 46 and the facility census was 87. Findings are: [NAME] Interview with Nursing Assistant (NA)-I on 6/19/17 at 2:00 PM revealed Resident 35 was provided incontinent cares right after lunch (1:00 PM) because the resident was very dirty. Further interview confirmed the resident was last checked at approximately 9:30 AM and then was not checked or changed until 1:00 PM (3.5 hours later). Interview with Registered Nurse (RN) - O on 6/21/17 at 8:45 AM confirmed Resident 35 was incontinent of bladder and the resident's incontinence product should be checked every 2 hours and as needed. Review of Resident 35's undated Care Plan did not indicate the resident was to be on a 2 hour check and change program due to incontinence. B. During observation of cares on 6/20/17 at 9:20 AM with NA-S, NA-S swabbed Resident 82's mouth with a toothette and then assisted the resident with mouthwash. NA-S stated the resident did have a toothbrush but the resident's gums had become sore, so NA-S used a toothette instead. NA-S was unable to find a toothbrush or toothpaste for the resident. Review of Resident 82's undated Care Plan did not reveal how staff were to complete oral cares for Resident 82. C. Resident 53 was observed in bed on 6/19/17 from 7:00 AM until 3:00 PM. During an interview on 6/20/17 at 11:30 AM, NA-R (the staff member responsible for Resident 53), confirmed Resident 53 only got out of bed on Tuesdays, Thursdays, Saturdays, and Sundays. NA-R was unsure of the reason Resident 53 only got out of bed 4 days per week. Review of Resident 53's undated Care Plan revealed no indication that the resident was only to be out of bed 4 days per week. D. Review of Resident 101's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/6/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had open [MEDICAL CONDITION] on the foot with application of dressings. Review of Resident 101's Progress Notes dated 5/27/17 at 5:20 AM revealed the resident was found sitting on the edge of the bed with a skin tear on the right hand which measured 2.0 centimeters (cm) x (by) .9 cm. Documentation indicated the resident commented about hitting it (the hand) on the bed. On 6/14/17 at 11:39 AM, Resident 101 was observed with bruising on the top of both hands and steri-strips (a brand of medical tape used to close wounds) were in place on the top of the right hand. On 6/19/17 at 8:00 AM, Resident 101 was observed with multiple areas of bruising on the top of both hands and forearms. Steri-strips were in place on the top of the resident's right hand. Review of a Weekly Skin Check (skin assessment) dated 6/16/17 at 12:48 AM revealed Resident 101 had a 5.0 cm x 2.0 cm skin tear on the left ankle. Review of Resident 101's Progress notes dated 6/19/17 at 5:16 PM revealed a 2.0 cm x 2.0 cm blister was noted to the resident's right medial calf (lower leg). RN-C was observed to complete Resident 101's skin treatments on 6/20/17 from 11:25 AM until 11:40 AM. The resident had a blistered area on the right lower leg and a skin tear on the back of the left ankle along the Achilles tendon area which was approximately 5 cm in length and 2 cm in width. Interview with RN-C and Resident 101's family member on 6/20/17 at 11:40 AM revealed the resident had a history of [REDACTED]. The resident's family member commented the resident's skin tears of the legs were possibly caused by friction as a result of the continuous movement of the legs. RN-C indicated the wound on the back of the resident's left ankle may have been caused by rubbing it across the foot pedal of the wheelchair. Review of the Care Plan (undated) revealed a goal for Resident 101's skin to remain intact. Interventions included the following: -Conduct weekly skin inspection; -Encourage to float heels (a resident's heel is positioned in such a way to remove all contact between the heel and the bed or any firm surface); and -Treatments as ordered. Further review of Resident 101's Care Plan (undated) revealed no evidence additional interventions for the prevention of bruising and/or skin tears were developed and implemented. Interview with RN-O on 6/20/17 at 10:52 AM confirmed Resident 101's Care Plan had not been revised to address additional interventions for the prevention of bruises and skin tears. E. Review of Resident 140's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact and required extensive assistance with transfers. Review of Resident 140's Care Plan (dated 5/12/17) revealed the resident required 1 to 2 assists with transfers. Interview with Resident 140 on 6/20/17 at 9:13 AM revealed staff used a mechanical lift to transfer the resident out of the wheelchair. Further review of Resident 140's Care Plan (dated 5/12/17) revealed no evidence the use of a mechanical lift for transfers was addressed.",2020-09-01
713,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,309,D,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2c Based on record review, observation and interview; the facility failed to assess causal factors for bruises and skin tears sustained by Resident 101 and additional interventions were not developed for the prevention of future skin injuries. The sample size was 46 and the facility census was 87. Findings are: Review of Resident 101's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/6/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had open [MEDICAL CONDITION] on the foot with application of dressings. Review of the Care Plan (undated) revealed a goal for Resident 101's skin to remain intact. Interventions included the following: -Conduct weekly skin inspection; -Encourage to float heels (a resident's heel is positioned in such a way to remove all contact between the heel and the bed or any firm surface); and -Treatments as ordered. Review of Resident 101's Progress Notes dated 5/27/17 at 5:20 AM revealed the resident was found sitting on the edge of the bed with a skin tear on the right hand which measured 2.0 centimeters (cm) x (by) .9 cm. Documentation indicated the resident commented about hitting it (the hand) on the bed. On 6/14/17 at 11:39 AM, Resident 101 was observed with bruising on the top of both hands and steri-strips (a brand of medical tape used to close wounds) were in place on the top of the right hand. On 6/19/17 at 8:00 AM, Resident 101 was observed with multiple areas of bruising on the top of both hands and forearms. Steri-strips were in place on the top of the resident's right hand. Review of Resident 101's medical record revealed no evidence to indicate the bruises were assessed and monitored. Interview with Registered Nurse (RN)-O on 6/20/17 at 11:25 AM revealed Resident 101 had fragile skin and that the resident had multiple areas of bruising on the hands and arms. RN-O confirmed there was no evidence Resident 101's bruises were assessed and monitored. Review of a Weekly Skin Check (skin assessment) dated 6/16/17 at 12:48 AM revealed Resident 101 had a 5.0 cm x 2.0 cm skin tear on the left ankle. Review of Resident 101's Progress notes dated 6/19/17 at 5:16 PM revealed a 2.0 cm x 2.0 cm blister was noted to the resident's right medial calf (lower leg). The following was observed during observation of Resident 101's skin treatments on 6/20/17 from 11:25 AM until 11:40 AM: -The resident was seated in a recliner with legs and feet elevated on the footrest. The resident's legs and heels were placed directly on the surface of the footrest (the heels were not floated); and -RN-C completed treatments to the blistered area on the resident's right lower leg and the skin tear on the left ankle. The skin tear on the left ankle was observed to be located on the back of the ankle along the Achilles tendon area and was approximately 5 cm in length and 2 cm in width. Interview with RN-C and Resident 101's family member on 6/20/17 at 11:40 AM revealed the resident had a history of [REDACTED]. The resident's family member commented the resident's skin tears of the legs were possibly caused by friction as a result of the continuous movement of the legs. RN-C indicated the wound on the back of the resident's left ankle may have been caused by rubbing it across the foot pedal of the wheelchair. Nursing Assistant (NA)-N was observed to transfer Resident 101 from the recliner into a wheelchair on 6/20/17 at 11:45 AM. After the resident was seated in the wheelchair, NA-N placed the resident's feet on the wheelchair foot pedals. There was no padding in place on the wheelchair foot pedals. This provided the potential for the wound on the back of the resident's left ankle to rest directly on the metal edge of the wheelchair foot pedal when the resident had restless leg movements and extended the left leg. On 6/20/17 at 2:30 PM, Resident 101 was observed seated in the recliner with legs and feet elevated on the footrest. The resident's legs and heels were placed directly on the surface of the footrest and the left Achilles tendon area was resting directly on the edge of the recliner footrest. Review of Resident 101's medical record revealed no evidence interventions for the prevention of bruising and/or skin tears were developed and implemented.",2020-09-01
714,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,312,E,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1C Based on observation, interview, and record review; the facility failed to ensure: 1) Resident 35 was provided incontinence cares; 2) Resident 82 was assisted with transfers, positioning, and oral cares; 3) Resident 53 was provided positioning according to the plan of care; and 4) Toileting assistance was provided for Resident 140. The sample size was 46 and the facility census was 87. [NAME] Review of Resident 35's undated Care Plan revealed the resident had advanced dementia and lower extremity paralysis. Further review revealed the resident wore an incontinence product and required 1-2 assist with toileting. Interview with Nursing Assistant (NA)-I on 6/19/17 at 2:00 PM revealed Resident 35 was provided incontinence cares right after lunch (1:00 PM) because the resident was very dirty. Further interview confirmed the resident was last checked at approximately 9:30 AM and then was not checked or changed until 1:00 PM (3.5 hours later). Interview with Registered Nurse (RN)-O on 6/21/17 at 8:45 AM confirmed Resident 35 was incontinent of bladder and the resident's incontinence product should be checked/changed every 2 hours and as needed. B. Review of Resident 82's undated Care Plan revealed the following: -The resident had alteration in Activities of Daily Living (ADL) status and required a sit to stand lift for transfers; -The resident had natural teeth and required staff assistance with oral cares; and -The resident required assistance with turning and positioning every 2 hours and as needed. Observations of Resident 82 on 6/19/17 revealed the following: -At 7:10 AM the resident was seated in the wheelchair in the resident's room; -From 7:37 AM until 9:17 AM the resident was sleeping in the wheelchair in the dining room; -At 9:17 AM the resident was assisted back to the resident's room and remained asleep in the wheelchair; -At 9:40 AM the resident remained asleep in the wheelchair, with the resident hunched forward and to the right side; -At 10:31 AM, 11:13 AM and 11:45 am, the resident remained asleep and hunched over in the wheelchair; and -At 12:43 PM the resident was awake and seated in the wheelchair in the dining room. During an interview with Nursing Assistant (NA)-S on 6/20/17 at 7:20 AM, NA-S verified working on 6/19/17 and was unsure why the resident did not get laid down between breakfast and lunch despite being asleep in the wheelchair. Further interview confirmed the resident should be laid down in bed if sleeping after meals. During observation of cares on 6/20/17 at 9:20 AM with NA-S, NA-S swabbed the resident's mouth with a toothette and then assisted the resident with mouthwash. NA-S stated the resident did have a toothbrush but the resident's gums had become sore, so NA-S used a toothette instead. NA-S was unable to find a toothbrush or toothpaste for the resident. NA-S then transferred Resident 82 from the wheelchair to the bed with a gait belt. NA-S tried multiple times unsuccessfully to get the resident to stand up during the transfer. After multiple attempts, NA-S held on to the gait belt and positioned NA-S's arms under Resident 82's arm pits and lifted the resident upwards to assist the resident to bed. During an interview with NA-V on 6/20/17 at 12:15 PM, NA-V revealed that NA-V also transferred Resident 86 with 1 staff assistance with a gait belt. Interview with the Assistant Director of Nursing on 6/21/17 at 9:45 AM confirmed Resident 86 should be transferred with the sit to stand lift. C. Review of Resident 53's undated Care Plan revealed the resident had an alteration in ADL status and required staff assistance with cares. Further review revealed the resident required 2 staff assistance with positioning. On 6/20/17 Resident 53 was observed at 7:00 AM, 7:30 AM, 8:00 AM, 8:30 AM, 9:15 AM, 9:55 AM, 10:30 AM, 11:15 AM, and 11:30 AM lying supine (lying on the back or face upward) in bed with the resident's left arm on top of the sheet and a pillow tucked under both sides of the resident. There was no evidence to indicate the resident had changed positions during this time (4.5 hours). During an interview on 6/20/17 at 11:30 AM with NA-R (the staff member responsible for Resident 53), NA-R confirmed Resident 53 had not been repositioned. NA-R revealed the NA-R had checked the resident's incontinence product at approximately 9:30 AM, but the resident had not been incontinent. NA-R went on to state the resident was not repositioned at that time because it takes 2 staff to reposition the resident and there was not enough staff available to help reposition Resident 53. D. Review of Resident 140's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact and required extensive assistance with transfers, toileting and personal hygiene. Review of Resident 140's Care Plan dated 5/12/17 revealed the resident required assistance with transfers and toileting and had a history of [REDACTED]. On 6/20/17 Resident 140's call light was observed to be on at 9:05 AM. The call light was turned off at 9:10 AM but the resident turned the call light on again at 9:11 AM. NA-N then entered the resident's room, turned off the call light and exited the room. Interview with Resident 140 at 9:13 AM on 6/20/17 revealed the resident turned on the call light to ask for assistance to the toilet. Resident 140 indicated NA-N turned off the call light and stated (NA-N) would be right back. Resident 140 stated staff frequently enter the room, turn off the call light, state they will be right back and then leave the room. Resident 140 further indicated staff don't come back right away which caused the resident to have urine incontinence. Resident 140 proceeded to turn the call light back on. Observations of Resident 140's care on 6/20/17 revealed the following: -The call light was on from 9:13 AM until 9:17 AM when NA-I entered the room. Resident 140 requested assistance to the toilet. NA-I stated they needed to help another resident and would be back to assist Resident 140. NA-I turned off the call light and exited the room; -Resident 140 turned the call light back on at 9:24 AM; -At 9:34 AM the call light was off and NA-I and NA-N provided toileting assistance (29 minutes after the resident first called for assistance to the toilet); -At 9:46 AM the resident turned on the call light for assistance off of the toilet; -At 10:06 AM RN-P entered Resident 140's room, turned off the call light and exited the room; and -At 10:19 AM NA-I and NA-N entered Resident 140's room to assist the resident off of the toilet (33 minutes after the resident call for assistance off of the toilet).",2020-09-01
715,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,314,D,0,1,FF7611,"**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 promote healing of Resident 28's pressure sore as treatments were not provided in accordance with physician orders. The sample size was 46 and the facility census was 87. Findings are: Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/16/17 indicated the resident was at risk for pressure sores. Review of a Weekly Skin Check form dated 6/9/17 revealed Resident 28 had a pressure sore on the lateral right foot measuring 5.3 cm (centimeters) x (by) 2.0 cm. Documentation indicated the pressure sore was treated with [MEDICATION NAME] gel (used to promote wound healing) and covered with [MEDICATION NAME] (a type of wound dressing). Review of physician's orders [REDACTED]. Review of a Weekly Skin Check form dated 6/16/17 indicated the pressure sore on Resident 28's lateral right foot measured 5.3 cm x 1.0 cm and the treatment was to apply [MEDICATION NAME] gel and cover with [MEDICATION NAME]. During observation of the treatment to Resident 28's pressure sore on 6/19/17 from 9:17 AM until 9:40 AM, Licensed Practical Nurse (LPN)-C removed the old dressing from the resident's right foot, applied [MEDICATION NAME] gel to the pressure sore on the lateral side of the foot, covered the area with [MEDICATION NAME], and secured the dressing with gauze wrap and tape. During interview on 6/19/17 from 3:02 PM until 3:14 PM, LPN-C verified Resident 28's pressure sore was covered with an [MEDICATION NAME] dressing instead of Xeroform. LPN-C further verified that [MEDICATION NAME] had also been used for the pressure sore treatment provided the previous day by a different staff person. LPN-C indicated the resident's treatment was redone using Xeroform and the [MEDICATION NAME] was removed from the resident's room. During interview on 6/20/17 at 10:53 AM, Registered Nurse (RN)-P verified Resident 28's pressure sore treatment was not completed in accordance with physician's orders [REDACTED].",2020-09-01
716,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,323,D,0,1,FF7611,"**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 implement fall prevention interventions for Resident 47, and failed to assess casual factors and to revise/develop fall prevention interventions to prevent ongoing falls for Resident 90. The sample size was 46 and the facility census was 87. Findings are: [NAME] Review of Resident 47's undated Care Plan revealed the resident was at risk for falls. Further review revealed the resident fell on [DATE] and interventions included reminding the resident to use the call light when needing help. Observations of Resident 47's room revealed the following: -On 6/15/17 at 1:00 PM the resident was resting in bed and the call light cord was draped between the mattress and the footboard of the bed, -On 6/20/17 at 9:55 AM the resident was resting in bed and the call light was on the floor between the bed and the wall, and -On 6/20/17 at 2:00 PM the resident was resting in bed and the call light remained on the floor between the bed and the wall. During an interview with Nursing Assistant (NA)-S on 6/20/17 at 9:15 AM, NA-S revealed Resident 47 did use the call light at times, especially when in bed. Further interview revealed the resident would often self-propel the wheelchair to the hallway to summon help when up in the wheelchair. B. Review of Resident 90's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/29/17 revealed the resident had current [DIAGNOSES REDACTED]. The assessment further revealed the resident's cognitive status was severely impaired, the resident required limited assistance with activities of daily living, had daily behaviors of wandering and the resident had 1 fall without injury since the previous assessment. Review of Resident 90's current Care Plan dated 1/26/17 revealed the resident was at risk for falls related to need for assistance with activities of daily living, episodes of incontinence, impaired decision making, constant wandering and poor safety awareness with [DIAGNOSES REDACTED]. Further review revealed the resident had falls on 5/4/17, 5/19/17, 5/30/17, 5/31/17, 6/1/17, 6/3/17, and 6/9/17. The Care Plan identified the following interventions: -Ensure resident is wearing appropriate footwear (gripper socks). -Ensure walkways are clear and attempt to involve resident in activities. -Monitor the resident for fatigue and position the resident for safety when tired. -Monitor resident when wandering and re-direct out of other resident's rooms. -Encourage rest periods when sleepy. -Encourage resident to sit down for meals and staff to sit next to resident to discourage wandering. -Bed alarm (an electronic pressure sensitive sensor pad designed for use in beds which will alarm if a resident tries to get up without assistance). -Ensure proper position in bed and in the wheelchair. -Bed to be in low position and fall mat to floor next to bed. -Ensure the strap is fastened/secured to the Merry Walker (walker/chair combination which allows a resident to sit or to walk independently while secured with a safety strap to reduce risk for falls). Review of an Incident Report dated 5/4/17 at 12:00 AM, revealed the resident was found on the floor leaning against the linen closet door in the corridor. The report indicated the resident was alert with periods of forgetfulness, was ambulatory without assistance and was a frequent wandering. A new intervention to have the clinical Pharmacist complete a review of the resident's medications was identified. Review of an Incident Report dated 5/19/17 at 12:58 PM, revealed the resident had been walking in the corridor near the Nurse's Station, carrying a glass of milk. The resident fell over backwards onto the floor. The resident's Care Plan indicated an intervention was developed to encourage the resident to remain seated in the dining room for meals with staff seated next to the resident to discourage wandering. Review of a Nursing Progress Note dated 5/30/17 at 5:53 PM, revealed the resident was found on the floor of the resident's room. There was no evidence potential causal factors were assessed or that additional interventions for the prevention of falls were developed. Review of an Incident Report dated 5/31/17 at 1:15 PM revealed the resident was found on knees bent over a tipped rocking chair. Further review of the report revealed the fall was not witnessed but staff felt the resident was tired, leaned on the rocker for support and fell due to movement of the rocker. Fall prevention interventions were not revised and no new interventions were developed. Review of an Incident Report dated 6/1/17 at 9:45 PM, revealed the resident was found on the floor near a recliner in the dining room. The resident was lying on right side asleep. No causal factors were identified and no new interventions were developed in an attempt to prevent ongoing falls. Review of a Nursing Progress Note dated 6/3/17 at 11:45 AM, revealed the resident was having difficulty standing. Staff assisted the resident to stand and when the resident attempted to walk, the resident leaned from side to side and fell . The resident was sent to the emergency room for assessment. No new interventions were developed to prevent further falls. Review of an Incident Report dated 6/9/17 at 7:45 PM, revealed the resident was found on the floor in the doorway of the resident's room, underneath of the Merry Walker. Further review of the report revealed the resident had slid to the floor as a strap which secured the resident in the device had not been fastened. Staff were educated on the need to ensure safety straps were secured when resident was in the Merry Walker. Interview with Licensed Practical Nurse (LPN)-K on 6/19/17 at 1:30 PM, verified there was no evidence to indicate causal factors were assessed following Resident 90's falls on 5/30/17 and 6/1/17 and no new interventions were developed to prevent ongoing falls after Resident 90 fell on [DATE], 5/31/17, 6/1/17 and 6/3/17.",2020-09-01
717,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,329,D,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1 Based on observation, record review, and interview; the facility failed to ensure Resident 46 was free from the use of unnecessary medications related to duration of insulin use and monitoring of insulin. The sample size was 46 and the facility census was 87. Findings are: Review of a Physician order [REDACTED]. completed. Review of Resident 46's Medication Administration Record dated 6/2017 revealed the resident had an order for [REDACTED]. Further review revealed the resident continued to receive the V-Go 40 insulin pump (instead of switching back to the V-Go 30 insulin pump). On 6/19/17 at 11:16 AM, Licensed Practical Nurse-W revealed Resident 46's blood sugar was 210 and instructed the resident to administer 6 units of [MEDICATION NAME]using the insulin pump. Further observation revealed the number of units given was not documented on the Medication Administration Record. LPN-W confirmed the insulin pump observed was a V-Go 40 and a V-Go 40 would continue to be used until the supply was gone, and then they would return to using a V-Go 30 insulin pump since the resident was no longer taking the [MEDICATION NAME][MEDICATION NAME]. During interviews with the Assistant Director of Nursing (ADON) on 6/20/17 at 2:30 PM and on 6/21/7 at 8:15 AM, the ADON confirmed the V-Go 40 insulin pump delivered 40 units of insulin every 24 hours (in addition to the sliding scale units that were manually self-administered) and the V-Go 30 insulin pump delivered 30 units of insulin every 24 hours (in addition to the sliding scale units that were manually self-administered).",2020-09-01
718,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,353,E,1,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observation, record review and interview; the facility failed to provide nursing staff to meet resident needs related to: 1) 8 of 20 confidential resident interviews and 6 of 7 confidential family interviews voiced concerns regarding a lack of staff; 2) the failure to answer call lights and provide assistance in a timely manner for Resident 140; 3) the failure to provide repositioning for Resident 53; 4) the failure to provide positioning, transfer assistance and oral care for Resident 82; 5) the failure to provide incontinence care for Resident 35; and 6) the failure to provide supervision for the prevention of falls and resident to resident altercations in the Alzheimer Care Units (ACU-secure unit for residents with [DIAGNOSES REDACTED]. The sample size was 46 and the facility census was 87. Finding are: [NAME] 8 of 20 confidential resident interviews conducted between 10:45 AM on 6/14/17 and 1:15 PM on 6/15/17 voiced concerns regarding insufficient nursing staff. Comments included the following: -Put call light on and had to wait 30 minutes. They don't always take time to meet your needs; -Wait a long time to get staff to assist and last night it took 2 hours. Staff came in and shut off the light and stated they would be right back but did not come back. The resident made repeated attempts until they provided assistance; -Call light response takes 30 minutes; and -I think they are always short of help .When you go to the dining room for meals it takes forever to get your food. There is not enough help at meals. B. 6 of 7 confidential family interviews conducted between 1:13 PM on 6/14/17 and 6/20/17 at 1:40 PM revealed the following: -1 family member reported it took at least 45 minutes before the call light was answered; -1 family member reported 3 Nursing Assistants (NA) were assigned to care for the residents residing on 2 halls of the facility. The family member indicated it took too long for staff to assist the resident which caused the resident to be incontinent; -Another family member indicated due to insufficient staffing the resident was incontinent while waiting to get to the bathroom. The family member further indicated it often took 30 minutes before staff were able to assist the resident off of the toilet; and -They do not have enough staff . (the resident) had to wait for pain medication and had to ask for it 3 times. C. A confidential staff interview indicated there were 2 nurses (or 1 nurse and 1 medication aide) and 3 nurse aides assigned to work on the Emerald Court and Diamond Hall. The staff member reported 13 of the 28 residents residing on these halls had to be transferred with mechanical lifts and it usually took 2 staff members to assist with the transfers. The staff member further indicated staffing had recently been readjusted and they no longer had a nursing assistant assigned to provide resident baths. D. Observations and interview with Resident 140 on 6/20/17 revealed the following: -Resident 140's call light was on from 7:15 AM until 7:33 AM (18 minutes); -Resident 140's call light was on at 9:05 AM. The call light was turned off at 9:10 AM but the resident turned the call light on again at 9:11 AM. Nursing Assistant (NA)-N then entered the resident's room, turned off the call light and exited the room; -At 9:13 AM Resident 140 reported using the call light to ask for assistance to the toilet. Resident 140 indicated NA-N turned off the call light and stated (NA-N) would be right back. Resident 140 stated staff frequently enter the room, turn off the call light, state they will be right back and then leave the room. Resident 140 further indicated staff don't come back right away which caused the resident to have urine incontinence. Resident 140 proceeded to turn the call light back on; -Resident 140's call light was on from 9:13 AM until 9:17 AM when NA-I entered the room. Resident 140 requested assistance to the toilet. NA-I stated they needed to help another resident and would be back to assist Resident 140. NA-I turned off the call light and exited the room; -Resident 140 turned the call light back on at 9:24 AM; -At 9:34 AM the call light was off and NA-I and NA-N provided toileting assistance (29 minutes after the resident first called for assistance to the toilet); -At 9:46 AM the resident turned on the call light for assistance off of the toilet; -At 10:06 AM Registered Nurse (RN)-P entered Resident 140's room, turned off the call light and exited the room; and -At 10:19 AM NA-I and NA-N entered Resident 140's room to assist the resident off of the toilet (33 minutes after the resident called for assistance to transfer off of the toilet). E. On 6/20/17 Resident 53 was observed at 7:00 AM, 7:30 AM, 8:00 AM, 8:30 AM, 9:15 AM, 9:55 AM, 10:30 AM, 11:15 AM, and 11:30 AM lying supine (lying on the back or face upward) in bed with the resident's left arm on top of the sheet and a pillow tucked under both sides of the resident. There was no evidence to indicate the resident had changed positions during this time (4.5 hours). During an interview on 6/20/17 at 11:30 AM with NA-R (the staff member responsible for Resident 53), NA-R confirmed Resident 53 had not been repositioned. NA-R revealed NA-R had checked the resident's incontinence product at approximately 9:30 AM, but the resident had not been incontinent. NA-R went on to state the resident was not repositioned at that time because it takes 2 staff to reposition the resident and there was not enough staff available to help reposition Resident 53. F. Review of Resident 35's undated Care Plan revealed the resident had advanced dementia and lower extremity paralysis. Further review revealed the resident wore an incontinence product and required 1-2 assist with toileting. Interview with NA-I on 6/19/17 at 2:00 PM revealed Resident 35 was provided incontinence cares right after lunch (1:00 PM) because the resident was very dirty. Further interview confirmed the resident was last checked at approximately 9:30 AM and then was not checked or changed until 1:00 PM (3.5 hours later). Interview with RN-O on 6/21/17 at 8:45 AM confirmed Resident 35 was incontinent of bladder and the resident's incontinence product should be checked/changed every 2 hours and as needed. [NAME] Review of Resident 82's undated Care Plan revealed the following: -The resident had alteration in Activities of Daily Living (ADL) status and required a sit to stand lift for transfers; -The resident had natural teeth and required staff assistance with oral cares; and -The resident required assistance with turning and positioning every 2 hours and as needed. Observations of Resident 82 on 6/19/17 revealed the following: -At 7:10 AM the resident was seated in the wheelchair in the resident's room; -From 7:37 AM until 9:17 AM the resident was sleeping in the wheelchair in the dining room; -At 9:17 AM the resident was assisted back to the resident's room and remained asleep in the wheelchair; -At 9:40 AM the resident remained asleep in the wheelchair, with the resident hunched forward and to the right side; -At 10:31 AM, 11:13 AM, and 11:45 AM the resident remained asleep and hunched over in the wheelchair; and -At 12:43 PM the resident was awake and seated in the wheelchair in the dining room. During an interview with NA-S on 6/20/17 at 7:20 AM, NA-S verified working on 6/19/17 and was unsure why the resident did not get laid down between breakfast and lunch despite being asleep in the wheelchair. Further interview confirmed the resident should be laid down in bed if sleeping after meals. During observation of cares on 6/20/17 at 9:20 AM with NA-S, NA-S swabbed the resident's mouth with a toothette and then assisted the resident with mouthwash. NA-S stated the resident did have a toothbrush but the resident's gums had become sore, so now NA-S used a toothette instead. NA-S was unable to find a toothbrush or toothpaste for the resident. NA-S then transferred Resident 82 from the wheelchair to the bed with a gait belt. NA-S tried multiple times unsuccessfully to get the resident to stand up during the transfer. After multiple attempts, NA-S held on to the gait belt and positioned NA-S's arms under Resident 82's arm pits and lifted the resident upwards to assist the resident to bed. During an interview with NA-V on 6/20/17 at 12:15 PM, NA-V revealed that NA-V also transferred Resident 86 with 1 staff assistance with a gait belt. Interview with the Assistant Director of Nursing on 6/21/17 at 9:45 AM confirmed Resident 86 should be transferred with the sit to stand lift. H. Review of Resident 90's current Care Plan dated 1/26/17 revealed the resident was at risk for falls related to need for assistance with activities of daily living, episodes of incontinence, impaired decision making, constant wandering and poor safety awareness with [DIAGNOSES REDACTED]. Further review revealed the resident had falls on 5/4/17, 5/19/17, 5/30/17, 5/31/17, 6/1/17, 6/3/17, and 6/9/17. The Care Plan identified the following interventions: -Ensure resident is wearing appropriate footwear (gripper socks). -Ensure walkways are clear and attempt to involve resident in activities. -Monitor the resident for fatigue and position the resident for safety when tired. -Monitor resident when wandering and re-direct out of other resident's rooms. -Encourage rest periods when sleepy. -Encourage resident to sit down for meals and staff to sit next to resident to discourage wandering. -Bed alarm (an electronic pressure sensitive sensor pad designed for use in beds which will alarm if a resident tries to get up without assistance). -Ensure proper position in bed and in the wheelchair. -Bed to be in low position and fall mat to floor next to bed. -Ensure the strap is fastened/secured to the Merry Walker (walker/chair combination which allows a resident to sit or to walk independently while secured with a safety strap to reduce risk for falls). Review of an Incident Report dated 5/4/17 at 12:00 AM, revealed the resident was found on the floor leaning against the linen closet door in the corridor. The report indicated the resident's fall was not witnessed and the resident had been unsupervised. Review of an Incident Report dated 5/19/17 at 12:58 PM, revealed the resident had been walking in the corridor near the Nurse's Station, carrying a glass of milk. The resident fell over backwards onto the floor. The resident's Care Plan indicated an intervention was developed for staff to remain seated next to the resident when eating meals to discourage the resident from wandering. Review of a Nursing Progress Note dated 5/30/17 at 5:53 PM, revealed the resident was found on the floor of the resident's room. The report indicated the resident's fall had been unwitnessed. Review of an Incident Report dated 5/31/17 at 1:15 PM revealed the resident was found on knees bent over a tipped rocking chair. Further review of the report revealed the fall was not witnessed and the resident had been unsupervised. Review of an Incident Report dated 6/1/17 at 9:45 PM, revealed the resident was found on the floor near a recliner in the dining room. The resident was lying on right side and had fallen asleep. The resident's fall was not witnessed and the resident had not been supervised. Review of a Nursing Progress Note dated 6/3/17 at 11:45 AM, revealed the resident was having difficulty standing. Staff assisted the resident to stand and when the resident attempted to walk, the resident leaned from side to side and fell . The resident was sent to the emergency room for assessment. Review of an Incident Report dated 6/9/17 at 7:45 PM, revealed the resident was found on the floor in the doorway of the resident's room, underneath of the Merry Walker. Further review of the report revealed the resident had slid to the floor as a strap which secured the resident in the device had not been fastened. Staff were educated on the need to ensure safety straps were secured when resident was in the Merry Walker. Interview with Licensed Practical Nurse (LPN)-K on 6/19/17 at 1:30 PM, verified the resident's falls on 5/4/17, 5/30/17, 5/31/17 and 6/1/17 were unwitnessed and staff had been unavailable at the time of the falls to provide the resident with supervision. I. Review of Resident 29's Nursing Progress Notes dated 6/14/17 at 8:35 PM, revealed the resident was involved in a physical altercation with another resident. The note indicated Resident 29 was aware of the resident's personal space and surroundings and had reacted negatively to another resident entering Resident 29's space. Resident 29 was assessed with [REDACTED]. Review of Resident 29's medical record revealed no evidence that 15 minute checks had been completed after the resident to resident altercation with Resident 96 to assure the resident's location. Review of Resident 96's Nursing Progress Notes dated 6/14/17 at 8:35 PM, revealed the resident had been involved in a physical altercation with another resident. The note further indicated the resident had a [DIAGNOSES REDACTED]. The resident was a wanderer and ambulated freely throughout the unit. Resident 96 was assessed with [REDACTED]. Review of Resident 96's medical record revealed no evidence the staff had completed visual checks every 15 minutes of the resident to assure no further altercations with Resident 29 occurred. Interview with the Alzheimer's Unit Coordinator on 6/15/17 from 9:30 AM to 10:00 AM, verified there was no documentation to indicate staff provided every 15 minute visual checks of Resident 96 and Resident 29 to assure no further altercations between the residents.",2020-09-01
719,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,371,F,0,1,FF7611,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to prepare, store, and serve foods in a manner to prevent cross contamination and assure food safety as: 1) food items were not dated when opened and/or stored in secure packaging; 2) prepared food items were not disposed of within time frames specified by facility policy; 3) refrigerators and freezers were not monitored to assure temperatures were maintained; 4) clean equipment was not protected from splatter and soil; 6) dietary staff failed to wash hands at appropriate times to prevent potential food contamination; and 7) nursing staff were observed to touch ready to eat food items with their bare hands while assisting resident to eat. Total sample size was 46 and the facility census was 87. Findings are: During the Initial Tour of the kitchen on 6/14/17 from 8:45 AM until 9:25 AM, accompanied by the Dietary Services Manager (DSM), the following were observed: [NAME] There were 2 refrigerators directly to the left of the entry into the kitchen from the dining room, 1 containing drinks and the other containing food items. There was also a walk-in refrigerator and a walk-in freezer. The refrigerators and the freezer had Temperature Logs attached to the doors that indicated temperatures were to be recorded 2 times daily in the morning (AM) and evening (PM). Review of the Temperature Logs revealed the following: -the temperature of the refrigerator containing drinks was monitored 12 times in 3/2017, 9 times in 4/2017, 9 times 5/2017, and 8 times in 6/2017; -the temperature of the refrigerator containing food items was monitored 33 times in 3/2017, 27 times in 4/2017, 8 times in 5/2017, and 11 times in 6/2017; -the temperature of the walk-in refrigerator was monitored 23 times in 3/2017, 20 times in 4/2017, 11 times in 5/2017, and 10 times in 6/2017; -the temperatures of the walk-in freezer were monitored 27 times in 3/2017, 18 times in 4/2017, 8 times in 5/2017, and 18 times in 6/2017; and -there was a 3 door freezer in the back storage room that had no temperature logs available. B. Interview with the DSM verified monitoring and recording of refrigerator/freezer temperatures was not kept up well and a work in progress. The DSM verified temperatures were to be monitored in the AM when dietary staff arrive to work, and in the PM before they leave. C. Food items stored in the refrigerators and freezers included the following: -a plastic storage container of ham dated 6/9/17; -a plastic container of sliced turkey dated 6/2/17; -2 open bottles of Ranch salad dressing and Dorothy Lynch salad dressing that were not dated as to when they were opened; -2 large commercial size bags of Caesar salad dressing that were open, 1 dated 3/5/17 and the other not dated as to when it was opened; -a large metal container half full of fried chicken, covered with plastic wrap and dated 5/28/17, and a small metal container of fried chicken that was not dated; -a 6 ounce container of yogurt with an expiration date of 5/31/17; -6 pieces of pie served out on individual plates, and 3 small bowls of pears that were uncovered and not dated; -2 opened and unsealed plastic bags that were not dated, 1 containing 3 individual frozen pizzas and the other containing frozen peas; and -an opened bag of frozen zucchini sticks that was not dated. D. Interview with the DSM revealed the following: -there was a 3 day expiration date on prepared food items; -there was no policy related to how long processed meats were to be kept once they were opened and repackaged; and -all food items in the refrigerators and freezers were to be resealed/repackaged and dated after they were opened. E. The following was observed in the Dishwashing Room: -there was a 5 shelf metal rack tightly positioned between the end of the clean dish line and the 3 compartment sink; --there was soapy water in 1 sink compartment and a soiled kettle in another sink compartment; and -there were clean, dried dishes and equipment stored on the metal rack. F. Interview with the DSM revealed soiled dishes and equipment were scrubbed and rinsed in the 3 compartment sink prior to being run through the dish washer. The DSM verified there was potential for splatter and contamination of the clean dishes and equipment stored on the metal rack between the sink and the dish line. [NAME] There were multiple boxes of food items stored on the floors of the walk-in refrigerator and walk-in freezer that blocked entry and access to the food stored on the shelves of the units. The floor of the back storage room was littered with multiple stacks of boxes containing food and disposable kitchen items, flats of canned food items, and empty boxes, blocking access to the storage room shelves. H. Interview with the DSM indicated they had a shipment of food come in on Monday (2 days ago). I. During observation of food preparation on 6/19/17 from 11:05 AM until 12:07 PM, the following were observed of Cook-F: -wiped both hands on clothing, and without washing hands, donned clean gloves, retrieved slices of bread from the plastic bag, placed them in the blender, pureed them with milk, and poured the pureed bread into steam cart containers; -removed gloves, wiped both hands on clothing, walked about the kitchen and dish room and collected serving utensils that were placed on top of the serving cart; -after washing hands at the sink, went directly to the back storage room and took a drink from a personal cup, returned to the kitchen to clean up the food preparation area and restock kitchen equipment; and -without washing hands, donned clean gloves and started to serve the noon meal. [NAME] The following were observed during noon meal observations: -6/14/17 from 11:56 AM until 12:13 PM, Nursing Assistant (NA)-B picked up Resident 16's dinner roll with bare hands and buttered it; -6/19/17 from 11:48 AM until 12:36 PM, NA-H and Licensed Practical Nurse (LPN)-A touched Resident 36's and Resident 71's biscuits with their bare hands as they buttered them. K. Review of the 7/2016 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service and sanitation practices revealed the following: -4-903.11(A) .cleaned equipment and utensils .shall be stored .(2) Where they are not exposed to splash, dust, or other contamination; -81-2,272.10(4) Food employees not serving a highly susceptible population may contact exposed, ready-to-eat food with their bare hands if they have washed their hands as specified in the act prior to handling the food; and -Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) .older adults; and (2) Obtaining food at a facility .such as .nursing home . -2-301.14 Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation .and: (after touching bare human body parts other than clean hands and clean, exposed portions of arms .(D) .after .eating, or drinking .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .(H) Before donning gloves for working with food; and (I) After engaging in other activities that contaminate he hands. -3-3-5.11 (A) Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 6 inches above the floor; -81-2,272.24(2) Except as specified in this section, refrigerated, ready-to-eat potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant and held refrigerated at such food establishment, shall be clearly marked, at the time the original container is opened in a food establishment, to indicate the date the food container was opened. The food shall be sold, consumed on the premises, or discarded within: (a) Seven calendar days or less if the food is held refrigerated at forty-one degrees Fahrenheit .or (b) Four calendar days or less if the food is held refrigerated between forty-five degrees Fahrenheit .and forty-one degrees Fahrenheit . -3-307.11 Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306; and -8-201.14(D)(6) Records to be maintained by the person in charge to demonstrate that the HACCP (Hazard Analysis and Critical Control Point-a written plan that delineates formal procedures) plan is properly operated and managed.",2020-09-01
720,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,425,E,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12 Based on record review and interview; the facility failed to ensure regularly scheduled medications were obtained and available for administration as ordered for 4 (Residents 29, 44, 96 and 115) of 46 sampled residents. Facility census was 87. Findings are: [NAME] Review of facility Policy for Medication Errors (undated) revealed if a resident's medication was omitted several times, the error was to be classified as a medication error. B. Review of Resident 44's Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of Resident 44's MAR for (MONTH) of (YEAR) revealed the resident did not receive the scheduled dose of Trazodone 75 mg at bedtime on 6/1/17, 6/2/17, 6/3/17 and 6/4/17 as the drug was unavailable from the pharmacy. C. Review of Resident 96's MAR for (MONTH) (YEAR) revealed an order for [REDACTED]. D. Review of Resident 115's MAR for (MONTH) of (YEAR) revealed the resident had an order for [REDACTED]. E. Review of Resident 29's MAR for (MONTH) of (YEAR) revealed an order for [REDACTED]. Review of the facility Medication Error Log from 5/1/17 through 6/21/17 revealed no documentation of a medication error for Resident 44, Resident 96, Resident 115 and Resident 29. During an interview on 6/21/17 from 2:30 PM to 2:45 PM, the Director of Nursing (DON) verified Resident 44 missed 7 doses of the scheduled Trazodone on 5/29/17, 5/30/17, 5/31/17, 6/1/17, 6/2/17, 6/3/17 and 6/4/17; Resident 96 missed 10 doses of the scheduled Namenda on 5/8/17, 5/9/17, 5/10/17, 5/11/17, 5/13/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, and 5/19/17; Resident 115 missed 3 doses of the scheduled Donepezil on 5/12/17, 5/19/17 and 5/27/17; and Resident 29 missed 1 dose of the scheduled Fentanyl Patch on 5/1/17 and 3 doses on 5/19/17, 5/22/17 and 5/25/17 which resulted in the resident going for 10 days without the pain medication. The DON indicated the medications were unavailable from the pharmacy as staff failed to reorder the medications and the medication omissions should have been reported as medication errors.",2020-09-01
721,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2017-06-21,441,E,0,1,FF7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interviews: the facility failed to prevent the potential for cross contamination related to: 1) hand hygiene during the provision of incontinent cares for Residents 44, 97, 8, 50 and 35 and during provision of a treatment for [REDACTED]. The sample size was 46 and the facility census was 87. Findings are: [NAME] Review of the facility policy titled Hand Hygiene (undated), a reference to provide guidelines for effective hand hygiene in order to prevent the transmission of bacteria, germs and infections, included the following situations in which hand washing was to be completed: -when hands were soiled; -before each resident contact; -after contact with the resident's intact skin, including taking a blood pressure or pulse, lifting or moving the resident; -after contact with medical equipment or supplies in resident areas; and -Always after removing gloves. The policy further indicated the following: -Gloves were to be worn when contact with blood, bodily fluids, mucous membranes, dressings, or non-intact skin was anticipated; -Gloves were to be changed and discarded after each resident contact; and -Gloves were to be changed when moving from a contaminated body site to a clean body site on the same resident. B. During observation of nursing care on 6/19/17 at 10:45 AM, Medication Aide (MA)-L provided incontinent care for Resident 50 who was incontinent of urine. MA-L provided perineal hygiene, but without removing soiled gloves, adjusted the resident's clothing and transferred the resident into a wheelchair. MA-L removed soiled gloves and without washing or sanitizing hands, placed foot pedals on the resident's wheelchair and assisted the resident into the dining room. MA-L then washed hands in the dining room sink. C. During observation of nursing care on 6/19/17 at 11:15 AM, MA-L and Licensed Practical Nurse (LPN)-K provided incontinent care for Resident 8. MA-L provided perineal hygiene and without removing soiled gloves, placed a clean incontinent brief on the resident, adjusted the resident's slacks and transferred the resident into a wheelchair using a mechanical lift. MA-L removed soiled gloves but failed to wash hands. MA-L adjusted the resident's positioning in the wheelchair, removed the sling from the resident and assisted the resident into the dining room before washing hands in the dining room sink. D. During observation of care on 6/19/17 at 11:50 AM, LPN-K and MA-L donned gloves and assisted Resident 97 onto the toilet. Upon completion of toileting, the resident was assisted to a standing position and MA-L provided perineal hygiene. Upon completion of perineal hygiene, MA-L did not remove gloves and proceeded to put a clean disposable incontinent brief on the resident, pulled up the resident's slacks then assisted with transferring the resident into a wheelchair. MA-L removed the soiled gloves and without washing or sanitizing hands proceeded to propel the resident out of the bathroom, adjusted the resident's positioning in the chair and placed foot pedals on the resident's wheelchair. MA-L exited the resident's room without washing or sanitizing hands. E. Observations of Resident 44's morning care on 6/20/17 at 7:53 AM revealed the following: -Nurse Aide (NA)-Q and LPN-K donned gloves and removed the resident's disposable incontinent brief, which was heavily saturated with urine; -NA-Q provided the resident's perineal hygiene and removed soiled gloves but failed to wash or sanitize hands before assisting the resident with washing hands and face, combing hair and oral hygiene; -NA-Q assisted the resident into a wheelchair and out of the bathroom, then returned to the bathroom and without donning gloves, used a pre-moistened cleansing cloth to remove a smear of feces from the toilet seat; -NA-Q assisted the resident to the dining room; -NA-Q returned to the resident's room to make the resident's bed; and NA-Q exited the resident's room, opened a drawer on the medication cart and removed a container of hand sanitizer which NA-Q used to sanitize hands. Interview with NA-Q and LPN-K on 6/20/17 at 8:30 AM confirmed staff members were expected to remove gloves and wash/sanitize hands following provision of perineal hygiene and before leaving the resident's room. F. During observation on 6/19/17 from 9:17 AM until 9:40 AM, the following was observed as LPN-C completed a dressing change on Resident 28's right foot: -Using bare hands, the resident's slipper, gripper sock, and nylon stocking were removed to reveal a gauze dressing wrapped around the entire foot; -Without washing hands, gloves were donned, the soiled dressing was removed, the wound on the right side of the resident's foot was rinsed with saline, and the soiled gloves were removed; -Without washing hands, a clean pair of gloves was donned, a piece of [MEDICATION NAME] (a type of wound dressing) was cut to size to fit the wound, [MEDICATION NAME] gel (a product used for wound healing) was applied to the wound, and the area was covered with the [MEDICATION NAME] dressing; -Using the same gloves, a piece of Xeroform (another type of wound dressing) was cut to size to fit a wound on the resident's right great toe, the dressing was applied to the toe and covered with a gauze pad, the dressings on both wounds were secured using a gauze wrap and tape, and the soiled gloves were removed; -Without washing hands, the resident's dresser drawer was opened to retrieve a clean gripper sock, the resident's nylon stocking, gripper sock and slipper were replaced, garbage was disposed of in the trash receptacle by the bed, the unused dressings and supplies were returned to the top drawer of the resident's dresser, and hands were washed in the bathroom prior to leaving the room; and -the garbage in the trash receptacle next to the resident's bed, including the soiled dressings and used gloves and equipment, were not removed from the room. During interview on 6/20/17 at 10:50 AM, Registered Nurse (RN)-P verified the garbage collected during the treatment to Resident 28's wounds should have been bagged and removed from the room. [NAME] During observation of nursing care on 6/20/17 from 10:35 AM until 10:45 AM, NA-I and NA-N provided incontinent care for Resident 35. The resident's incontinent brief was wet with urine. NA-I performed anterior and posterior perineal hygiene using gloved hands. With soiled gloves, NA-I dispensed barrier cream from the tube and applied it to the resident's rectal area, then removed the soiled gloves. Without washing hands, NA-I assisted with placing a clean incontinent brief on the resident. NA-I adjusted the resident's clothing, and picked up the package of perineal cleansing wipes and the tube of barrier cream and replaced them into the top drawer of the resident's dresser. NA-I then went to the bathroom to wash hands at the sink. H. The following was observed during the noon meal on 6/14/17 from 12:27 PM until 1:10 PM: -NA-B was seated at the assisted table in the dining room and feeding Residents 14 and 82, including touching Resident 82's clothing; -Without washing hands, NA-B approached Resident 16 who was eating independently, crushed saltine crackers in their packages and dumped them into Resident 16's soup, picked up the resident's spoon and stirred the crackers into the soup; and -Without washing hands, NA-B returned to feeding Residents 14 and 82. I. The following was observed during the breakfast meal on 6/19/17 from 8:47 AM until 9:05 AM: -LPN-A was seated at the assisted table in the dining room assisting Residents 14, 16, 70 and 82 to eat; -Using the right hand, LPN-A rubbed Resident 82's back, and using the same hand picked up Resident 14's spoon. LPN-A then handed a bottle of ketchup to Resident 16 who took it and used it independently; -Without washing hands, LPN-A handed a spoon to Resident 70, then wiped hand on the napkin lying in the resident's lap; and -Without washing hands, LPN-A returned to Resident 82 and picked up the resident's spoon to feed cereal to the resident. [NAME] Observations of resident rooms on 6/14/17 from 11:27 AM to 6/15/17 at 7:51 AM revealed the following: -Resident 122's nebulizer machine (device used to deliver medication in the form of a mist which is inhaled into the lungs) with attached tubing and an inhalation device was stored uncovered on a dresser; -Resident 101's nebulizer mask was uncovered and stored in a small box; and -Resident 150's oxygen tubing including the nasal cannula (a 2 pronged tube which is placed in the nostrils) was uncovered and draped over the walker in the resident's room. Observations of resident rooms during the environmental tour on 6/20/17 from 10:30 AM to 11:15 AM revealed: -Resident 101's nebulizer mask remained uncovered; -Resident 150's oxygen tubing remained uncovered; and -Resident 122's nebulizer and tubing remained uncovered. Interviews with the Interim Administrator on 6/20/17 from 10:30 AM to 11:15 AM confirmed the respiratory equipment was stored uncovered. K. Review of the undated facility policy titled Oxygen Service - OXY-MASK confirmed, when not in use, oxygen masks should be stored in a bag. L. Review of the facility policy titled Respiratory Practices with a revision date of 5/1/11 confirmed nebulizer masks and inhalation devices should be stored in a bag.",2020-09-01
722,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2018-08-16,677,D,1,1,48Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interviews; the facility failed to provide Resident 68 assistance with repositioning and incontinence cares and to provide Resident 27 timely toileting assistance. Sample size was 3 and the facility census was 68. Findings are: [NAME] Review of Resident 68's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 7/24/18 revealed [DIAGNOSES REDACTED]. The assessment identified the resident's cognition was severely impaired, the resident required extensive assist for transfers, personal hygiene and toileting and was frequently incontinent of bowel and bladder. Review of Resident 68's current Care Plan with a revision date of 7/5/18 revealed the resident required assistance with transfers and toileting and was incontinent of bowel and bladder. Observations of Resident 68 on 8/14/18 revealed the following: -7:30 AM the resident was lying in bed in the resident's room and was positioned on the resident's right side; -9:30 AM (2 hours later) the resident remained in bed and positioned on the resident's right side; -10:30 AM (3 hours later) the resident remained in bed with position unchanged. Resident 68 was not provided assistance with repositioning and/or toileting and was not checked for incontinence during these observations; and -10:34 AM Nursing Assistant (NA)-C entered the resident's room and provided the resident with incontinence cares, dressed the resident and transferred the resident into a wheelchair. Resident 68's disposable incontinent product was saturated with urine. During an interview on 8/14/18 at 10:30 AM NA-C confirmed Resident 68 required extensive staff assistance with repositioning and with incontinence cares. NA-C indicated staff had been told to allow the resident to sleep in but the resident should have been repositioned and checked for incontinence to assure the resident's skin did not breakdown. B. Review of Resident 27's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The assessment further identified the resident had short and long term memory loss with impaired decision making skills; required extensive assistance with toilet use and personal hygiene; and was frequently incontinent of urine and always involuntary of bowel. Review of Resident 27's current Care Plan with revision date of 6/19/18 revealed the resident had a history of [REDACTED]. An intervention for staff to provide frequent assistance to assure completion of the task was identified. Observations of Resident 27 on 8/14/18 revealed the following: -7:00 AM the resident was seated in a chair in the dining room; -9:06 AM the resident remained in the dining room and was eating the breakfast meal; -9:36 AM the resident remained seated in the dining room. The resident's breakfast meal had been removed and the resident sat with arms folded on the table and head resting on the resident's folded arms; -9:49 AM the resident was approached in the dining room by NA-C and the resident was assisted from the dining room to the resident's room. NA-C encouraged the resident to sit on the bed and then to lay down on the bed. NA-C then exited the resident's room without offering the resident a chance to use the bathroom. -11:08 AM the resident self-transferred from the side of the bed to a recliner in the corner of the resident's room; and -12:00 PM to 1:00 PM the resident was seated in the dining room for the noon meal. The resident had not been offered an opportunity to use the bathroom or assessed for incontinence throughout the morning. During an interview on 8/14/18 at 2:45 PM, NA-C confirmed the resident had not been provided assistance with toileting or checked for incontinence since the resident was assisted with getting dressed that morning. NA-C indicated the resident was assisted to use the bathroom after the noon meal and the resident had been incontinent of urine. NA-C further confirmed the resident was to be assisted to the bathroom at least every 2 hours.",2020-09-01
723,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2018-08-16,692,D,0,1,48Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on observations, record review and interview, the facility failed to implement nutritional interventions for 3 (Residents 14, 66 and 35) of 4 sampled residents with weight loss and/or nutritional needs. The facility census was 68. Findings are: [NAME] Review of Resident 14's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/15/18 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident's cognition was severely impaired and required supervision to limited staff assistance with eating. The resident's weight was 125 pounds (lbs.) and the assessment identified the resident was not on a prescribed weight lost regime. Review of Weights and Vitals Summary Sheet (document used to record the resident's weights) revealed Resident 41's weight on 7/14/18 was 134 lbs. Review of a Progress Note by the Registered Dietician (RD) dated 7/20/18 at 12:31 PM revealed the resident was on a fortified (addition of added calories and nutrients to food items to improve nutrition and weight loss) diet and indicated the resident's intake at meals had dropped to an average of 37%. The note identified the resident received 206 Juice (high calorie/high protein drink) twice a day with the usual intake of 100%. Review of Weights and Vitals Summary Sheet revealed the following regarding Resident 14's weights: -8/4/18 124 lbs. (down 10 lbs. in 3 weeks or a 7% loss). -8/11/18 120 lbs. (down 14 lbs. or a 10% weight loss in 1 month) Review of a Progress Note by the RD dated 8/13/18 at 6:24 PM revealed the resident had a significant weight loss over the previous month. The RD identified the resident remained on a fortified diet but that meal intakes had decreased from an average of 39% to an average of 19%. A recommendation was received for the resident to receive the 206 Juice three times a day instead of just twice a day. Review of the resident's current Care Plan dated 8/13/18 revealed the resident was at risk for altered nutrition and weight loss due to inconsistent intake of food due to [DIAGNOSES REDACTED]. -Monitor intake at all meals and offer alternates as needed. Alert the RD and the resident's physician to any decline in intake. -Provide diet as ordered, mechanical soft regular diet with thin liquids. -Provide supplement as ordered; 206 Juice twice a day. -Provide fortified foods for weight maintenance. During an observation on 8/9/18 at 9:09 AM, the resident was seated in the Advanced Alzheimer's Care Unit (AACU-an enclosed wing or hallway which specializes in care of residents with advanced dementia or [MEDICAL CONDITION]) dining room for the breakfast meal. The resident had been served a bowl of cold cereal, scrambled eggs, and ground sausage with gravy. The resident would take a small bite of the breakfast meal, chew and then spit the food out onto the floor. Staff in the area would encourage the resident to swallow the food whenever they walked by the resident's table. During an observation of the breakfast meal on 8/14/18 at 9:03 AM in the AACU dining room, Resident 14 was observed with a bowl of cold cereal, scrambled eggs, a banana and a muffin. The resident made no attempt to eat the meal. During an observation on 8/15/18 at 7:59 AM the resident was seated at a table in the AACU dining room. The resident was served a cheese omelet, ground sausage with gravy and a bowl of cold cereal. During an interview on 8/15/18 at 8:06 AM, Dietary Aide (DA)-P identified the only fortified food provided at the breakfast meal was super-cereal (hot cereal with added brown sugar, butter and powdered milk). DA-P confirmed Resident 14 did not receive any fortification with the resident's breakfast meal. During an interview on 8/15/18 at 10:30 AM the Dietary Manager (DM) identified residents receiving a fortified diet were to get the super-cereal at breakfast and fortified mashed potatoes (extra butter and powdered milk) at the other meals. If the resident was not served one of these items, then no fortification was provided. The DM confirmed Resident 14 was on a fortified diet. Review of the resident's medical record from 8/13/18 through 8/16/18 revealed no documentation to indicate the resident's 206 Juice was increased from twice a day to three times a day as recommended by the RD. Interview with the RD on 8/16/18 at 10:00 AM confirmed the resident had not been receiving the 206 Juice three times a day as recommended by the RD on 8/13/18. Review of Resident 14's Weights and Vitals Summary Sheet revealed the resident's weight on 8/16/18 was 125 lbs. B. Review of Resident 66's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident's weight was 207 pounds. Review of the MDS dated [DATE] revealed Resident 66's weight was 198 pounds and the MDS dated [DATE] revealed a weight of 197 pounds. Review of Resident 66's Weights and Vitals Summary form revealed the following weights were recorded: -5/25/18-193 pounds; -6/23/18-191 pounds; and -6/30/18-191.2 pounds. Review of Progress Notes by the RD dated 6/30/18 at 6:02 PM and 7/21/18 at 6:09 PM included documentation that Resident 66 was receiving a regular diet with fortified foods. Review of Progress Notes by the RD dated 7/28/18 at 2:47 PM revealed Resident 66's current body weight was 188.8 pounds. Documentation further indicated the resident continued to receive fortified foods and per family request, ice cream would be provided at lunch and supper meals. Observations of the noon meal on 8/15/18 at 12:13 PM revealed Resident 66 was not served ice cream. Observations of the breakfast meal on 8/16/18 at 8:24 AM revealed Resident 66 received cold cereal, a ham slice, toast, coffee and a small glass of milk. Interview with Dietary Cook (DC)-Q on 8/16/18 at 8:27 AM revealed the fortified menu item for the breakfast meal that day was hot cereal. DC-Q confirmed Resident 66 was not served any fortified foods for the breakfast meal that morning. C. Review of Resident 35's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 35's Progress Notes dated 4/19/18 at 7:52 AM revealed the RD recommended adding 1 scoop of a high protein supplement to menu items 3 times daily to meet the resident's nutritional needs. Review of Resident 35's Medication Administration Record [REDACTED]. Interview with the DON on 8/16/18 at 11:45 AM revealed the expectation was for the high protein supplement to be started right away and not 8 days after the RD made the recommendation.",2020-09-01
724,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2018-08-16,759,D,1,1,48Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, record review and interview; the facility failed to assure a medication error rate of less than 5% as medication errors were noted for 2 of 25 residents observed (Residents 13 and 44) resulting in a medication error rate of 8%. The facility census was 68. Findings are: [NAME] During observation of Medication Administration on 8/15/18 from 7:32 AM until 8:02 AM, Licensed Practical Nurse (LPN)-F administered Alendronate Sodium ([MEDICATION NAME]-a medication used for the treatment and prevention of bone resorting caused by [MEDICAL CONDITION]) 70 milligrams (mg) to Resident 44 with a small amount of water. Review of Resident 44's Medication Administration Record [REDACTED]. The MAR further instructed that the medication be administered with 8 ounces of water. During interviews on 8/15/18, the following was revealed: -9:10 AM - LPN-F verified Resident 44's Alendronate Sodium was administered with 4 ounces of water instead of the 8 ounces recommended because the resident did not take fluids well; and -10:00 AM - the Director of Nursing (DON) verified that in order to decrease the risk for irritation to the esophagus (the tube that connects the throat to the stomach), the minimum acceptable amount of water for the administration of Alendronate Sodium was 6 ounces according to the Consultant Pharmacist. B. During observation of Medication Administration on 8/15/18 from 8:14 AM until 8:23 AM, LPN-D administered [MEDICATION NAME] (a medication used for the control of diabetes) 5 mg to Resident 13 who was seated at the dining room table and had finished eating the breakfast meal. Review of Resident 13's MAR indicated [REDACTED]. During interview on 8/15/18 at 10:40 AM, the DON verified [MEDICATION NAME] was supposed to be administered 30 minutes prior to meals.",2020-09-01
725,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2018-08-16,812,F,0,1,48Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E and 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to 1) assure food temperatures were maintained at a level to prevent the potential for food borne illness in the Alzheimer's Care Unit (ACU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]) and the Advanced Alzheimer's Care Unit (AACU); 2) assure outdated foods were not available for use in the AACU and 3) date and label food items stored in the cupboard and in the mini-refrigerator of the AACU. The sample size was 15 with a facility census of 68. Findings are: [NAME] Review of the facility policy for Food Temperatures (undated) revealed all hot foods were to be cooked to the appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F) . B. Review of the facility policy for Use of Left Overs (undated) revealed left overs were to be covered, labeled and dated. Any food item not used at the time of meal service was to be reheated to 165 degrees (F) for a minimum of 15 seconds for hot foods. C. Observation of the breakfast meal service in the ACU and the AACU on 8/15/18 revealed the following: -7:45 AM, 2 covered plates were left stored on a counter top of the AACU dining room. Further observation revealed the plates both contained the following items: a hard-boiled egg, a cheese omelet, 2 sausage links and 1/2 slice of a buttered biscuit which had been spread with a jelly. -9:16 AM (1 hour and 31 minutes later) Resident 68 was seated at the table in the ACU dining room. The resident had a plate of food which contained a hard-boiled egg, a cheese omelet, 2 sausage links and 1/2 of a buttered biscuit with jelly. Nursing Assistant (NA)-O confirmed serving the resident 1 of the plates which had been left sitting out on the counter in the AACU dining room. NA-O identified having placed the meal in the microwave for 30 seconds. NA-O further indicated the plate felt hot so the NA though the food would be hot. -9:18 AM request for Dietary Aide (DA)-P to obtain a temperature of the food items on the resident's plate. DA-P used a facility thermometer and obtained a temperature of 107 degrees (F) for the cheese omelet and 126 degrees (F) for the sausage links. DA-P indicated the foods should have been at least 150 degrees (F) before serving to the resident. -10:45 AM (3 hours later) Resident 67 was observed in a small sitting area at the entrance of the AACU. The resident was in a wheelchair with 2 family members. The family had a plate with food items from the breakfast meal which they were attempting to assist Resident 67 to eat. -11:00 AM interview with Licensed Practical Nurse (LPN)-D revealed the family had been given the remaining plate which had been left on the counter of the AACU to give to Resident 67 for breakfast. Observation on 8/15/18 at 10:30 AM of the kitchenette of the AACU dining room with the Dietary Manager (DM) revealed the following: -a prepackaged loaf of bread with an open date of 7/1/18; -a small container of peanut butter which was not labeled or dated; and -a small container with sliced cucumbers in a white liquid sauce in the mini-refrigerator. The container was not labeled and had no date. D. Interview with the Dietary Manager on 8/15/18 at 11:00 AM confirmed the following: -if a resident was not available at the time of the meal service, either a plate of food should be placed in a refrigerator for the resident or a new meal should be prepared when the resident was ready to be served; -Resident 67 and 68 should not have been served food which had been left sitting out and not refrigerated and meals should have been served at the appropriate temperature; -all foods items were to be labeled and dated before placed in an area for storage; and -the outdated loaf of bread should have been discarded. E. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for the food services sanitation practices, revealed the following: -3-201.11(C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9CFR 317 Labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.18; -3-403.11 (B) Potentially hazardous food reheated in the microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees (F); and -3-501.17 of the Food Code, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hour shall be clearly marked to indicate the date of preparation.",2020-09-01
726,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2018-08-16,880,D,0,1,48Y811,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview: the facility failed to prevent potential cross contamination between residents as hands were not washed at appropriate intervals during the provision of incontinence cares for Residents 68. The sample size was 8 current residents with a facility census of 68. Findings are: [NAME] Review of the facility policy titled Infection Prevention and Control Program dated 5/17, revealed the following regarding hand hygiene protocol: -all staff were to wash hands when coming on duty, between resident contacts, after handling contaminated objects, after removal of personal protective equipment and before going off duty; -staff shall wash their hands before and after performing resident care procedures; and -hands shall be washed in accordance with the facility's established hand washing procedure. B. During observation of nursing care on 8/14/18 at 10:34 AM, Nursing Assistant (NA)-C provided incontinence cares for Resident 68. NA-C removed soiled gloves and then placed lotion on the resident's extremities, dressed the resident, applied a brace to the resident's right hand, placed a gait belt on the resident, transferred the resident into a wheelchair, removed the resident's gait belt, placed foot pedals on the wheelchair, adjusted the resident's positioning in the chair and then assisted the resident with oral hygiene before washing hands in the resident's bathroom. C. Interview with the Director of Nursing on 8/16/18 at 11:48 AM, confirmed NA-C was expected to remove gloves and wash/sanitize hands following provision of incontinence cares and removal of soiled gloves.",2020-09-01
727,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,584,E,0,1,JTH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure the facility environment was well maintained and in good repair. The sample size was 30 and the facility census was 82. Findings are: [NAME] Observations on 9/23/19 at 1:02 PM, on 9/24/19 at 8:02 AM and on 9/25/19 at 9:39 AM revealed the following environmental concerns: -the baseboard next to an exit door and underneath a pane of frosted glass on the Advanced Alzheimer's Care Unit (AACU) with a heavy layer of a dark brown substance which resembled rust; -a window curtain rod broken with the curtain hanging off in the AACU dining room; -cover for an air conditioning/heater unit below a window in the AACU dining room was unattached; -gouged hole in the wooden door of the bathroom for resident room [ROOM NUMBER] on the AACU; -no door to a closet in resident room [ROOM NUMBER] on the AACU; -the walls in the corridor outside of the AACU and the Assisted Living Wing with multiple areas of joint compound which had not been sanded/[MEDICATION NAME] and then painted; and -brown staining to the wall around the door frame of a supply closet outside of the Assisted Living Wing in addition to the joint compound. B. Interview on 9/26/19 at 7:53 AM confirmed the identified environmental concerns needed to be repaired. C. Observations of the facility on 9/26/19 from 10:45 AM to 11:00 AM with the Administrator revealed: - In the hallway outside of the Emerald bath house the baseboard trim was missing in an area measuring approximately 4 inches by 4 inches, which left sharp edges. - In room B5 the walls along the East wall had a large amount of missing/scraped up paint, and the North wall had a hole in it. - Room B12's bathroom door had wood missing/splintered off in multiple areas. - The main dining room partial divider wall had missing paint and missing drywall. - The main dining room back door (leading outside) was rusted out at the bottom of the door frame. Interviews with the Administrator on 9/26/19 from 10:45 AM to 11:00 AM confirmed the observations and confirmed repairs were needed.",2020-09-01
728,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,641,D,0,1,JTH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on observation, record review, and staff interview the facility failed to accurately code Resident 19's MDS (Minimum Data Set/Federally mandated assessment requirement used for Care Plan development) to accurately reflect the resident's status. The sample size was 30 and the facility census was 82. Findings are: On 9/24/19 at 8:38 AM Resident 19 was approached for an interview and the resident requested an interpreter. The review of Resident 19's MDS dated [DATE] revealed: -the resident's primary language was Spanish; - section A question 1100 was coded as No which indicated the resident did not need or desire interpretation; -the resident's [DIAGNOSES REDACTED]. -the resident required extensive to total assistance with activities of daily living; and -the resident's BIMS (Brief interview for mental status) score was 15/15 indicating normal cognitive function. Interview with Register Nurse (RN)-G on 9/25/19 at 10:15 AM confirmed Residents 19's primary language was Spanish. Further interview confirmed section A question 1100 of Resident 19's MDS dated [DATE] was inaccurately coded.",2020-09-01
729,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,656,D,0,1,JTH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number 175 NAC 12-006.09C Based on record review and staff interview, the facility failed to develop a comprehensive plan of care to address Resident 19's language barrier and Resident 32's safe smoking off facility grounds. The sample size was 30 and the facility census was 82. Findings are: [NAME] On 9/24/19 at 8:38 AM Resident 19 was approached for an interview and the resident requested an interpreter. Review of Resident 19's MDS (Minimum Data Set/Federally mandated assessment requirement used for Care Plan development) dated 7/2/19 revealed the following: -The resident's primary language was Spanish, -the resident had a BIMS (Brief Interview for mental status) score of 15/15 which indicated normal cognitive function, -the resident required extensive to total assistance with activities of daily living, and -the resident had [DIAGNOSES REDACTED]. Review of Resident 19's Care Plan with a revision date of 7/2/19 revealed no interventions in place to address the resident's language barrier or communication deficit. During an Interview on 9/25/19 at 10:15 AM, Registered Nurse (RN)-G confirmed that Resident 19's Care Plan failed to include a comprehensive plan for communication. Further interview confirmed Resident 19's primary language was Spanish and a communication plan was needed to address Resident 19's language barrier and communication. B. During an interview on 9/25/19 at 10:00 AM, Resident 32 reported that the resident normally left the facility grounds independently 5 to 7 times a day to smoke cigarettes. On 9/25/19 at 2:50 PM, Resident 32 was observed outside of facility (off facility grounds) smoking independently. Review of Resident 32's MDS dated [DATE] revealed the following: -The resident had [DIAGNOSES REDACTED]. -The resident required set-up and supervision with activities of daily living. -The resident had a BIMS assessment score of 15/15 on 7/16/19 which indicated normal cognitive function. Review of Resident 32's Care Plan with a revision date of 7/26/19 revealed the following: - The resident had a history of [REDACTED]. - The resident frequently signed out of the facility to go outside and smoke. - The resident's primary mode of mobility was a wheelchair. Resident 32's Care Plan did not identify a plan or interventions to assure the resident's safety for off premises smoking. During an interview on 9/25/19 at 9:16 AM, the Clinical Nurse Consultant confirmed that interventions implemented to determine Resident 32's safety for leaving the facility grounds independently for smoking should have been included in Resident 32's comprehensive Care Plan.",2020-09-01
730,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,684,D,0,1,JTH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to meet Resident 30's needs related to bowel management and failed to provide monitoring and care for Residents 4 and 36 after an identified change in condition. The sample size was 3 and the facility census was 82. Findings are: [NAME] Review of the facility Bowel Protocol policy revised 12/22/18 revealed the purpose of the policy was to prevent constipation. Guidelines included: - Residents who had not had a bowel movement for 3 days were identified and considered to be at risk for constipation. -Nursing staff would encourage the resident to increase ingestion of fluids. -Nursing staff would encourage daily mobility, as capable, to help increase peristalsis and keep bowels moving. -Prune juice or bran/fiber supplements may be provided as needed (PRN) or routinely to those residents that were identified as having a history of constipation. -An alert would be generated in the electronic health record to notify the nursing staff when a resident had not had a bowel movement for 3 consecutive days. -For those residents identified without a recorded bowel movement within 3 days nursing was to auscultate for active bowel sounds, administer ordered PRN stool softener/laxative, dietary would supply nursing with prune juice, and the interventions would be documented. - If prune juice/non-medicinal interventions were ineffective, administer stool softener/laxative on day 3. B. Review of Resident 30's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/16/19 revealed the resident had severely impaired cognition. Review of Resident 30's current Care Plan with a revision date of 7/19/19 revealed the resident had an alteration in elimination of bowel and would yell out while having a bowel movement. The resident would yell out after having a bowel movement my butt hole hurts. Interventions included providing bowel medication as ordered with monitoring of the use and effectiveness, and to monitor bowel status frequently. Review of Resident 30's Bowel documentation dated 8/1/19 through 9/26/19 revealed: - The resident didn't have a bowel movement on 8/1/19, 8/2/19, or 8/3/19. - The resident didn't have a bowel movement on 8/8/19, 8/9/19, 8/10/19, or 8/11/19. On 8/12/19 the resident had 2 large hard bowel movements. - The resident didn't have a bowel movement on 8/29/19, 8/30/19, or 8/31/19. On 9/1/19 the resident had a small hard bowel movement. Review of Resident 30's Medication Administration Record's dated 8/2019 and 9/2019 and Progress Notes dated 8/1/19 through 9/26/19 revealed no evidence to indicate additional non-pharmacological or PRN pharmacological interventions were utilized to prevent/treat potential constipation. On 9/25/19 at 10:45 AM, during an interview with the resident and the resident's family member, the resident's family member stated the resident had a lot of pain during bowel movements. Shortly after, as the interview continued, the resident's face turned red and the resident was grimacing. The resident's family member stated the resident was trying to have a bowel movement. During an interview on 9/26/19 at 9:55 AM, Registered Nurse (RN)-K confirmed Resident 30 had trouble with constipation. RN-K confirmed the charge nurses should run a report to identify which residents had gone 3 days without a bowel movement and therefore needed to be given a stool softener/laxative. C. Review of the facility policy for Notification of Condition Change: Physician with revision date 12/17/18 revealed a change in a resident's condition was to be reported to the physician and the responsible party in a timely manner. Types of conditions that may require notification of the physician include: -altered mental status; -bleeding; -chest pain; -emesis; -falls; -changes in vital signs; -pain; -changes in behaviors; and -decreased dietary intakes and weight loss. D. Review of Resident 36's MDS dated [DATE] revealed the following regarding the resident: -required limited staff assistance with eating; -no therapeutic diet; -no loss of food or liquids from mouth with eating or drinking; -no coughing or choking with meals; -no broken or loosely fitting full or partial dentures, no tooth fragments and no obvious or likely cavity or broken natural teeth; and -no mouth pain or difficulty chewing. Review of a Nursing Progress Note dated 8/1/19 at 12:40 PM revealed the resident had spit out all offered foods during the noon meal. Review of a Nursing Progress Note dated 9/5/19 at 10:35 AM revealed the facility had reported the resident had loose teeth to the resident's Power of Attorney (POA). The POA indicated the resident should be seen by the dentist who comes to the facility and sees residents in house. Review of a Nursing Progress Note dated 9/15/19 at 9:36 AM revealed the resident had complained about tooth pain and was not eating meals. Review of a Progress Note dated 9/21/19 at 6:56 PM revealed the resident had a loose tooth and was refusing to eat the evening meal. Review of a Nursing Progress Note dated 9/23/19 at 2:26 PM revealed the resident's physician was notified regarding the resident's difficulty with chewing, oral pain and poor intakes with a new order for the resident to be evaluated by the Speech Therapist. Review of a Swallowing Ability and Function Evaluation completed by the Speech Therapist on 9/24/19 revealed the resident had little to no teeth for chewing with intolerance of regular or mechanically soft textures. A trial recommendation was identified for a puree diet to decrease the risk for malnutrition. Review of Resident 36's meal intakes from 9/1/19 through 9/25/19 revealed the following: -for the breakfast meal the resident consumed 25% or less on 9/2, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/14, 9/15, 9/16, 9/17, 9/18, 9/20, 9/22 and on 9/25 ( a total of 18 out of 25 days); -for the noon meal the resident consumed 25% or less on 9/1, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/12, 9/13, 9/14, 9/15, 9/16, 9/17, 9/18, 9/19, 9/20, 9/21, 9/22, 9/24, and on 9/25 (a total of 22 out of 25 days); and -for the evening meal the resident consumed 25% or less on 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/15, 9/16, 9/17, 9/18, 9/20, 9/21, 9/22, 9/23, 9/24, and on 9/25 ( a total of 22 out of 25 days). Review of Resident 36's medical record revealed no evidence the resident was seen by a dentist for ongoing concerns with mouth pain and poor dentation. During an interview on 9/25/19 at 9:10 AM, Licensed Practical Nurse (LPN)-H verified the following regarding Resident 36: -had difficulty chewing and was spitting out food at meals; -during oral cares staff identified the resident had only a few teeth remaining and these teeth appeared to be loose; -9/5/19 the resident's POA was contacted about having the resident seen by the dentist. The facility worked with a dental company that came to the facility to see residents and they usually came once a month or every other month; -the resident had not yet been seen by the dentist; -the resident continued to have poor intakes; and -the resident's physician was not notified until 9/23/19 of the resident's dental status and poor intakes. E. Review of Resident 4's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The resident's cognition was severely impaired and the resident required limited staff assistance with eating. Review of Resident 4's Nursing Progress Note dated 8/29/19 at 2:16 PM revealed the resident remained seated in the dining room after the noon meal. The resident had just gotten done with lunch when the resident had an emesis. The resident did not appear to have choked. The resident's skin was cold and pale. Review of a Nursing Progress Note dated 8/29/19 at 9:07 PM revealed the resident was lying in bed. Staff went to check on the resident and found the resident had vomited and vomit was observed on the resident's face, chin and chest, as well as the bed linens. The resident was assisted out of bed and was cleansed with the bed linens changed. The resident was assisted back to bed with the head of the bed elevated. The resident's oxygen saturation (amount of oxygen in the blood) was recorded at 86% (normal range for an adult is 96%-99%). Further review of the resident's medical record revealed [REDACTED]. In addition, there was no evidence to indicate the resident's physician was notified of the resident's change in condition. Review of Nursing Progress Notes for 8/30/19 revealed the following regarding Resident 4: -5:14 AM the resident's oxygen saturation level was 90%. review of the resident's medical record revealed [REDACTED]. -1:39 PM the resident had a few sips of fluids and a few bites of chicken broth for the noon meal and then had another emesis. The resident's vital signs were normal. A facsimile was sent to the resident's physician regarding the resident's repeated episodes of emesis and a request was made for a Speech Therapy evaluation; -1:56 PM the resident had another emesis which was dark brown in color and the physician was notified with an order for [REDACTED].>-7:42 PM the facility was notified by the hospital that the resident had been admitted . Interview on 9/25/19 at 2:29 PM with LPN-H confirmed the following regarding Resident 4: -emesis on 8/29/19 after the noon meal and after the resident had been assisted to bed that evening. Staff should have done a complete assessment of the resident's respiratory status when an oxygen saturation of 86% was received. In addition, the resident's physician should have been notified regarding the resident's change in condition; and -the resident's oxygen saturation level remained low the next morning. A full respiratory assessment should have been completed with the resident's physician notified.",2020-09-01
731,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,689,D,0,1,JTH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observations, record review and interview; the facility failed to develop interventions to prevent injuries for Resident 59 related to use of a Merry Walker (walker/chair combination which allows a person who would normally be wheelchair bound to ambulate independently) and to assure grab bars were secured to the resident's beds for Residents 37 and 49. The sample size was 6 and the facility census was 82. Findings are: [NAME] Review of Resident 59's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/27/19 revealed [DIAGNOSES REDACTED]. The MDS identified the following regarding the resident: -required extensive staff assistance with bed mobility, transfers, dressing, personal hygiene and with toileting; -severely impaired decision making skills; -wandering which occurred on a daily basis; and -the resident had 2 falls without injury since the previous assessment. Review of the resident's current Care Plan with a revision date of 6/13/19 revealed the resident was at risk for injury related to impaired safety awareness with [DIAGNOSES REDACTED]. Review of a Nursing Progress Note dated 8/3/19 at 3:31 PM revealed the resident was in the Merry Walker and had approached a table. The resident pushed the frame of the walker against the table in an attempt to tip over the walker. The resident was also observed running into things and into other people with the walker. Review of a Nursing Progress Note dated 8/4/19 at 2:10 PM revealed the resident was wandering into other resident's rooms, trying to push through places the walker would not fit and running into other people. Review of a Nursing Progress Note dated 8/17/19 at 4:58 PM revealed the resident was going full speed in the walker with head down and running into things and other residents. The resident over-powered the staff when staff attempted to redirect the resident. The resident was observed to strike the resident's right hand and the hand was bleeding. The note further indicated it took 3 staff to cleanse the resident's hand and to apply a clean dressing to the injury. The resident continued to go up and down the corridor at full speed. The resident was given 1:1 as much as possible. Review of a Nursing Progress Note dated 8/18/19 at 5:34 PM revealed the resident had been active in the Merry Walker all afternoon and had been bumping into furniture. Review of a Nursing Progress Note dated 8/25/19 at 1:24 PM revealed the resident was in the Merry Walker and inappropriately running into people. Review of a Nursing Progress Note dated 9/10/19 at 1:26 PM revealed the resident had a 1.2 centimeter (cm) by 1 cm bruise under right eye. The resident had been walking in the Merry Walker and glasses were found on the floor. The resident bumped glasses and they fell off. Review of a Nursing Progress Note dated 9/12/19 at 10:56 PM revealed the resident had an injury of unknown origin with a 2 cm by 1.6 cm abrasion to the resident's right eyebrow. The note further indicated the resident had been walking around in the Merry Walker and bumping into objects with the walker. Review of an Injury of Unknown Origin Investigation dated 9/13/19 revealed the resident was independent with the walker and at times would lean forward resting face on the walker. The resident had a history of [REDACTED]. Unit (ACU). A staff member reported opening the doors and bumping the resident's walker on 9/12/19. Staff further reported if the resident was bent forward, the doors may have also bumped the resident's head causing the abrasion to the right eyebrow. A sign was posted to open the doors between the units slowly to avoid potential further injury. Review of a Nursing Progress Note dated 9/14/19 at 4:09 PM revealed the resident had been wandering in the corridor and in the dining room. The resident would run into other resident's while ambulating in the walker. Review of a Nursing Progress Note dated 9/14/19 at 9:18 PM revealed the resident continued to wander in the corridor and was running into other residents. Review of a Nursing Progress Note dated 9/22/19 at 1:18 PM revealed the resident was wandering in and out of other resident's rooms and bumping into staff, other residents and other objects. During observations on 9/23/19 from 12:00 PM to 12:30 PM and on 9/24/19 from 10:11 AM to 11:22 AM, the resident was seated in the Merry Walker. Resident 59 ambulated in the walker from one end of the corridor to the opposite end. Once the resident reached the ends of the corridor, the resident would use the frame of the walker to repeatedly push into the exit doors until staff approached the resident and redirected from the exits. The resident kept head down as the resident paced up and down the corridor. Observations on 9/25/19 revealed the following: -11:20 AM the doors between the AACU and the ACU had been left open. Resident 59 was positioned inside of the Merry Walker and exited the ACU where the resident's room was located and entered into the AACU. The resident bumped into the medication cart and then kept walking until the resident reached the corner between an outside exit door and the AACU dining room. The resident pushed the frame of the walker repeatedly into the glass of the exit door in an attempt to advance the walker but was unsuccessful; and -11:27 AM (7 minutes after the resident left the secured ACU) Licensed Practical Nurse (LPN)-H entered the AACU looking for the resident and re-directed Resident 59 to the ACU. LPN-H then closed the doors between the 2 units. During an interview with the Director of Nursing (DON) on 9/26/19 at 9:32 AM, the DON confirmed the following regarding Resident 59: -at risk for injury due to daily episodes of wandering and poor safety awareness; -staff had been instructed to provide monitoring when the resident was more active; and -no additional interventions had been developed and/or initiated to maintain the resident's safety while positioned in the Merry Walker. B. Observations of Resident 37's room on 9/23/19 at 11:45 AM, 9/24/19 at 1:00 PM and on 9/25/19 at 12:00 PM revealed that the grab bar on the left side of the bed was loose. Review of the care plan, goal date 11/2/19, revealed that the resident used the grab bar for repositioning in bed. C. Observations of Resident 49's room on 9/23/19 at 10:00 Am and on 9/25/19 at 12:00 PM revealed that the grab bars on each side of the bed were loose. Interview with the resident on 9/23/19 at 10:00 AM revealed that the grab bars were used for repositioning in bed. Interview with the Maintenance Director on 9/25/19 at 12:00 PM confirmed that the residents' grab bars were loose and needed to be tightened to reduce the risk for accidents.",2020-09-01
732,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,695,D,0,1,JTH111,"Licensure Reference Number: 175 NAC 12-006.09D6(7) Based on observations, record review and interview; the facility failed to document oxygen use for one current sampled resident (Resident 29) to ensure that the resident's respiratory needs were met. The facility census was 82 with five sampled residents for medication regime review. Findings are: Observations on 9/25/19 at 7:34 AM revealed Resident 29 resting in bed with oxygen on per concentrator. Further observations at 1:14 PM revealed the resident seated in a wheelchair in the hallway by the front nurses station with no supplemental oxygen in place. Review of the ETAR(Electronic Treatment Administration Record), dated (MONTH) 2019, revealed an order, beginning on 9/3/19, for oxygen at two liters per minute as needed to keep oxygen saturation above 90%. Further review revealed no documentation that the resident received oxygen this month. Interview with the Director of Nursing on 9/25/19 at 9:45 AM revealed that the resident used the oxygen at night when needed. Further interview confirmed that the nurses were to document the oxygen used on the ETAR to ensure that the resident's respiratory needs were met.",2020-09-01
733,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,697,D,0,1,JTH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to address Resident 30's ongoing complaints of pain. The sample size was 1 and the facility census was 82. Findings are: Review of the facility Pain Management policy dated 11/2017 revealed the facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility would utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Behavioral signs and symptoms that may suggest the presence of pain include but were not limited to: change in gait, loss of function, decline in activity level, resisting cares/striking out, bracing/guarding/rubbing, fidgeting/increased or recurring restlessness, facial expressions such as grimacing/frowning/fear/grinding of teeth, change in behavior, loss of appetite, sleeping poorly, and sighing/groaning/crying/heavily breathing. The pain assessment should include identifying key characteristics of pain such as duration, frequency, location, onset, pattern, and [MEDICAL CONDITION]. If the resident's pain was not controlled by the current treatment regimen, the practitioner should be notified. The interdisciplinary team and the resident would collaborate to arrive at pertinent, realistic, and measureable goals for treatment. If re-assessment findings indicate pain was not adequately controlled, revise the pain management regimen and plan of care as indicated. Review of Resident 30's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/16/19 revealed the resident had severely impaired cognition. Further review revealed the resident had indicators of possible pain/pain which included non-verbal sounds, facial expressions, and vocal complaints of pain. The resident had pain/possible pain daily. Review of Resident 30's current Care Plan with a revision date of 7/19/19 revealed the resident was at risk for pain. Interventions included: - Administering pain medications as tolerated, observe and document the frequency and intensity of the pain symptoms. - Use the resident's verbal reports and staff's clinical judgment for the pain assessment. Follow a standardized assessment tool. -Observe/document for side effects of pain medication. -Observe/document the effectiveness or ineffectiveness of medication and notify the practitioner as needed. The resident's Care Plan failed to identify the standardized assessment tool that was to be used and failed to identify a measurable target pain control goal. Review of Resident 30's Medication Administration Records dated 8/2019 and 9/2019 revealed the resident had a pain scale rating of 5 or above on 12 occasions. Further review revealed on only 2 of the 12 occasions the resident received a PRN (as needed) pain medication. On 9/25/19 at 10:45 AM, an interview was completed with the resident and a family member. When asked about pain control the resident stated no no (which is the resident's frequent response due to limited abilities to verbalize). When the resident was asked if the resident wanted more for pain relief the resident stated yes. An observation of Resident 30's Wound Vac (a device that drains seeping liquids from a wound by forming an airtight cover and pumping the liquid out) dressing change was completed on 9/25/19 from 11:25 AM to 11:45 AM with Licensed Practical Nurse (LPN)-E and Registered Nurse (RN)-K. Resident 30 yelled out as LPN-E removed the old dressing and cleaned the areas. Resident 30 was then quiet while the protective draping for the Wound Vac was put into place and with the placement of the [MEDICATION NAME] (a dressing used with Wound Vac therapy) into the coccyx wound. LPN-E then went to pack the [MEDICATION NAME] into the resident's trochanter wound and the resident yelled out oww,oww repeatedly during that time. Interviews with LPN-E and RN-K on 9/25/19 at 11:40 AM confirmed Resident 30 had not received any pain medication prior to the wound treatment. During a follow up interview on 9/26/19 at 9:55 AM, RN-K was unsure at what pain rating the facility should give a PRN pain medication for Resident 30 (who cannot make most needs known). RN-K stated RN-K would give a PRN pain medication if the resident was acting like they were having more pain than usual. During an interview on 9/26/19 at 10:45 AM, the Director of Nursing confirmed it could be anticipated that a resident would likely have pain during a wound care treatment with a wound as significant as Resident 30's.",2020-09-01
734,EMERALD NURSING & REHAB COLUMBUS,285092,"P O BOX 625, 2855 40TH AVENUE",COLUMBUS,NE,68602,2019-09-26,880,D,0,1,JTH111,"Licensure Reference Number: 175 NAC 12-006.17B Based on observation and interview, the facility failed to ensure that 1) personal care items were marked in a shared bathroom for two current sampled residents (Residents 31 and 249) and 2) personal care items were not stored on the bathroom floor for one current sampled resident (Resident 45) to reduce the risk for cross contamination. The facility census was 82 with 22 current sampled residents. Findings are: [NAME] Observations of Resident 31 and 249's bathroom on 9/23/19 at 11:45 AM, 9/24/19 at 1:30 PM and on 9/25/19 at 7:15 AM and 11:45 AM revealed a variety of unlabeled personal care items, including mouthwash, lotions, perineal wash and wipes, were stored on the back of the toilet and on a shelf above the toilet. B. Observations of Resident 45's bathroom on 9/23/19 at 11:45 AM, 9/24/19 at 1:30 PM and on 9/25/19 at 7:15 AM and 11:45 AM revealed an uncovered plastic wash basin with oral care items stored on the bathroom floor behind the toilet. Interview with the Director of Nursing on 9/25/19 at 11:45 AM confirmed that personal care items, stored in a shared bathroom, needed to be labeled with the residents' names to reduce the risk for cross contamination. Further interview confirmed that personal care items were not to be stored on the bathroom floor to reduce the risk of cross contamination.",2020-09-01
735,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-02-07,623,D,1,0,Y9LY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (5) Based on interview and record review, the facility failed to issue Resident 1 a 30 day notice of discharge from the facility. This affected 1 of 3 sampled residents. The facility identified a census of 58 at the time of survey. Findings are: Review of Resident 1's Discharge Tracking Form dated 1/11/2018 revealed Resident 1 was admitted to the facility on [DATE] and discharged from the facility to the hospital return not anticipated on 1/11/2018. Interview with Resident 1's legal representative on 2/7/2018 at 12:12 PM revealed the facility had not given Resident 1's legal representative 30 days notice that Resident 1 would not be allowed to return to the facility. Interview with the facility Administrator on 2/7/2018 at 3:59 PM confirmed that Resident 1 was discharged to the hospital and would not be returning to the facility. Review of Resident 1's medical record revealed no documentation Resident 1's legal representative had been given 30 days notice that Resident 1 would not be allowed to return to the facility. Interview with the DON (Director of Nursing) on 2/7/2018 at 3:59 PM confirmed there was no written documentation Resident 1's legal representative was given 30 days notice that Resident 1 would not be allowed to return to the facility. Review of the undated facility policy Bed Hold Policy and Notification revealed the following: It is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation or therapeutic leave of our bed hold policy and notification. Each resident/legal representative will be informed by of the Facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave.",2020-09-01
736,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-02-07,625,D,1,0,Y9LY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to notify the legal representative for Resident 1 and Resident 3 of the facility Bed Hold policy at the time of discharge. This affected 2 of 3 sampled residents. The facility identified a census of 58 at the time of discharge. Findings are: [NAME] Review of Resident 1's Discharge Tracking Form dated 1/11/2018 revealed Resident 1 was admitted to the facility on [DATE] and discharged from the facility to the hospital on [DATE]. Interview with Resident 1's legal representative on 2/7/2018 at 12:12 PM revealed the facility had not given Resident 1's legal representative notice of Bed Hold when Resident 1 was transferred to the hospital. Review of Resident 1's medical record revealed no documentation Resident 1's legal representative had been given notice of Bed Hold upon discharge to the hospital. B. Review of Resident 3's Discharge Tracking Form dated 12/26/2017 revealed Resident 3 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of Resident 3's medical record revealed no documentation Resident 3's legal representative had been given notice of Bed Hold when Resident 3 was transferred to the hospital. Interview with the DON (Director of Nursing) on 2/7/2018 at 3:59 PM confirmed there was no written documentation the legal representatives for Resident 1 or Resident 3 were given notice of Bed Hold. Interview with the interim SSD (Social Services Director) on 2/7/2018 at 4:05 PM confirmed the facility residents and/or legal representatives were to be issued the facility Bed Hold policy at the time of transfer and/or discharge. Review of the undated facility policy Bed Hold Policy and Notification revealed the following: It is our policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation or therapeutic leave of our bed hold policy and notification. Each resident/legal representative will be informed by of the Facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident leaves for hospitalization , observation or therapeutic leave.",2020-09-01
737,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,164,D,0,1,5XF311,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (20) Based on observation, interview, and record review; the facility staff failed to maintain resident privacy by posting care instructions in areas visible to the public for Resident 52. This affected 1 of 3 sampled residents. The facility identified a census of 57 at the time of survey. Review of Resident 52's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plant) dated 3/31/2017 revealed Resident 52 had an entry date of 3/24/2017. Resident 52 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 52 was cognitively intact. Resident 52 required extensive assistance from 2 staff persons for bed mobility, dressing, and personal hygiene and Resident 52 was dependent upon 2 staff persons for transfers and toilet use. Observation of Resident 52's room on 8/16/2017 at 1:27 PM revealed signage regarding specific care instructions for how to transfer Resident 52 hanging on the wall by the recliner and on the bathroom door. The signage on the wall by Resident 52's recliner was visible from Resident 52's door to passers-by. Review of Resident 52's care plan dated 6/22/2017 revealed no documentation that Resident 52 had requested that facility staff post care information in view of the public. Interview with Resident 52 on 8/16/2017 at 1:59 PM revealed Resident 52 preferred the signage with care instructions not be posted in the room in view of others. Interview with the DON (Director of Nursing) on 8/16/2017 at 2:48 PM revealed the signage with care instructions should not be posted in areas visible to the public. Review of the facility policy Dignity dated 3/31/2016 revealed the following: Policy statement: All residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. Purpose: Treating residents with dignity and respect maintains and enhances each resident's self-worth and improves his or her psychosocial well-being and quality of life. Maintaining Dignity: Through example, education, and monitoring, the social services staff will promote the following types of staff interaction with residents, which maintain their dignity: Respecting residents' private space and property.",2020-09-01
738,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,226,D,1,1,5XF311,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3b Based on interview and record review, the facility failed to follow the facility policy for screening employees for potential abuse and neglect for 2 of 5 sampled personnel files for MA-E and F (Medication Aide). The facility identified a census of 57 at the time of survey. Findings are: [NAME] Review of MA (Medication Aide)-E's personnel file revealed MA-E's name was misspelled on the Nebraska Central Registry Check Request for APS (Adult Protective Services) and CPS (Child Protection Services) dated (MONTH) 14, (YEAR). There was no documentation the form had been corrected and the request resubmitted. MA-E's date of hire was 4/12/2017. B. Review of MA-F's personnel file revealed a Nebraska Central Registry Check Request notification dated (MONTH) 4, (YEAR) for MA-F which indicated the request for APS and CPS registry check was returned and not processed due to missing information. There was no documentation the APS and CPS registry check had been completed. MA-F's date of hire was 5/4/2017. Interview with HR (Human Resources) on 8/15/2017 at 2:47 PM confirmed there was no documentation the APS and CPS registry checks had been completed for MA-E and MA-F. Interview with RN (Registered Nurse)-C on 8/15/2017 at 2:55 PM confirmed the personnel files for MA-E and MA-F did not contain evidence the APS and CPS registry checks had been completed. Interview with the facility Administrator on 8/15/2017 at 2:58 PM confirmed MA-E and MA-F were both working in the facility and had been providing direct resident care. Interview with the DON (Director of Nursing) on 8/15/2017 at 3:30 PM confirmed that MA-E had completed training and started working unsupervised on 4/19/2017 and MA-F had completed training and started working unsupervised on 5/13/2017. The DON confirmed that MA-E and MA-F were working in the facility and providing direct resident care. Interview with RN-C on 8/15/2017 at 3:53 PM revealed RN-C and HR had to contact APS and CPS to obtain the necessary registry checks as they were not in their personnel files prior to the current date. Review of the Nursing Schedule for April, May, June, July, and (MONTH) (YEAR) revealed MA-E and MA-F were scheduled to work. Review of the facility policy Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property dated 9/7/2016 revealed the following: All applicants for employment in the company shall, at a minimum, have the following screening checks conducted: appropriate licensing board or registry check.",2020-09-01
739,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,241,E,0,1,5XF311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to maintain resident dignity by failing to knock and wait for permission to enter the rooms of Residents 52, 62, 3, and 26; failing to ensure that the disposable incontinent underpads were not left on top of the beds in view of others for Residents 26, 72, 11 and 53; failing to ask Resident 11's permission to apply a clothing protector; and failing to sit down next to Residents 41, 55, 3, and 63 while assisting them with eating. This affected 10 of 57 sampled residents. The facility identified a census of 57 at the time of survey. [NAME] Review of Resident 52's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plant) dated 3/31/2017 revealed Resident 52 had an entry date of 3/24/2017. Resident 52 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 52 was cognitively intact. Resident 52 required extensive assistance from 2 staff persons for bed mobility, dressing, and personal hygiene and Resident 52 was dependent upon 2 staff persons for transfers and toilet use. Observation of Resident 52's room on 8/15/2017 at 12:47 PM revealed LPN (Licensed Practical Nurse)-I opened Resident 52's closed door without knocking and waiting for permission to enter. Review of Resident 52's care plan dated 6/22/2017 revealed no documentation that Resident 52 had requested that facility staff could enter their room without knocking and requesting permission to enter. Interview with Resident 52 on 08/16/2017 on 1:59 PM revealed Resident 52 expected facility staff to knock and wait for permission to enter their room. Interview with the DON (Director of Nursing) on 8/16/2017 at 2:48 PM revealed the facility staff were expected to knock and wait for permission before entering a resident's room. Review of the facility policy Dignity dated 3/31/2016 revealed the following: Policy statement: All residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. Purpose: Treating residents with dignity and respect maintains and enhances each resident's self-worth and improves his or her psychosocial well-being and quality of life. Maintaining Dignity: Through example, education, and monitoring, the social services staff will promote the following types of staff interaction with residents, which maintain their dignity: Respecting residents' private space and property. B. Observation on 8/14/2017 at 1:48 PM identified a disposable incontinent underpad was placed on top of Resident 26's bed while the resident was out of their room. Observation on 8/14/2017 at 2:01 PM identified a disposable incontinent underpad was placed on top of Resident 72's bed while the resident was out of their room. Observation on 8/14/2017 at 2:02 PM identified a disposable incontinent underpad was placed on top of Resident 11's bed while the resident was out of their room. Observation on 8/14/2017 at 3:58 PM identified a disposable incontinent underpad was placed on top of Resident 53's bed while the resident was out of their room. C. Observation on 8/15/2017 at 1:20 PM identified that LPN-A opened the doors to room [ROOM NUMBER] and room [ROOM NUMBER] without knocking on the doors nor introducing self prior to entering the rooms . D. Observation on 8/14/2017 at 11:53 AM identified that NA-G (Nurse Aide) put on a clothing protector for Resident 11 without asking the resident's permission nor told the resident what they were doing. Observation on 8/15/2017 at 11:08 AM identified that NA-G put on a clothing protector for Resident 11 without asking the resident's permission nor told the resident what they were doing. Resident 11 asked NA-G what they were doing after putting on the resident's clothing protector. E. Observation on 8/14/2017 at 11:53 AM identified that NA-G stood up next to Resident 3 while assisting the resident to eat. Observation on 8/15/2017 at 12:12 PM identified that NA-G stood up next to Residents 41 and 55 while assisting the residents to eat and NA-H stood up next to Residents 3 and 63 while assisting the residents to eat. Review of facility policy titled, Dignity, dated 3/31/2016, identified that the purpose of the policy is, Treating residents with dignity and respect maintains and enhances each resident's self-worth and improves his or her psychosocial well-being and quality of life. Interview with the DON (Director of Nursing) and ACU Director on 8/15/2017 at 2:30 PM confirmed that the expectations of the nursing staff were not to leave disposable incontinent underpads on top of beds, to knock on the resident's door and introduce self prior to entering the resident's room, to ask the resident's permission to put on their clothing protector prior to putting it on the resident, and to sit down next to the residents when they were assisting them with eating.",2020-09-01
740,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,244,E,0,1,5XF311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.06 Based on record review and interviews, the facility failed to address and resolve the resident's grievances. This affected one identified resident (Resident 28) and four unidentified residents out of 5 sampled residents. Facility census was 57 at the time of survey. Findings are: [NAME] Interview with a family member for Resident 28 on 8/17/17 at 8:56 AM revealed a complaint about noise of loud televisions at night. The Family Member had entered the facility on 8/16/17 at 8:30 PM last evening and the televisions in the 100 wing were loud and stated, we have been battling this for years. The Family Member said, Resident 28 complained that the television noise goes on until 1 AM. The Family Member had talked to the Administrator, on various occasions, to be told the television noise could be up as loud as the other residents wished. The Family Member revealed nothing has been done about the television noise late at night. The Family Member had talked to the Ombudsman, date unknown, to be told the residents have the right to turn up their televisions. Interview with Resident 28 on 08/17/2017 at 12:00 PM revealed the television noise goes on from 6:30 AM to very late at night. The resident then stated, I cannot sleep. Review of a form entitled Noise Control, presented by the Family Member, dated 5/1/11, revealed the form stated to keep the sound level of radios and televisions at a level that will not disturb other residents, their families, or visitors. Resident 28 and their Family Member presented grievance forms dated 11/29/16 about a loud television half of the night every night and also dated 1/23/17 that there was television noise at night. A resolution note dated 3/21/17 read unresolved due to resident believing volumes were still excessive. Record review revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation of the noise level in the 100 hall at 10:30 AM on 8/17/17 revealed the television could be heard in the hall outside rooms 102, 104 and 101. Observation of the noise level in the 100 hall on 08/17/2017 at 12:00 PM revealed the television could be heard from rooms [ROOM NUMBERS] in the hall. Observation of the noise level in the 100 hall on 08/17/2017 at 1:10:48 PM revealed the televisions could be heard from the hall from room [ROOM NUMBER], 102, and 104. On 08/17/2017 at 1:21 PM the Administrator and the Social Service Director stood in the hall near the front nurse's station and heard the television noise. Interview on 08/17/2017 at 1:24:18 PM with the Administrator and the Social Service Director acknowledged the complaints of television noise in the 100 hall.",2020-09-01
741,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,248,D,1,1,5XF311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 175 NAC 12-006.09D5b Based on observations, record review and interviews; the facility failed to provide individualized activities for 3 (Residents 53, 62, and 26) of 11 sampled residents who resided in the AACU (Advanced Alzheimer's Care Unit). The facility census was 57. Findings are: [NAME] Observation on 8/14/2017 at 8:48 AM identified that Resident 53 was in bed with pajamas on, the lights on, the television on and the drapes pulled open. Observation on 8/14/2017 at 10:24 AM identified that Resident 53 was in bed with the lights off and the door closed. Observation on 8/14/2017 at 12:20 PM identified that Resident 53 was sitting at the dining room table in a wheelchair waiting for the lunch meal to be served. Observation on 8/14/207 at 4:05 PM identified that Resident 53 was sitting in the wheelchair in the resident's room with the lights on, the drapes pulled open and the door closed. Review of the (MONTH) activity calendar for AACU identified that Manicures was the activity for the day. There was no time posted as to when the activity was to begin. Observation on 8/15/2017 at 10:48 AM identified that Resident 53 was sitting at the dining room table alone in a wheelchair with eyes closed. Observation on 8/15/2017 at 11:23 AM identified that Resident 53 was sitting at the dining room table with eyes open waiting for the lunch meal to be served. Observation on 8/15/2017 at 12:55 PM identified that Resident 53 ambulated self from the dining room in the wheelchair to the resident's room. Observation on 8/15/2017 at 1:25 PM identified that the Director of Nursing went into Resident 53's room to assist the resident with toileting. Observation on 8/15/2017 at 2:50 PM identified that Resident 53 was assisted to the bathhouse by nursing staff to get a whirlpool bath. Review of the (MONTH) (YEAR) activity calendar for AACU, identified that Walk Outside was the activity for the day. There was no time posted as to when the activity was to begin. Observation on 8/16/2017 at 8:55 AM identified that Resident 53 was sitting at the dining room table with their head tilted to the side and sleeping. Observation on 8/16/2017 at 11:05 AM identified that Resident 53 was sleeping on top of the bed in the resident's room with a blanket over the resident. Review of the Annual 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 6/07/2017 for Resident 53 identified that the resident stated that participating in a favorite activity was very important. Review of the Comprehensive Care Plan dated 6/16/2017 included interventions for the resident to be involved in activities that didn't depend on the patient's ability to communicate such as music, parties and games. The Care plan also included interventions such as exercising, including walk and dine program to allow muscles to be limber and have decreased joint pain and to invite resident to food related activities. B. Observation on 8/14/2017 at 8:51 AM identified that Resident 62 was sleeping in bed with the lights off and the drapes closed. Observation on 8/14/2017 at 10:20 AM identified that Resident 62 was sleeping in bed with the lights off and drapes closed. Observation on 8/14/2017 at 11:44 AM identified that Resident 62 was sitting at the dining room table eating the lunch meal. Observation on 8/14/2017 at 2:45 PM identified that Resident 62 was sitting at the dining room table. The television in the dining room was turned off. Observation on 8/14/2017 at 4:00 PM identified that Resident 62 was sitting in a recliner in the dining room. The television in the dining room was turned off. Review of the (MONTH) (YEAR) activity calendar for the AACU identified that Manicures was the activity for the day. There was no time posted as to when the activity was to begin. Observation on 8/15/2017 at 10:51 AM identified that Resident 62 was sitting on the bed with their back against the wall in the resident's room. The lights were on and the drapes were pulled open and the door was open to the room. Observation on 8/15/2017 at 12:55 PM identified that Resident 62 was laying on the bed with a blanket and their eyes were open. Observation on 8/15/2017 at 12:57 PM identified that Resident 62 was walking down the hallway towards the dining room. The nursing staff assisted the resident to the dining room table. At 1:07 PM, the Director of Nursing assisted the resident back to the room to change the resident's pants. Observation on 8/15/2017 at 2:46 PM identified that Resident 62 was laying on top of the bed in the resident's room with the lights on. Observation on 8/15/2017 at 3:50 PM identified that Resident 62 was sitting on top of the bed crying. Nursing staff assisted the resident to the dining room and gave the resident a roll and a glass of milk. Review of the (MONTH) (YEAR) activity calendar for the AACU identified that Walk Outside was the activity for the day. There was no time posted as to when the activity was to begin. Observation on 8/16/2017 at 9:03 AM identified that Resident 62 was laying on top of the bed, fully clothed and the lights were on to the room. Observation on 8/16/2017 at 11:04 AM identified that Resident 62 was laying on top of the bed in the resident's room. Review of the MDS dated [DATE] identified the following regarding activities for Resident 62: Reading books, newspapers and magazines were somewhat important; listening to music was very important; doing things with groups of people were very important; doing resident's favorite activity was very important; going outside was somewhat important. Review of the care plan dated 6/29/2017 for Resident 62, stated that the resident would like to continue to participate in the recreational activities that the resident currently enjoyed. The interventions included in the care plan were to assist with simple activities/puzzles, ball throw, small truck, etc.; supervise the resident in the courtyard area, listen to music related to favorite artists and styles; assist with reading materials related to favorite authors and interests and primarily looking at newspapers. Interview with the ACU (Alzheimer's Care Unit) Director on 8/16/2017 at 10:00 AM identified that nursing staff provided the activities for the AACU residents. Interview with LPN (Licensed Practical Nurse)-A, on 8/16/2017 at 10:02 AM confirmed that manicures was not provided on Monday, (MONTH) 14, (YEAR), walking outside was not provided on Tuesday, (MONTH) 15, (YEAR), and manicures was not an appropriate activity for the men residing in the AACU. It was confirmed that no activity was provided for the residents the past two days in the AACU. Interview with the Activities Director, on 8/16/2017 at 10:23 AM revealed that the activities department did not provide activities for the AACU. C. Observation of Resident 26 on 8/14/17 at 1:10 PM found the resident in the room and no activities offered. Observation of Resident 26 on 08/15/2017 at 10:51:37 AM found the resident laying on the bed with their eyes closed and no activities offered. Observation of cares for Resident 26 on 08/15/2017 at 11:32 AM revealed no talking with the resident about anything other than the cares being provided by the staff. Observation of Resident 26 on 8/15/17 at 2:00 PM found the resident sitting in the resident's room in the wheelchair with no activities offered, Observation of Resident 26 on 08/15/2017 at 4:14:10 PM found the resident laying in the bed in their room and no activities offered. Observation of Resident 26 on 08/16/2017 at 8:18:23 AM found the resident sitting at the breakfast table eating. Review of Resident 26's face sheet revealed an admission date of [DATE]. Review of Resident 26's MDS dated [DATE], revealed the resident had short and long term memory problems, was severely impaired for daily decision making, had verbal behaviors, and needed staff assistance for , bed mobility, transfers, and locomotion on and off the unit. Review of Resident 26's MDS dated [DATE] revealed animals and pets were very important to the resident as well as, to get outside for fresh air when the weather was good. Review of the activity calendar for (MONTH) (YEAR) revealed Monday, 8/14/17, was scheduled manicures, 8/15/17, walk outside, 8/16/17, painting. Observations did not reveal the resident was in any of the listed activities. Interview with the AACU Director on 08/16/2017 at 10:00 AM revealed the AACU staff were responsible to offer activities to the residents. Interview with LPN-A (Licensed Practical Nurse) on 08/16/2017 at 10:02 AM revealed that manicures activity was not completed as scheduled for Monday and that the walk outside was scheduled for Tuesday and it did not happen. Interview with the Activity Director on 08/16/2017 at 10:27 AM revealed the staff on the AACU do the activities.",2020-09-01
742,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,253,E,0,1,5XF311,"LICENSURE REFERENCE 175 NAC 12-006.18A(1) Based on observations and interviews, the facility failed to ensure that; 1) bathroom light fixtures above the sink were free from dead bugs and debris affecting Residents 26, 7, 29, 53, and 11; 2) floors were free from stains around the toilets affecting Residents 86 and 4; 3) windows were free from white film and cloudy substances affecting Residents 32, 52, and 58; 4) privacy curtains were free from stains affecting Residents 26 and 90; 5) bathroom sinks were free from rust for Residents 79 and 91; 6) bathrooms were free from odors affecting Resident 26; 7) floor tiles in front of the bathroom were free from cracks affecting Resident 26; 8) a bathroom vent hanging from the ceiling affecting Resident 86; 9) bathroom and resident room walls were free from holes and marred areas affecting Residents 26, 52, 25, 38, 58, 29, and 90; 10) bathroom and resident room doors were free from holes, chips, marred areas and torn covers affecting Resident 24, 79, 58, 29, 46, 86, 4, 24, 18; and 11) an uncovered toilet riser was sitting on the floor under the bathroom sink affecting Resident 11. This affected 18 out of 49 sampled residents (Residents 52, 32, 79, 7, 25, 38, 58, 29, 46, 26, 86, 4, 24, 18, 53, 91, 90, and 11). The facility census was 57. Findings are: [NAME] Tour of the resident room occupied by Resident 90 on 8/14/2017 at 9:03 AM revealed that the privacy curtain was stained with a dark brown substance and the bathroom walls were marred and had holes in them. B. Tour of the resident room occupied by Resident 86 on 8/14/2017 at 9:07 AM revealed that there was a brown stain on the floor around the toilet and the cover on the inside of the bathroom door was torn. C. Tour of the resident room occupied by Resident 32 on 8/14/207 at 2:10 PM revealed that the window had a white film and a splattered stain on it. D. Tour of the resident room occupied by Resident 4 on 8/14/2017 at 10:56 AM revealed that there was a stain on the floor around the toilet and the inside cover of the bathroom door was torn. E. Tour of the resident room occupied by Resident 18 on 8/14/2017 at 11:35 AM revealed that the inside cover of the bathroom door was coming off of the door. F. Tour of the resident room occupied by Resident 11 on 8/14/2017 at 12:00 PM revealed that there were dead bugs in the light fixture above the bathroom sink and there was a toilet riser sitting on the floor below the bathroom sink. [NAME] Tour of the resident room occupied by Resident 25 on 8/14/2017 at 12:03 PM revealed that the bathroom walls were marred and had holes in them. H. Tour of the resident room occupied by Resident 26 on 8/14/2017 at 1:13 PM revealed that the bathroom had a strong ammonia odor, the bathroom walls were marred up, there were dead bugs and debris in the light fixture above the bathroom sink, the floor tiles in front of the bathroom were cracked and the privacy curtain was stained with a dark brown substance. I. Tour of the resident room occupied by Resident 52 on 8/14/2017 at 2:05 PM revealed that the wall behind the resident's recliner was marred and the window had a cloudy substance on it. [NAME] Tour of the resident room occupied by Resident 79 on 8/14/2017 at 2:18 PM revealed that resident room door was chipped and the overflow drain in the bathroom sink was rusty. K. Tour of the resident room occupied by Resident 38 on 8/14/2017 at 2:21 PM revealed that there was a tear in the drywall on the bathroom wall. L. Tour of the resident room occupied by Resident 58 on 8/14/2017 at 2:36 PM revealed a drywall patch on the bathroom wall, the resident room door was chipped, and the room windows had a white filmy substance on them. M. Tour of the resident room occupied by Resident 46 on 8/14/2017 at 2:41 PM revealed that the resident room door was marred and chipped. N. Tour of the resident room occupied by Resident 24 on 8/14/2017 at 2:44 PM revealed that the bathroom door was marred. O. Tour of the resident room occupied by Resident 91 on 8/14/2017 at 2:48 PM revealed that there were rust stains on the inside of the bathroom sink. P. Tour of the resident room occupied by Resident 7 on 8/14/2017 at 3:52 PM revealed that there were dead bugs and debris inside the light fixture above the bathroom sink. Q. Tour of the resident room occupied by Resident 53 on 8/14/2017 at 3:57 PM revealed that there were dead bugs and debris inside the light fixture above the bathroom sink. R. Tour of the resident room occupied by Resident 29 on 8/15/2017 at 8:06 AM revealed the bathroom door was marred, the wall next to the bed contained holes in the drywall, and there were dead bugs and debris in the light fixture above the bathroom sink. S. Tour of the building on 8/17/2017 between 8:00 AM and 9:15 AM with the Administrator and Maintenance Director revealed that the bathroom light fixtures contained dead bugs and debris, the floors were stained in the bathrooms, the windows were cloudy and stained, the privacy curtains were stained , bathroom sinks that were rusty, cracked floor tiles, a bathroom vent hanging down from the ceiling, bathroom and resident room walls marred up and contained holes, bathroom and resident room doors were chipped and marred up, a bathroom that contained an odor, and a toilet riser that was sitting on the floor under the bathroom sink. T. Interview on 8/17/2017 at 9:00 AM with the Administrator and Maintenance Director confirmed that the bathroom light fixtures needed to be free from dead bugs and debris, the bathroom floors needed cleaned, the resident room windows needed to be free from cloudy and white filmy substances, the privacy curtains needed cleaned, the bathroom sinks needed to be free from rust, the cracked tiles needed replaced, the bathroom vent needed to be reattached to the ceiling, the walls and doors to the resident rooms and bathrooms needed repaired, the bathroom needed to be free from odors and the toilet riser needed to be removed from the floor under the bathroom sink.",2020-09-01
743,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,258,D,0,1,5XF311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.18A(3) Based on record review and interviews, the facility failed to provide a comfortable sound level for 2 sampled residents (Residents 90 and 28). This affected 2 of 2 sampled residents. Facility census was 57 . Findings are: [NAME] Interview with Resident 90 on 8/14/2017 at 9:04 AM revealed that the roommate (Resident 2) hollered out during the night. Resident 90 stated that the roommate was on hospice and that the resident had not gotten very much sleep with the roommate hollering out during the night. Resident 90 also stated that the facility has not offered to move the resident to another room due to the noise. Review of the nursing progress notes revealed that Resident 25 had been calling out 4 times on 8/08, 8/10, 8/11, 8/15 and 8/16. Interview with the DON (Director of Nursing) on 8/14/2017 at 11:40 AM confirmed that the facility had not offered to move Resident 90 due to the noisy roommate. The DON stated it was felt by SSD (Social Services Director) and DON that Resident 90 had just moved into that room, after a hospital discharge, and another move would have been difficult for the resident. The DON also stated that they had other room moves going on and that they hadn't talked to the resident about moving to another room. B. Interview with a family member for Resident 28 on 8/17/17 at 8:56 AM revealed a complaint about noise of loud televisions at night. The Family Member had entered the facility on 8/16/17 at 8:30 PM and heard the televisions in the 100 wing. The televisions were loud and the Family Member stated, we have been battling this for years. The Family Member said, Resident 28 complained the television noise goes on until 1 AM. The Family Member had talked to the Administrator, on various occasions, to be told the television noise could be up as loud as the other residents wished. The Family Member had talked to the Ombudsman, date unknown, to be told the residents have the right to turn up their televisions. Interview with Resident 28 on 08/17/2017 at 12:00 PM revealed the television noise goes on from 6:30 AM to very late at night. Stated, I cannot sleep. Review of a form entitled Noise Control, presented by the Family Member, dated 5/1/11, revealed keep the sound level of radios and televisions at a level that will not disturb other residents, their families or visitors. Resident 28 and their Family Member presented grievance forms dated 11/29/16 on a loud television half of the night every night and also dated 1/23/17 television noise at night. A resolution note dated 3/21/17 read unresolved due to resident believing volumes were still excessive. Record review revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation of the noise level in the 100 hall at 10:30 AM on 8/17/17 revealed the television could be heard in the hall outside Rooms 102, 104 and 101. Observation of the noise level in the 100 hall on 08/17/2017 at 12:00 PM revealed the television could be heard from rooms [ROOM NUMBERS] in the hall. Observation of the noise level in the 100 hall on 08/17/2017 at 1:10:48 PM revealed the televisions could be heard from the hall from room [ROOM NUMBER], 102, and 104. On 08/17/2017 at 1:21 PM the Administrator and the Social Service Director stood in the hall near the front nurse's station and heard the television noise. Interview on 08/17/2017 at 1:24:18 PM with the Administrator and the Social Service Director acknowledged the complaints of television noise in the 100 hall.",2020-09-01
744,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,312,D,0,1,5XF311,"LICENSURE REFERENCE 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to provide eye glasses as needed for one sampled resident (Resident 72). Facility census was 57. Findings are: Observation on 8/14/2017 at 8:50 AM identified that Resident 72 was lying in bed with the lights off and the drapes pulled shut. Observation on 8/14/2017 at 10:26 AM identified that Resident 72 walked down the hallway towards the dining room but was not wearing eye glasses. Observation on 8/14/2017 at 11:49 AM identified that Resident 72 was sitting at the dining table with lunch meal in front of the resident. Resident 72 was not wearing eye glasses. Observation on 8/14/2017 at 4:00 PM identified that Resident 72 was walking down the hallway and was not wearing eye glasses. Observation on 8/15/2017 at 10:30 AM identified that Resident 72 walked down the hallway with no eye glasses on. Observation on 8/15/2017 at 11:20 AM identified that Resident 72 walked in and out of the dining room and was not wearing eye glasses. Observation on 8/15/2017 at 11:30 AM identified that Resident 72 walked down the hallway and was not wearing eye glasses. Observation on 8/15/2017 at 12:40 PM identified that Resident 72 walked into the dining room and back into the hallway without wearing eye glasses. Observation on 8/16/2017 at 9:15 AM identified that Resident 72 walked into the dining room, but was not wearing eye glasses. Review of the 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 6/01/2017 for Resident 72, identified that the resident required limited assistance with dressing and extensive assist with oral cares. Review of the Comprehensive Care Plan dated 2/27/2017 for Resident 72, identified that the resident had impaired communication due to not always able to understand the communication input or make needs known. The interventions for the resident included to encourage the resident to wear eye glasses as the resident will agree. Review of the facility policy titled, Dignity, dated on 3/31/2017, revealed that the nursing staff would assist residents in daily care in a dignified manner and advocated that residents be groomed as they wish to be (e.g. hair combed, beards shaved/trimmed, nails clean). Interview with the ACU (Alzheimer's Care Unit) Director on 8/16/2017 at 4:10 PM revealed that the expectation for the nursing staff was that resident's hair and teeth were brushed in the morning and made sure that the resident was wearing eye glasses.",2020-09-01
745,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,323,D,0,1,5XF311,"LICENSURE REFERENCE 175 NAC 12-006.18E4 Based on observation, record review and interview, the facility failed to assure that hazardous chemicals in the ACU (Alzheimer's Care Unit) Director's office were secured from wandering residents for one sampled resident (Resident 71). Facility census was 57. Findings are: Observation on 8/14/2017 at 2:08 PM identified a container of Clorox Disinfecting Wipes on the table in the ACU Director's office, with the office door open. A warning label on the container stated, Keep out Of Reach of Children. Resident 71 was observed walking in and out of their own room, located across the hall from the ACU office, and walking up and down the hallway during the time the Clorox Disinfecting Wipes were observed in the ACU Director's office. Review of the MSDS (Material Safety Data Sheet) sheet for the Clorox Disinfecting Wipes indicated that: Eye Contact: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Remove contact lenses, if present, after the first 5 minutes, then continue rinsing eye. If irritation persists, call a doctor. Skin Contact: Wash thoroughly with soap and water. If irritation persists, call a doctor. Ingestion: Drink a glassful of water. Call a doctor or poison control center. Inhalation: Move person to fresh air. If breathing problems develop, call a doctor. Review of the 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 6/22/2017 for Resident 71 identified the resident to wander. Review of the Comprehensive Care Plan dated 7/03/2017 for Resident 71 identified; Resident sometimes has behaviors which include; wandering, going into others' rooms, trying to tell others what to do. Interventions: Allow resident to wander secured hallway as long as it does not interfere with privacy or wellbeing of myself or others. Interview with the DON (Director of Nursing) and the ACU Director on 8/14/2017 at 2:20 PM confirmed the container of Clorox Disinfecting Wipes were on the table in the ACU Director's office, with the door open and were accessible to wandering residents.",2020-09-01
746,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,371,E,0,1,5XF311,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during dining affecting Residents 32, 59, 29, 79, 91, 39, 46, 89, 28, 45, and 4 unidentified residents. The facility staff also failed to assist residents with eating without possible cross-contamination of their food for Residents 3 and 55; deliver resident food items without touching areas for possible cross-contamination affecting Residents 7, 72, 26, 3, 55, and 53; and ensure residents ate their own food that was served to them affecting Residents 72 and 7. This affected 20 of the 57 residents who were served food from the 3 facility dining rooms. The facility identified a census of 57 at the time of survey. Findings are: [NAME] Observation of the ACU (Alzheimer's Care Unit) dining room on 8/14/2017 at 11:25:24 AM revealed the following: NA (Nurse Aide)-D applied gloves then put a hair net on their head. NA-D used the gloved hands to push the hair up under the hair net. On 8/14/2017 at 11:31 AM NA-D touched a stack of plates and moved them with the same gloved hands. NA-D then took a stack of bowls out of the cupboard with the same gloved hands. NA-D lifted the cover off a salad and put a scoop into it. MA (Medication Aide)-J then scooped salad into the bowls and gave it to residents. 7 residents including Residents 32, 59, 29, 79, 91 and 2 unidentified residents received salad in the bowls that had been touched after NA-D touched their hair with the gloves. LPN (Licensed Practical Nurse)-I scooped food onto the plates that NA-D had touched and NA-D took the plates to the residents. All 7 residents were observed eating from the bowls and plates. NA-D then took a plate of food to Resident 79, touched the silverware and put a bite of food up to Resident 79's mouth. On 8/14/2017 at 11:40 AM Resident 79 was observed using the same fork touched by NA-D with the soiled/contaminated gloves and using it to eat the salad. Observation of NA-D on 08/14/2017 at 11:43 AM revealed NA-D removed the gloves and followed LPN-I down the hall to the other dining room. NA-D did not wash hands or use hand sanitizer to sanitize the hands. NA-D then took a pair of gloves out of NA-D's pocket and put them on. NA-D touched the outside of the gloves while applying them. Observation of NA-D on 8/14/2017 at 11:44 AM revealed NA-D was flipping coffee cups over, touching the handles, and pouring coffee. Residents 39, 46, and 89 received coffee and all three were observed touching the handles of the coffee cups after NA-D touched them. B. Observation of the skilled dining room on 8/15/2017 at 12:15 PM revealed the SSD (Social Services Director) did hand hygiene for 3 seconds with hand sanitizer, took a plate of food to an unidentified resident, did a 2 second hand sanitizer scrub and served a plate of food to another unidentified resident. C. Observation of the skilled dining room on 8/15/2017 at 12:21 PM revealed the AD (Activity Director) standing in the service window line and was observed scratching their head touching their hair, dropping their eye glasses on the floor, picking up the glasses, then taking a Styrofoam bowl to Resident 28. The AD did not perform hand hygiene after touching their hair or picking up the eye glasses off the floor before taking the bowl to Resident 28. Resident 28 then put part of their fajita in the bowl and was observed eating the food out of the bowl. The AD then did a 5 second hand scrub with hand sanitizer and sat down next to Resident 45. The AD touched Resident 45's plate, silverware, a bottle of salsa then touched the tortilla and opened it with their bare hands. The AD then put salsa on the fajita, touched the tortilla with their bare hands then was observed feeding the tortilla to Resident 45. Interview with the RD (Registered Dietitian) on 8/15/2017 at 1:52 PM revealed it was their expectation that the staff did not touch ready to eat food with their bare hands and the staff were expected to perform hand hygiene before serving food to residents. Review of the facility policy Infection Control-Disposable Gloves dated 2/29/2016 revealed the following: Policy Statement: the appropriate use of utensils such as gloves, tongs, deli paper, and spatulas was essential in preventing foodborne illness. Bare hand contact with foods is prohibited such as working with ready-to-eat foods or with raw animal foods. When to change gloves: after sneezing, coughing, or touching face or hair. Review of the facility policy Infection Control-Hand Washing revised 3/29/2016 revealed the following: Policy statement: dining service employees must keep their hands and exposed portions of their arms clean by washing hands and rinsing exposed portions of arm vigorously for a minimum of 20 seconds. Dining services employees must effectively clean hands. Hand sanitizing in dining area: not to be used when handling food by and or by the use of gloves, but instead limited to situations that involve no direct contact with food by the bare hands. Review of the Ecolab Facilipro Waterless Foam Hand Sanitizer manufacturers' guidelines provided by the RD and identified by the RD as the hand sanitizer utilized by the facility: Fully cover your hands. Rub hand sanitizer to cover the entire surface area of the hands, paying special attention to the areas between fingers and around nails. Review of the undated Centers for Disease Control and Prevention Hand washing and Hand Sanitizer Use revealed the following: Alcohol-Based Hand Sanitizer: Put enough product on hands to cover all surfaces. Rub hands together until hands feel dry. This should take around 20 seconds. LICENSURE REFERENCE 175 NAC 12-006.11C D. Observation on 8/14/2017 at 11:53 AM identified that NA-G blew on a spoonful of pureed food to cool it down prior to feeding it to Resident 3 on 4 occasions. E. Observation on 8/15/2017 at 11:50 AM identified that NA-G blew on a spoonful of pureed food to cool it down prior to feeding it to Resident 55 on 1 occasion. F. Observation on 8/15/2017 at 11:40 AM identified that LPN-A put on a pair of gloves, reached into their pocket and pulled out some keys to unlock the refrigerator padlock. LPN-A opened the refrigerator door and took out pitchers of ice tea, juice and water and sat them on the counter. LPN-A grabbed a stack of glasses, held them at the top edges and poured the various fluids into the glasses. LPN-A carried the glasses by the top edges and delivered them to the table settings for Residents 7, 72, 26, 3, 55 and 53. [NAME] Observation on 8/15/2017 at 11:52 AM identified that Resident 72 sat at the dining room table with a plate of food that contained a soft shell taco and refried beans. Resident 72 touched the soft shell taco with their hands, then Resident 72 reached across the table and took Resident 7's plate and began to eat the taco that was on the plate. Resident 7 was not at the table at the time. Resident 72 took several bites from the taco, then reached across the table and drank a half of a glass of water. LPN-A walked to the table and took Resident 72's plate and moved it over to Resident 7's place and moved Resident 7's plate closer to Resident 72 so that the resident could continue to eat from the plate. LPN-A also moved back the glass that Resident 72 drank from and sat it back over to Resident 7's place. At 11:59 AM, Resident 7 arrived at the table and began to touch the taco, opened it up and ate a piece of meat from inside the taco. Again, Resident 72 reached across the table and took a glass of tea for Resident 7 and drank it until it was gone. Then, Resident 72 reached across the table and took one apricot half from the bowl in front of Resident 7 using fingers and ate it. Resident 7 also ate two apricot halves from the same bowl using fingers. Resident 72 ate all of the soft shell taco and the apricot halves. Resident 7 ate one piece of meat from the soft shell taco. I. Interview with the Administrator, Director of Nursing and the ACU (Alzheimer's Care Unit) Director on 8/15/2017 at 2:00 PM confirmed that NA-G should not have blown on the food for Resident 3 and 55; that LPN-A should not have handled the glasses by touching the top edges; and that LPN-A should not have switched the plates of food for Residents 72 and 7 once Resident 72 ate from Resident 7's plate.",2020-09-01
747,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,425,D,0,1,5XF311,"LICENSURE REFERENCE NUMBER: 12-006.10B1 Based on observation, record review and interview; the facility staff failed to observe the resident (Resident 53) taking medication. This affected 1 of 7 sampled residents. The facility census was 58. Findings are: Observation on 8/15/207 at 1:42 PM found MA-A (Medication Aide) took the medication to Resident 53 and said here are your pills and walked away from the table. MA-A did not observe the resident swallow the pills. Interview with the Director of Nurses on 8/16/2017 at 10:00 AM revealed the expectation was for the staff to observe residents take their medication. Review of the facility policy on Medication Administration, dated 5/1/11, revealed staff were to remain with the resident/patient until all medication was taken.",2020-09-01
748,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,441,E,0,1,5XF311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent possible cross contamination during cares; failed to perform hand hygiene between residents during medication administration, failed to cover clean linens for transport, and failed to ensure the handling of clean and soiled linens to prevent the possibility of cross-contamination. These practices affected 9 of 9 sampled residents (Residents 24, 41, 53, 7, 72, 63, 62, 26, and 20) and had the potential to affect the 11 residents who received linen from the AACU (Alzheimer's Unit) bathhouse. The facility identified a census of 57 at the time of survey. Findings are: [NAME] Observation of LPN (Licensed Practical Nurse)-B providing toileting assistance for Resident 24 on 8/16/2017 at 11:05 AM revealed the following: LPN-B applied gloves to lower Resident 24's pants and assist Resident 24 with sitting on the toilet. LPN-B then removed the gloves and stood outside the bathroom door. After Resident 24 was done using the toilet, LPN-B then went into the bathroom, washed hands for 5 seconds and applied gloves. LPN-B assisted Resident 24 with peri-care, removed gloves, then washed the hands for 5 seconds. LPN-B then assisted Resident 24 with walking to the recliner, helped Resident 24 to sit down and removed the gait belt. LPN-B then helped Resident 24 put their feet up, gave them the call light, picked up the water pitcher to make sure there was cold water in it and placed it back on the stand by Resident 24's recliner. Interview with the DON (Director of Nursing) on 8/16/2017 at 3:08 PM confirmed LPN-B should have washed their hands for more than 5 seconds. Review of the facility policy Handwashing/hand hygiene Revised (MONTH) 2014: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub or soap and water for the following situations: before and after direct contact with residents. Before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact kin after contact with blood or bodily fluids; after contact with objects in the immediate vicinity of the resident; and after removing gloves. Procedure: vigorously lather hands with soap and water and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. Perform hand hygiene before applying non-sterile gloves. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. Perform hand hygiene. B. Observation of a medication administration on 08/15/2017 at 12:15 PM revealed LPN-A (Licensed Practical Nurse) did not perform hand hygiene before or after medication was administered to Resident 53. LPN-A prepared the medication for Resident 7 by handling the medication cards with a gloved hand before putting the medication in a cup then touched the mouse to the computer and administered the medication. LPN-A touched the computer then took off the gloves and put on new gloves, administered medication to Resident 72 after touching the med cards. LPN-A changed gloves and touched the med cards before the medication was administered to Resident 63. LPN-A took off gloves and re-gloved, handled the medication cards then placed the medication in a bag, dropped the bag on the floor, picked up the bag and destroyed the medication. LPN-A placed more pills in a med cup, put the medication in a bag and crushed the medications before the medication was administered to Resident 41. LPN-A was not observed performing hand hygiene with the medication administration. C. Observation on 8/15/17 at 12:50 PM found LPN-A assisted a resident with eating then removed the gloves and put on new gloves. LPN-A administered medication to Resident 62. LPN-A removed the gloves to put on new gloves, took the keys to the medication cart out of the pocket, unlocked the cart, and administered medication to Resident 26. LPN-A removed the gloves to put on new gloves and administered medication to Resident 20. LPN-A was not observed to perform hand hygiene during the medication administration. Interview with the Director of Nurses on 08/16/2017 at 12:21 PM revealed the staff need to perform hand hygiene between residents when passing medication. The gloves should have been changed after the item on the floor was picked up. Review of the facility policy entitled Hand Washing, with a revised date of (MONTH) 2014, revealed the purpose of the policy for hand hygiene was the primary means to prevent the spread of infections. Wash hands with soap and water after contact with a resident, whenever you feel a buildup of hand gel/rub on your hands, alcohol based hand rub before and after direct contact with residents, before preparing or handling medications and after removing gloves. D. Observation on 8/16/2017 at 1:20 PM identified that LPN-A came out of room [ROOM NUMBER] with dirty linen in their arms and up against their body and put the dirty linen into a utility cart located in the AACU hallway. Then, LPN-A walked out of the AACU and returned within a few minutes with an armful of clean bedding up against LPN-A's body. LPN-A placed the bedding in the bathhouse and took one white cover sheet into room [ROOM NUMBER]. No handwashing was observed after handling the soiled linens. Review of the facility policy titled, Departmental (Environmental Services) - Laundry and Linen identified that one of the steps under In Resident Rooms was Do not allow linen, clean or soiled, to touch clothing or uniform and Wash and dry hands thoroughly after contact with soiled linen. Interview with the DON (Director of Nursing) on 8/16/2017 at 1:42 PM confirmed that the nursing staff were to take a linen cart to transport clean linens into the AACU to be stored into the bathhouse. DON also confirmed that LPN-A should have washed hands after handling the soiled linens and before picking up the clean linens. The DON's expectation was that LPN-A should not have handled the soiled and clean linens up against the uniform and body.",2020-09-01
749,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,467,E,0,1,5XF311,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04D Based on observations and interview, the facility failed to ensure that the ventilation fans were working in 4 resident bathrooms affecting Residents 38, 58, 46 and 56. Findings are: [NAME] Observation on 8/14/2017 at 9:07 AM identified that the bathroom vent for Resident 46 was not working. B. Observation on 8/14/2017 at 2:21 PM identified that the bathroom vent for Resident 38 was not working. C. Observation on 8/14/2017 at 2:36 PM identified that the bathroom vent for Resident 58 was not working. D. Observation on 8/14/2017 at 2:52 PM identified that the bathroom vent for Resident 59 was not working. E. Tour of the building on 8/17/2017 between 8:00 AM and 9:15 AM with the Administrator and Maintenance Director revealed that the bathroom vents were not working. F. Interview on 8/17/2017 at 9:00 AM with the Administrator and Maintenance Director confirmed that the bathroom vents should have been working.",2020-09-01
750,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-08-17,520,E,0,1,5XF311,"LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07 Based on record review and interviews, the facility failed to re-evaluate prior plans of correction to correct and maintain correction for previously cited deficient practice related to: resident dignity issues, clean windows and repair walls and doors in resident rooms and hand hygiene to prevent cross contamination. This had the potential to affect all 57 residents residing in the facility. Findings are: Record review of the previous annual survey deficiencies dated 9/13/2016 revealed the following deficiencies: -F241: The facility failed to ensure respect and dignity for the residents. -F253: The facility failed to clean the windows and make repairs on the doors and the walls. -F371: The facility failed to ensure the use of hand hygiene to prevent cross contamination. Interview with the Administrator on 8/17/2017 at 3:20 PM revealed that the facility used a QAPI (Quality Assurance Process Improvement) process to identify issues. However, the QAPI committee had not corrected the resident dignity issues, made the repairs to the walls and the doors nor cleaned the windows, and failed to monitor the hand hygiene practices of the facility staff. Cross reference to F241, F258 and F371, and F441.",2020-09-01
751,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,604,D,0,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (8) Based on observation, record review, and interviews, the facility failed to recognize the use of a physical restraint and used the restraints without medical signs and symptoms for 2 residents (Resident 35 and 31) out of 2 residents sampled. The facility census was 55. Findings are: [NAME] Review of Resident 35's medical record revealed an admission date of [DATE]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 8/11/18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) 99. The score of 99 indicates severe impairment. Review of the MDS dated [DATE] revealed Resident 35 required extensive assist of 2 staff persons for bed mobility and total assist with 2 staff for transfers. Review of Progress Notes dated 9/10/18 revealed that Resident 35 continues on strict non weight bearing. Resident 35 requires a full body lift with transfers. Review of Progress Note dated 8/1/18 revealed Resident 35 was found laying on back with left leg internally rotated. Resident 35 was sent to the hospital and treated for [REDACTED]. Review of undated Care Plan revealed Resident 35 has no interventions in place for the use of blue foam wedges to be used during Resident 35's care. Review of [DIAGNOSES REDACTED]. On 9/12/18 at 3:10 PM Observation of Resident 35 revealed the resident laying in bed on the left side against the wall with the mattress of the bed tilted at a 45 degree angle. Resident 35 was against the wall and trying to go up the incline to the other side of the bed. There was one pillow in the room which was under Resident 35's head. Further observation revealed 2 blue position wedges were placed under the mattress of the bed. An interview with the DON (Director of Nursing) confirmed the blue wedges were in place under the mattress of the bed. The DON then informed the Charge Nurse and staff that the wedge under the mattress or the fitted sheet is a restraint. B. Review of the Face Sheet dated 9-13-18 for Resident 31 revealed the [DIAGNOSES REDACTED]. Review of Resident 31's (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 8-1-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) result of severely impaired cognition. Resident 13 exhibited 1-3 days of physical behaviors that interfered with resident cares and rejection of cares. The resident required extensive assist of 2 staff with bed mobility, transfers, walking, locomotion, dressing, toilet use, and personal hygiene. The resident had a wander alarm worn daily and did not have restraints. Review of Resident 31's careplan revealed the resident had use of wedges to the outside of the bed to help define the edge of the bed with date initiated 8-10-17 and last revised 8-22-18. Observation on 09/12/18 at 04:43 PM of Resident 31's room revealed absence of any wedges laying on the bed, chairs, or in the closet. The resident was observed in the wheelchair in the dining room at this time. Interview on 09/12/18 at 04:45 PM with LPN-F (Licensed Practical Nurse) revealed the resident still used the wedges every time the resident was in the bed. LPN-F agreed to go to the room and show the surveyor where the wedges were. Observation on 9-12-18 at 4:45 PM in Resident 31's room, LPN-F went to the bed which had one side against the wall. On the outer aspect of the bed, LPN-F lifted up the covers to the bed then lifted up the mattress and revealed a wedged placed under the mattress which lifted up the outer aspect of the matter and tilted it downward towards the wall. Interview on 09/12/18 at 04:55 PM with the DON (Director of Nursing) revealed the DON was aware of the wedge used on this resident as it was careplanned but not that the staff had placed the wedge under the mattress.",2020-09-01
752,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,609,D,1,1,YA8S11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record reviews and interviews, the facility failed to ensure to report within 2 hours to the Administrative Staff 2 incidences of potential abuse for Resident 39 and 26, and the facility failed to submit one final written investigation within 5 working for one resident, Resident 39. Findings are: [NAME] Record review of facility investigation report dated 6-26-18 revealed the SSD (Social Service Designee) reported Resident 39 reported during Resident Council about an incident whereas staff caused injury to the resident during a transfer with a mechanical lift several days ago. The investigation revealed the incident did occur but staff examined the resident and did not see immediate injury so did not report it. Administrative staff reported suspended the employee during the investigation as soon as they became aware of the incident and and reported it to the appropriate authorities on 6-26-18. However, review of the cover fax sheet revealed the final written report was not sent until 7-6-18, the 7th day. Interview on 09-17-18 at 4:45 PM with the DON (Direction of Nursing) confirmed the staff did not report the incident to any administrative staff or a charge nurse so the resident could be assessed for injury. The DON confirmed the final report was sent after the 5 day required time frame to the State Authorities. B. Record review of facility investigation report revealed on 9-11-18 at 11:00 PM Resident 26 asked a NA (Nurse Aide) to ask Resident 39 who lived next door to turn the resident's TV (television) set down in volume. Resident 39 became upset and yelled loud enough that Resident 26 and staff heard the foul language and the foul name Resident 39 called Resident 26. The staff did not report the incident to the Administrative staff until 9-12-18 around 08:30 [NAME]M. when the DON was informed in report. Interview on 9-17-18 at 4:45 PM with the DON confirmed the staff did not report the incident to the Administrative staff immediately like it should have been.",2020-09-01
753,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,625,D,0,1,YA8S11,"Based on record review and interview, the facility failed to notify the residents' legal representative of the bed hold policy within 24 hours of transfer to the hospital for 1 of 1 sampled residents (Resident 35). The facility census was 55. Findings are: On 9/11/18 at 12:28 PM during the resident representative interview for Resident 35 it was revealed on 8/1/18 that the resident had a fall and was sent to the hospital. The guardian was notified of the fall and transfer to the emergency room , there is no documentation of notification of the bed hold policy. Review of Progress Note dated 8/1/18 revealed Resident 35 was found laying on the floor and was sent to the emergency room . It is documented that the Guardian was notified of being found on the floor and the transfer to the emergency room . The Guardian was notified but documentation was absent about the bed hold policy education. Review of a Progress Note dated 8/4/18 revealed Resident 35 returned from the Hospital on that date. Interview with DON (Director of Nursing) on 9/12/18 at 5:30 PM revealed a bed hold form was not signed by the Guardian and that it was not understood that the letter needed to be sent to the resident's representative. Review of the Bed Hold Policy and Notification form revealed that the form was not signed by the Guardian. Interview with (OM) Office Manager on 9/12/18 at 5:45 PM revealed that the bed hold letter was not sent to the representatives for a signature and written notification. The facility practice was to make out the form and put notified per phone. Interview with DON on 9/13/18 at 9:20 AM revealed that the bed hold policy had been overlooked and was not being done.",2020-09-01
754,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,641,D,1,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (The Long Term Minimum Data Set, 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 Medicaid-certified long term care facility) was not coded as having an unspecified [MEDICAL CONDITION] on the MDS, therefore the comprehensive assessment was not complete to include that diagnosis. This affected 1 out of 2 sampled. Facility census was 56. Findings are: Record review revealed that Resident 10 was admitted from an acute care hospital 12-18-17, with type 2 Diabetes, [MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), adjustment disorder with mixed and anxiety and depressed mood, and unspecified dementia without behavioral disturbance, and unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition was on the resident's written chart. Interview on 9/12/18 at 3:08 PM with SSD(Social Services Director) revealed that the resident upon admission from the hospital with the [DIAGNOSES REDACTED].",2020-09-01
755,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,645,D,0,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure PASARR ((Pre-Admission Screening and Resident Review) for residents with a SMI (serious mental illness) had been completed to determine if a Level 11 PASARR was required for two (Resident 41 and 10) residents out of two sampled residents. The facility census was 55. Findings are: Review of Resident 41's Face Sheet dated 8-12-18 revealed an admission date of [DATE]. Review of Resident 41's Face Sheet dated 8-12-18 revealed the [DIAGNOSES REDACTED]. Review of the undated Physician orders [REDACTED]. Review of Resident 41's admission PASARR dated 5-10-17 revealed a Level 1 was completed and the resident did not have a SMI but did have anxiety and depression listed. Review of Resident 41's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 8-15-18 revealed the resident had [MEDICAL CONDITION] and a [MEDICAL CONDITION] (other than [MEDICAL CONDITION]). The MDS also revealed the resident was on an antipsychotic medication and had not had a level 2 PASARR completed. Review of Resident 41's Careplan revealed the resident was on the medication [MEDICATION NAME] for [MEDICAL CONDITION] disorder. Interview on 09/12/18 at 09:02 AM with SSD confirmed the only PASARR that had been completed on Resident 41 had been the Level 1 at admission 5-11-17 and it did not have the [DIAGNOSES REDACTED]. The SSD confirmed the resident should have been re-evaluated at the time of admission since the resident was admitted with the diagnosis. B. Review of Resident 10's PASARR dated 12-18-17, revealed the resident had no serious MI (mental illness) or ID (intellectual disability). The resident did have an adjustment disorder with mixed anxiety and depressed mood, and the resident was on [MEDICATION NAME] (antianxiety) and [MEDICATION NAME] (antidepressant). The PASARR I that had been completed revealed the resident did not need a level II PASARR. Record review revealed that the [DIAGNOSES REDACTED]. Interview with SSD (Social Services Director) on 9-12-18 at 4:13 PM reviewed the resident's current medical diagnosis, medication, and confirmed that the resident should have had a review for potential level II services.",2020-09-01
756,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,657,D,0,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record reviews and interview, the facility failed to update the Careplan for two residents (Resident 29 and Resident 35). The facility census was 55. Review of Resident 29's PN (Progress Notes) dated 5-8-18 revealed the SSD (Social Service Designee) was still trying to find placement for the resident as per the Guardian request for alternerative living arrangements. The SSD documented currently the resident lived on the ACU (Alzheimer's Care Unit) and the SSD had difficulty finding other living arrangements related to the resident's behavioral issues and fall risk. Further review of the PN to the current date revealed absence of further documentation about any further communication with the Guardian to discuss discharge planning. Review of Resident 29's Careplan dated as last Care Plan review completed 8-1-18 revealed the resident planned on long term admission due the the resident's disease process. The goal dated as initiated on 8-14-17 was documented as being able to reside on the ACU as long as the resident could benefit and fit the criteria. Review of the Careplan revealed absence of any documentation of the Guardian's wishes to find alternate living arrangements. Interview on 9-13-18 at 11:29 AM with the SSD revealed in (MONTH) the Guardian had announced the Guardian's wishes of alternate living arrangements and the SSD acted upon and made many calls to other facilities but without success at that time. The SSD revealed the SSD thought the Guardian's wishes were just a short lived wish and had changed their mind now and were satisfied with long term placement in the facility but confirmed the SSD should have done a follow up call with the Guardian and documented it. Review of PN dated 9-13-18 at 1:14 PM revealed the SSD called and spoke with the Guardian about discharge planning. The Guardian informed the SSD they still wanted to pursue discharging the resident from the current facility until further notice. B. Review of Resident 35s PN (Progress Notes) dated 8/1/18 revealed the resident was found on the floor and sent to the emergency room . The resident was admitted with a fractured femur. Review of PN dated 8/4/18 revealed Resident 35 returned to facility via ambulance. Dressing was in place to left hip from surgical incision. Resident was non weight bearing to left leg due to a recent femur fracture. Resident will transfer with full lift and assist of two. Review of PN dated 9/6/18 revealed that Resident continued on hip precautions. Review of the Admission Status for Resident 35 revealed a transfer to the hospital on [DATE]. Review of Physician order [REDACTED].>Review of undated Care Plan for Resident #35 revealed revisions dated 8/8/18 on the care plan for other areas of concern, there were no interventions for strict hip dislocation precautions listed on the Care Plan. Interview with ADM (Administrator) on 9/12/18 at 2:39 PM revealed the facility does not have a policy on hip precautions. Interview with RNAC (Registered Nurse Assessment Coordinator, responsible for coordination of assessment of patients and care planning) on 9/12/18 at 5:59 PM revealed the care plans are updated by the MDS Coordinator, Director of Nursing and Charge Nurses. The MDS-RN confirmed that there were no interventions on the care plan for strict hip precautions.",2020-09-01
757,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,690,D,0,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review, and interview, the facility failed to provide an anchor for a suprapubic urinary catheter (tube inserted into the bladder to drain urine) to prevent the potential for repeat injury to one resident (Resident 26). The facility census was 55. Findings are: Review of Resident 26's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 7-25-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 26 had no cognition impairment. Resident 26 required extensive assistance of 2 staff with bed mobility and extensive assistance of 1 staff with dressing. The resident required total dependence with transfers and toileting. The resident had a catheter. Review of the undated [DIAGNOSES REDACTED]. Interview on 09/11/18 at 10:55 AM with Resident 26 revealed a few days ago the BA (Bath Aide) was assisting the resident with morning dressing cares when the and the BA accidentally pulled strongly on the suprapubic catheter tubing when the BA pulled down the residents underwear. The pain was intense enough it caused the resident to cry and shake. Resident 26 revealed the resident was allergic to tape so had refused tape to the abdomen to secure the catheter but denied the facility having tried other methods to secure the catheter tubing to prevent it from being pulled. The resident revealed the staff try to be careful but it still becomes entangled and gets pulled. Observation on 09/12/18 at 11:05 AM of nursing staff transferred Resident 26 from the bed to a wheelchair. Throughout the procedure as much as possible, the resident was observed to hold on to the catheter tubing to prevent it from being pulled. However, when the resident was rolled side to side in the bed with dressing and peri-cares, the resident holds onto the grabs bars and the was unable to hold onto the catheter tubing also at the same time. When the resident was placed into the wheelchair, instead of a catheter anchor strap which was designed to be placed design wise on a catheter to help prevent it from being pulled, the staff placed a catheter leg bag strap to hold the tubing to the leg but if the catheter got pulled, would not prevent it from being pulled from the ostomy site. Interview on 09/13/18 at 12:59 PM with with PD (Purchasing Director) revealed the facility had Cath-Secures which were a [MEDICATION NAME] like catheter anchor that held the catheter tubing in place and could be used either on the leg or the abdomen. The PD denied ever being asked to look into any other kinds of catheter anchors that could be used for Resident 26 who was allergic to tape. Review of the facility policy titled Suprapubic Catheter Care dated 2-4-16 revealed catheters were to be secured to the abdomen with tape or tube holder to reduce tension. Review of Resident 26's careplan revealed the resident had a suprapubic catheter and was to have an anchor for the catheter to avoid excessive tugging during transfers and delivering of care. The careplan was absent of documentation of trying other alternative anchors or that the resident was allergic to tape and not to use the only tape of catheter anchors the facility had. Interview on 09/17/18 at 10:34 AM with the DON (Director of Nursing) revealed the resident had refused to secure the tubing in the past because of a tape allergy. The DON denied the facility trying other alternatives besides tape to secure the tubing.",2020-09-01
758,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,726,F,0,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].04C Based on interview and record review the facility failed to ensure that nursing personnel were knowledgeable and had demonstrated competency and skill sets to perform mechanical lifts and failed to ensure the staff were competencied in resident cares, including the handwashing. The failure had the potential to affect 2 resident (Resident 39 and 26) for the mechanical lifts and for all residents for the cares/handwashing. The facility census was 55. Findings are: Interview on [DATE] at 03:10 PM with Resident 39 revealed a Nurse Aide dropped Resident 29 into the wheelchair and caused the skin tear which was on the resident's left elbow. The resident revealed the staff used the FBL (full body lift) for all of the residents. The resident revealed the Nurse Aide had trouble maneuvering the FBL and could not position the resident correctly. Observation on [DATE] at 11:15 AM revealed NA-B (Nurse Aide) and NA-G transferred Resident 26 from the bed into the wheelchair using the mechanical FBL. Interview with NA-B revealed if the battery on the FBL died with the resident in the air, NA-B did not know how to work the lift to get the resident down. NA-B confirmed the Nurse Aide had not received training on the lift. Interview on [DATE] at 11:16 AM with NA-G confirmed the Nurse Aide did not know how to get a resident down from the FBL if the battery died with the resident in the air. NA-G confirmed (gender) had not been trained on the use of the lift. Review of the Facility Staffing Assessment revealed planned education for all disciplines included but was not limited to hand hygiene: hand washing competency. Interview [DATE] at 09:18 AM with the DON (Director of Nursing) revealed (YEAR) annual competencies did not get completed on nurse aides or nurses and the annual competencies did not include competencies on the mechanical lifts. The DON revealed the annual competencies did include hand hygiene and hand washing but those did not get completed for the annual competencies in (YEAR).",2020-09-01
759,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,730,F,0,1,YA8S11,"Licensure Reference Number: 175 NAC 12-006.04B2a Based on record reviews and interviews, the facility failed to ensure 4 out of 5 sampled NA's (Nurse Aides) (NA-H, I, K, and L) received a minimum of 12 hours of in-service education per year and failed to ensure 5 Nurse Aides out of 5 sampled received a Performance Review. The Nurse Aides provided direct care to all residents. Facility census was 55. Findings are: Record review of staff education provided by the DON (Director of Nursing) for the calendar year (YEAR) (MONTH) - (MONTH) revealed 4 Nurse Aides (NA-H, I, K, and L) out of 5 Nurse Aides reviewed had not reached their 12 hours of education per year (2017) as required. NA-H had 9 hours, NA-I had 11 hours, NA-K had 11 hours, and NA-L had 6 hours of in-service education completed. To determine if the in-service education was based off of the employees performance review outcomes, the DON was asked to provide all 5 employees sampled performance reviews for (YEAR). Interview on 09/12/18 at 09:18 AM with the DON revealed none of the (YEAR) performance reviews were completed.",2020-09-01
760,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,760,D,0,1,YA8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview, the facility failed to ensure one resident (Resident 39) was free from significant medication errors out of one resident sampled. The facility census was 55. Findings are: Interview on 9-11-18 at 3:45 PM with Resident 39 revealed the when the Surveyors were not in the building, the nursing staff administered the residents insulin shots at various times and not the 15 minutes before the meals as directed by the Physician. The resident revealed the insulin shots were usually given 30 minutes prior to meals but at times were given up to 1 hour prior to meals and 1 or more hours after a meal. Review of Resident 39's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 8-15-18 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated no cognitive impairment. Review of the '38th Edition Nursing (YEAR) Drug Handbook' by Wolters Kluwer revealed the [MEDICATION NAME] Insulin when given subcutaneously had a rapid onset of 15 minutes after the injection and should be taken 15 minutes before a meal consistently. Review of Resident 39's undated Physician orders [REDACTED]. Review of the resident's MARs (Medication Administration Records) revealed the insulin was scheduled to be given 15 minutes before the 3 meals at 7:45 AM, 11:45 AM and 5:45 PM. Review of Resident 39's (MONTH) (YEAR) MARS (Medication Administration Record) revealed several entries whereas the insulin was given out of the required parameter and without any documentation to explain why. On 8/1 at 7:45 [NAME]M. the insulin was documented as given at 7:19 [NAME]M. On 8/1 at 11:45 [NAME]M. the insulin was documented as given at 11:13 AM. On 8/2 at 7:45 [NAME]M. the insulin was documented as given at 7:28 [NAME]M. On 8/6 at 7:45 [NAME]M. the insulin was documented as given at 8:43 [NAME]M. On 8/6 at 11:45 [NAME]M. the insulin was documented as given at 11:00 [NAME]M. On 8/8 at 11:45 [NAME]M. the insulin was documented as given at 11:25 [NAME]M. On 8/9 at 7:45 [NAME]M. the insulin was documented as given at 10:20 [NAME]M. On 8/11 at 7:45 [NAME]M. the insulin was documented as given at 7:19 [NAME]M. On 8/11 at 5.45 P.M. the insulin was documented as given at 5:28 P.M. On 8/12 at 7:45 [NAME]M. the insulin was documented as given at 7:13 [NAME]M. On 8/12 at 11:45 [NAME]M. the insulin was documented as given at 11:12 [NAME]M. Review of Resident 39's (MONTH) (YEAR) MARs revealed: On 9/4 at 11:45 AM the insulin was documented as given at 1:00 PM. On 9/5 at 5:45 PM the insulin was documented as given at 5:19 PM. On 9/6 at 7:45 AM the insulin was documented as given at 7:21 AM. On 9/8 at 7:45 AM the insulin was documented as given at 7:26 AM. On 9/9 at 11.45 AM the insulin was documented as given at 12:42 PM. On 9/11 at 5:45 PM the insulin was documented as given at 7:08 PM. On 9/13 at 5:45 PM the insulin was documented as given at 5:.33 PM. On 9/14 at 7:45 AM the insulin was documented as given at 4:34 AM. Interview on 09/17/18 at 10:17 AM with Resident 39 revealed when the insulin was given out of the parameter of 15 min before the meals, the staff did not provided the resident with a snack or remind the resident to eat a snack. Interview on 09/17/18 at 10:58 AM with LPN-D (Licensed Practical Nurse) revealed [MEDICATION NAME]was to be given 15 min prior to a meal. Interview on 09/17/18 at 10:59 AM with LPN-E revealed [MEDICATION NAME]was to be given 15 min before the meal. Interview on 09/17/18 at 11:54 AM with the DON (Director of Nursing) confirmed the nursing staff were to administer [MEDICATION NAME]only 15 min prior to the meal or if it must be given 5-10 min earlier, ensure a snack was provided. The DON revealed if the insulin was given an hour before or after the scheduled time, there should have been documentation to explain why and the DON confirmed there was none.",2020-09-01
761,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,812,E,0,1,YA8S11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure food in the ACU (Alzheimer's Care Unit) kitchenette was secured from confused residents who had access and therefore contaminated the food and there was food that was not dated when opened. No hair net, not washing hands, The census on the ACU was 12. Findings are: [NAME] Observation on 09/10/18 at 06:40 AM in the ACU kitchenette revealed the refrigerator and freezer had a lock on it but the refrigerator was not locked. The cereal cupboard was not locked and the cereal was in Rubbermaid type containers with labels of the type of cereal but they were not dated when opened. On the countertop was a bread box without a lock and inside was 3/4 a loaf of bread. B. Observation on 09/10/18 at 06:55 AM in the ACU kitchenette revealed Resident 3 had opened the bread box and had the loaf of bread. The resident had taken bread out of the loaf and was laying it on the counter. Next Resident 3 went over to the freezer, which was locked, and the resident started trying to the lock open and the door open to the freezer. A staff person came along and intervened and distracted the resident. Observation on 09/10/18 at 07:28 AM in the ACU kitchenette revealed a NA (Nurse Aide) poured cereal from the Rubbermaid type containers into a bowl then serve it to a resident. However, when NA poured the opened the lid to the cereal container, the NA held the inside of the lid open with one hand and poured holding the outside of the container with the other hand. The inside of the lid when closed came into direct contact with the cereal. When done pouring the cereal, the NA left the cereal container on the counter. At 7:26 AM, Resident 3 got up from the table and opened up the cereal container and started pouring the cereal into (gender) used cereal bowl. C. Observation on 09/12/18 at 07:42 AM in the ACU kitchenette revealed DA-A serving breakfast from a hot food cart and was not wearing a hair net. Surveyor left the Kitchenette for 2 minutes and returned and observed DA-A applying a hair net but left the entire back length of (gender) hair uncovered. DA-A after applying the hair net and touching the aide's hair did not perform hand hygiene and immediately returned to serving up plates of breakfast food Interview on 09/12/18 at 06:01 PM with the DM (Dietary Manager) confirmed the bread and the cereal in the ACU should be locked up so the residents do not have access to it. DM also confirmed the NA contaminated the cereal container when the NA touched the inside of the lid when pouring the cereal. The DM confirmed hair nets were to be worn when food is served even in the satellite dining rooms. Record Review of the facility policy Routine Handwashing dated 5-2017 revealed handwashing should be done before preparing food and after touching hair.",2020-09-01
762,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2018-09-17,880,F,0,1,YA8S11,"LICENSURE REFERENCE NUMBER 175 NAC 12.006.17 Based on observation, interviews, and record reviews, the facility failed to ensure hand hygiene was followed when working with two residents (Resident DA & 31). The facility census was 55. Findings are: [NAME] Observation on 9-12-18 at 9:59 AM of staff transferred Resident 39 from the wheelchair to the commode. The staff had gloves on during the transfer. The first step the staff placed the resident onto the bed and removed the resident's pants which urine had leaked onto. The urine soaked brief was removed from the resident by NA-B (Nurse Aide) and placed into the trashcan. Without changing gloves, NA-B then grabbed then the remote control to the mechanical lift and maneuvered the resident from the bed onto the commode. Throughout the process, NA-B touched the remote control, the handles on the lift, and the resident. B. Observation on 9-12-18 at 3:35 PM of staff toileting Resident 31. The staff placed gloves on their hands and assisted the resident to walk from the wheelchair into the bathroom. While the resident was standing, NA-C pulled the resident's pants and brief down and touched the inside of the brief then commented about how the brief was still dry. The resident was assisted to sit on the toilet. NA-C did not change gloves and while waiting for the resident to urinate, the staff were visiting, and NA-C placed the contaminated gloved hand that had been on the inside of the brief on the doorway wall as NA-C leaned on it while talking. Review of the facility policy titled Routine Handwashing dated 05-17 revealed hands should be washed after contact with a source that likely to be contaminated. Interview on 09/12/18 at 04:43 PM with the DON (Director of Nursing) confirmed the staff were to perform hand hygiene after removing gloves and to remove gloves if gloves are contaminated. C. Observation on 9/10/18 at 10:00 AM of the water and ice dispenser in the main dining room revealed that the tray on the machine has a grayish brown hard debris on the tray and the wire shelf inside the tray. There was water constantly dripping from the machine. Interview on 9/11/18 at 11:30 AM with DM (Dietary Manager) confirmed that the machine had a grayish brown hard debris on the tray and the wire shelf inside the tray. Dietary Manager stated that several things had been tried to remove the debris from the tray and nothing was working.",2020-09-01
763,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2017-10-11,225,D,1,0,ZHM111,"> LICENSURE REFERENCE 175 NAC 12-006.04A3b1 Based on record review and interviews, the facility failed to ensure that the Nurse Aide Registry was checked for 3 dietary employees (DA(Dietary Aide)-B, DA-C and DA-D) that were hired in the past 4 months. The facility census was 62. Findings are: Review of the personnel file for DA-B identified that there was no documentation that the Nurse Aide Registry was checked prior to or after the employee was hired. Interview with the Administrator on 10/11/2017 at 3:00 PM revealed that the Administrator was not aware that the Nurse Aide Registry had to be checked when hiring non-nursing personnel. Review of the personnel files for DA-C and DA-D identified that there was no documentation that the Nurse Aide Registry was checked prior to or after the employees were hired. Interview with the Administrator on 10/11/2017 at 3:15 PM confirmed that the three non-nursing personnel files reviewed did not contain the required documentation that the Nurse Aide Registry was checked.",2020-09-01
764,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,561,E,0,1,VSU711,"**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 staff failed to honor resident choices for bathing. This affected 4 of 4 residents (Residents 37, 20, 2, and 4) investigated for choices. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 2's Quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 2 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 2 required extensive assistance from 1 staff person for bathing. Interview with Resident 2 on 11/04/19 at 1:13 PM revealed they were supposed to get 2 baths a week. Resident 2 revealed they didn't receive a bath at all this past week. Review of Resident 2's Documentation Survey Report for bathing revealed Resident 2 received a bath on the following dates for 2019: June 17; June 27-10 days with no bath; July 4; July 11-7 days with no bath; July 18-7 days with no bath; July 25-7 days with no bath; August 1; August 8; 7 days with no bath; August 26-18 days with no bath. August 29; September 5; September 19; 14 days with no bath; September 26; 7 days with no bath; October 3; October 10-7 days with no bath; October 24-14 days with no bath; November 5-12 days with no bath. B. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 had a BIMS score of 15 which indicated Resident 4 was cognitively intact. Resident 4 was dependent upon staff for bathing. Interview with Resident 4 on 11/04/19 at 2:26 PM revealed they were supposed to get a bath on Mondays and Thursdays and sometimes they didn't get a bath; Resident 4 revealed sometimes they do not even receive at least one bath a week; Review of Resident 4's Care Plan dated 1/3/2018 revealed the following: Bathing assist total of one. Prefers bed bath in the early morning 2 times week. Review of Resident 4's Documentation Survey Report for bathing for 2019 revealed the following baths were documented: July 15; July 25-10 days with no bath; August 1-7 days with no bath; August 8-7 days with no bath; August 15-7 days with no bath; August 26-11 days with no bath; September 12-17 days with no bath; September 19-7 days with no bath; September 26-7 days with no bath; October 10-14 days with no bath; October 24-10 days with no bath; November 4-11 days with no bath. C. Review of Resident 20's Annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 20 had a BIMS score of 15 which indicated Resident 20 was cognitively intact. Resident 20 required extensive assistance from staff for bathing. Interview with Resident 20 on 11/04/19 at 10:24 AM revealed they were supposed to get 2 baths a week but sometimes they only got one. Review of Resident 20's Documentation Survey Report for bathing for 2019 revealed documentation Resident 20 received a bath on the following dates: July 2; July 19: 17 days with no bath; July 23; July 26; July 30th; August 23rd: 24 days with no bath; September 3rd: 11 days with no bath. October 29th: 56 days with no bath. D. Review of Resident 37's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 37 had a BIMS score of 15. Resident 37 required limited assistance from staff for transfers and locomotion. Bathing did not occur during the 7 day MDS look back period. Interview with resident 37 on 11/04/19 at 1:31 PM revealed they were supposed to get 2 baths a week. Resident 37 revealed sometimes they did not even get one bath a week. Review of Resident 37's Documentation Survey Report for bathing for 2019 revealed documentation Resident 37 received a bath on the following days: There was no documentation resident received a bath in (MONTH) or September. Resident 37 was out of the facility from 8/30 to 9/9. From admitted ,[DATE] to discharge date of ,[DATE] Resident 37 went 21 days with no bath; When Resident 37 returned on 9/9 they went from 9/9 to 10/14, 36 days with no bath; Resident 37 received a bath on (MONTH) 14 and (MONTH) 1 (18 days with no bath). Interview with RN-A (Registered Nurse) on 11/07/19 at 2:29 PM baths should be given as the residents request. Interview with the facility Administrator on 11/07/2019 at 2:29 PM confirmed baths should be given per resident request. Review of the facility policy Nursing Department Staff reviewed 1/3/2019 revealed the following: Residents shall have baths or shower at least once (1) times each week or more often if requested by the residents.",2020-09-01
765,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,583,D,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to maintain resident privacy by performing medical procedures in public areas for Residents 13 and 30; and failing to ensure Resident 4 was not exposed during catheter care. This affected 3 of 3 residents reviewed for privacy. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 4's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/24/2019 revealed an admission date of [DATE]. Resident 4 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 4 was cognitively intact. Resident 4 required extensive assistance of 2 staff for bed mobility and was totally dependent upon 2 staff for transfer. Resident 4 had an indwelling suprapubic catheter (a tube surgically inserted directly into the bladder through the lower abdomen to drain urine). Observation of MA-F (Medication Aide) on 11/06/19 on 11:13 AM providing catheter care to Resident 4 revealed they lowered Resident 4's pants and exposed their belly and pubic area. MA-F did not close Resident 4's blinds and their room was visible from the street in front of the facility, potentially exposing Resident 4 to passers-by. MA-F and the DON (Director of Nursing) who was also present did not ask Resident 4 if they wanted their blinds closed during the cares. Interview with the DON on 11/06/2019 at 1:30 PM revealed Resident 4 would not allow staff to close their blinds. The DON said it was Resident 4's choice to leave the blinds open; The DON revealed Resident 4 was to let staff know when they wanted their blinds closed. Review of Resident 4's Care Plan dated 1/27/2017 revealed no documentation to leave the blinds open during cares. Interview with the facility Administrator on 11/7/2019 at 7:40 PM revealed they would need to find a way to protect Resident 4's privacy during cares if Resident 4 wanted their blinds left open. B. Review of Resident 13's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 13 had no BIMS score as Resident 13 was rarely/never understood. Resident 13 was dependent upon staff for locomotion. Observation of Resident 13 on 11/06/19 at 10:44 AM revealed they were sitting in the Activity Room with other residents present. MA-D proceeded to check Resident 13's blood pressure with the readout on the screen visible to other residents in the Activity Room. C. Review of Resident 30's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 30 had no BIMS score as Resident 30 was rarely/never understood. Resident 30 required extensive assistance from staff for locomotion. Observation of Resident 30 on 11/06/19 at 10:40 AM revealed they were sitting in their wheelchair in the lounge area by the nurses' station in view of other residents and passers-by. MA-D proceeded to check Resident 30's blood pressure while Resident 30 was sitting in the area by the nurses' station. The screen on the blood pressure machine was visible to other residents and passers-by. Interview with the DON (Director of Nursing) on 11/07/19 at 3:59 PM confirmed the staff should not be taking resident blood pressures in public areas. Review of the facility policy Promoting/Maintaining Resident Dignity dated 5/2017 revealed the following: Maintain resident privacy.",2020-09-01
766,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,604,D,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on record review, and interview, the facility failed to monitor and evaluate the need of physical restraints for 1 resident (Resident 50) out of 1 sampled resident. Facility census was 52 at time of survey. Findings Are: Review of Resident 50's EHR (Electronic Health Record) revealed the Physician order [REDACTED].>Resident use of 1/2 lap tray or lap buddy is considered a restraint, which it is a medically necessity for him to maintain safety in wheelchair. Resident will be released from 1/2 lap tray or lap buddy at least Every 2 hours and as needed. Review of the undated Care Plan for Resident 50 revealed one of the interventions for the physical restraint was to complete appropriate restraint assessment per living center policy. Review of the EHR (Electronic Health Record) for Resident 50 revealed the last assessment for Resident 50 for restraint use was completed on 2/1/17. Review of Resident 50's Paper Chart revealed the last assessment for the restraint was 2/1/17. Review of the Restraint Free Environment Policy revealed the following guideline: When the use of a restraint is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Review of the Authorization of Use of Restraints/Side Rails dated 10/7/19 and signed by Resident 50's POA (Power of Attorney) /Spouse was done so with the believe, that the facility will actively attempt to identify an alternative to any restraint. Any restraints currently used will be continually monitored and evaluated for less restrictive measures and discontinuation. Use of restraints/side rails as authorized by a physician for specified and limited period of time, as necessary to protect the resident from injury. An interview on 11/06/19 at 4:28 PM with RN-A (Registered Nurse Consultant) revealed and confirmed the facility had been informed the assessments needed to be completed quarterly on this resident and the assessments had not be completed.",2020-09-01
767,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,606,D,0,1,VSU711,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3c Based on interview and record review, the facility failed to ensure 1 nursing staff person (NA-G (Nurse Aide) was not employed in the facility who had a conviction that could potentially affect the well being, property, and safety of the residents and there was no documentation of the facility administration's decision to hire NA-G or how they would not jeopardize the well being of the residents. This affected 1 of 7 personnel files reviewed. The facility identified a census of 52 at the time of survey. Findings are: Review of NA-G's personnel file revealed a DOH (Date of Hire) of 3/16/2019. NA-G's Criminal Background Check revealed NA-G had the following charges which were incurred after they received their NA certification 9/23/2010: [NAME] 10/25/2016: misdemeanor steal money or goods less than $300.00. Disposition: guilty. Sentence was $100.00 fine. B. 1/28/2017: Theft-Shoplifting. Disposition: Guilty. $200.00 fine. C. 1/28/2017: false reporting. Disposition: Guilty. $150.00 fine. D. 10/20/2016: Steal money or goods less than $300.00. Disposition: Guilty. Sentence $200.00 fine. E. 5/22/2012: No operator's license. Disposition: Guilty: $75.00 fine. There was no documentation in NA-G personnel file of the facility's hiring decision including how NA-G would not be a threat to the facility residents or their property. Interview with the facility Administrator on 11/6/2019 at 3:00 PM confirmed their was no documentation in NA-G's personnel file of the facility's hiring decision based on NA-G's criminal background check or how NA-G would not pose a threat to the well being of the facility residents. The facility Administrator confirmed NA-G had been working in the facility and caring for residents since NA-G was hired. Review of the facility Nursing Staff Schedules for March, April, May, June, July, August, September, October, and (MONTH) 2019 revealed documentation that NA-G had been working in the facility since they were hired. Review of the facility policy Abuse Protection reviewed/revised (MONTH) 1, 2019 revealed the following: Each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals.",2020-09-01
768,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,641,D,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to code the restraints correctly on the MDS (Minimum Data Set, federally mandated comprehensive assessment used for care planning) for 1 resident (Resident 50) out of 28 sampled residents. The facility census was 52 at the time of the survey. Findings Are: Review of the Quarterly MDS for Resident 50 dated 10/23/19 revealed for Section P - Restraints and Alarms P - Restraints and Alarms revealed the MDS listed physical restraint was not used for Resident 50. The MDS had not being coded to show that a physical restraint was being used. Review of Annual MDS dated [DATE] for Resident 50 revealed for Section P- Restraints and Alarms P - Restraints and Alarms revealed the MDS listed Physical Restraint was not used for Resident 50. The MDS had not being coded to show that a physical restraint was being used. Review of the Practitioner's orders for Resident 50 revealed: Residents use of 1/2 lap tray or lap buddy is considered a restraint, which it is a medically necessity for him to maintain safety in wheelchair. Resident will be released from 1/2 lap tray or lap buddy at least every 2 hours and as needed. An interview on 11/06/19 at 4:28 PM with RN-A (Registered Nurse Consultant) revealed the facility had been informed the assessments needed to be completed quarterly on this resident for the physical restraint and had not been completed. The coding of the MDS did not reflect the information that a physical restraint was in use for Resident 50. An interview on 11/06/19 at 5:03 PM with DON/MDS (Director of Nursing/Minimum Data Set Coordinator) revealed and confirmed that the MDS's dated 10/23/19 and 7/24/19 were not coded for Resident 50 to reflect the use of the physical restraint.",2020-09-01
769,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,655,E,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility staff failed to give a copy of the initial care plan to the responsible party and ensure they understood it for 2 of 11 residents admitted to the facility since prior survey (Resident 10 and 30) and failed to ensure a baseline care plan was completed upon admission for 2 of 11 residents (Resident 26 and Resident 37). The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 10's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/7/2019 revealed an admission date of [DATE]. Resident 10 had a BIMS (Brief Interview for Mental Status) score of 7 which indicated severe cognitive impairment. Review of Resident 10's Baseline Care Plan dated 5/3/2019 revealed no documentation it had been reviewed with Resident 10's responsible party or that a copy had been provided to them. B. Review of Resident 26's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 26 had a BIMS score of 14 which indicated Resident 26 was cognitively intact. Review of Resident 26's Medical Record revealed no documentation a baseline care plan had been completed for Resident 26 upon admission. C. Review of Resident 30's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 30 had no BIMS score as Resident 30 was rarely/never understood. Review of Resident 30's baseline Care Plan dated 6/11/2019 revealed no documentation it had been reviewed with the responsible party or that a copy of it had been provided to them. D. Review of Resident 37's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 37 had a BIMS score of 15. Review of Resident 37's medical record revealed no documentation a baseline Care Plan was completed for Resident 37 upon admission. Interview with the DON (Director of Nursing) 11/07/19 at 4:18 PM revealed the facility staff were expected to complete baseline care plans and they were to be reviewed with the residents and/or resident responsible parties. The DON confirmed this had not been completed for Residents 10, 26, 30 and 37. Interview with NA-C (Nurse Aide) on 11/07/19 at 3:50 PM revealed they got the information they needed to care for the residents from the care plan.",2020-09-01
770,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,657,D,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, interview, and record review; the facility failed to document fall interventions on Resident 28's Care Plan. This affected 1 of 32 residents whose care plans were reviewed. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 28's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/4/2019 revealed an admission date of [DATE]. Resident 28 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 28 required extensive assistance from staff for bed mobility and transfer. Resident 28 was dependent upon staff for locomotion off unit. Observation of Resident 28 on 11/05/19 at 1:53 PM, 11/5/19 at 3:43 PM, and 11/6/19 at 5:01 PM revealed they were resting in bed. A landing strip style fall mat (a beveled low profile mat placed by the bed to prevent injury in the event of a fall) was on the floor under their bed. Review of Resident 28's Care Plan dated 9/5/2017 revealed no documentation of the landing strip fall mat. Interview with the DON (Director of Nursing) on 11/06/2019 at 1:30 PM revealed the fall mat was supposed to be on the floor beside Resident 28's bed, not under the bed. Interview with the facility Administrator on 11/7/2019 at 8:00 PM confirmed the residents' care plans were to be updated. Interview with NA-C (Nurse Aide) on 11/07/19 at 3:50 PM revealed they got the information they needed to care for the residents from the care plan.",2020-09-01
771,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,677,E,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on interview and record review; the facility failed to ensure residents received at least 1 bath per week. This affected 6 of 6 residents investigated for ADL (Activities of Daily Living) assistance (Resident 2, 4, 12, 20, 37, and 45). The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 2's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/17/2019 revealed an admission date of [DATE]. Resident 2 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 2 required extensive assistance from 1 staff person for bathing. Interview with Resident 2 on 11/04/19 at 1:13 PM revealed they were supposed to get 2 baths a week. Resident 2 revealed they didn't receive a bath at all this past week. Review of Resident 2's Documentation Survey Report for bathing revealed Resident 2 received a bath on the following dates for 2019: June 17; June 27th-10 days with no bath; July 4; July 11th-7 days with no bath; July 18th-7 days with no bath; July 25th-7 days with no bath; August 1; August 8th- 7 days with no bath; August 26th-18 days with no bath. August 29; September 5; September 19th-14 days with no bath; September 26th-7 days with no bath; October 3; October 10th-7 days with no bath; October 24th-14 days with no bath; November 5th-12 days with no bath. Bathing was marked R, or refused on (MONTH) 6th. Bathing was marked NA on (MONTH) 8, (MONTH) 15 and 19; (MONTH) 9, 12, 23, and 30; (MONTH) 14, and (MONTH) 4. B. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 had a BIMS score of 15 which indicated Resident 4 was cognitively intact. Resident 4 was dependent upon staff for bathing. Interview with Resident 4 on 11/04/19 at 2:26 PM revealed they were supposed to get a bath on Mondays and Thursdays and sometimes they didn't get a bath; Resident 4 revealed sometimes they did not even receive at least one bath a week. Review of Resident 4's Care Plan dated 1/3/2018 revealed the following: Bathing assist total of one. Prefers bed bath in the early morning 2 times week. Review of Resident 4's Documentation Survey Report for bathing for 2019 revealed the following baths were documented: July 15; July 25th-10 days with no bath; August 1st-7 days with no bath; August 8th-7 days with no bath; August 15th-7 days with no bath; August 26th-11 days with no bath; September 12th-17 days with no bath; September 19th-7 days with no bath; September 26th-7 days with no bath; October 10th-14 days with no bath; October 24th-10 days with no bath; November 4th-11 days with no bath. Bathing was marked R on (MONTH) 8 and (MONTH) 29. Bathing was marked NA on (MONTH) 29; (MONTH) 19 and 22; (MONTH) 2, 5, 23, and 30; and (MONTH) 17. C. Review of Resident 20's Annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 20 had a BIMS score of 15. Resident 20 required extensive assistance from staff for bathing. Interview with Resident 20 on 11/04/19 at 10:24 AM revealed they were supposed to get 2 baths a week but sometimes they only got one. Review of Resident 20's Documentation Survey Report for bathing for 2019 revealed documentation Resident 20 received a bath on the following dates: June 4; June 11th-7 days with no bath; July 2; July 19th- 17 days with no bath; July 23; July 26; July 30th; August 23rd- 24 days with no bath; September 3rd- 11 days with no bath. October 29th- 56 days with no bath. Bathing was marked NA on (MONTH) 7; (MONTH) 2, 9, 20, and 30; (MONTH) 6, 24, and 27; (MONTH) 4, 11, 18, 22, and 25; and (MONTH) 1. Review of Resident 20's Care Plan dated 9/4/2018 revealed the following: Prefers a shower in the afternoon 1 time per week D. Review of Resident 37's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 37 had a BIMS score of 15. Resident 37 required limited assistance from staff for transfers and locomotion. Bathing did not occur during the 7 day MDS look back period. Interview with Resident 37 on 11/04/19 at 1:31 PM revealed they were supposed to get 2 baths a week. Resident 37 revealed sometimes they did not even get one bath a week. Review of Resident 37's Documentation Survey Report for bathing for 2019 revealed documentation Resident 37 received a bath on the following days: There was no documentation resident received a bath in (MONTH) or September. Resident 37 was out of the facility from 8/30 to 9/9. From the admitted ,[DATE] to Resident 37's discharge date of ,[DATE] Resident 37 went 21 days with no bath; When Resident 37 returned on 9/9 they went from 9/9 to 10/14 with no bath or 36 days without a bath; Resident 37 received a bath on (MONTH) 14 and (MONTH) 1 (18 days with no bath). Bathing was marked NA on Resident 37's Documentation Survey Report for bathing on (MONTH) 9 and 27, (MONTH) 6, 10, 13, 17, and 27; and (MONTH) 4, 11, 18, 25, and 29. R was marked on (MONTH) 20. Resident 37 was marked out of the facility on (MONTH) 30 and (MONTH) 3. Review of Resident 37's Care Plan dated 8/28/2019 revealed the following: Resident prefers a bath in the morning 1 time per week E. Review of Resident 45's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 45 had a BIMS score of 15. Resident 45 required extensive assistance from staff for bathing. Review of Resident 45's Care Plan dated 4/19/2018 revealed Resident 45 required bathing assist of extensive to total assist of one. Prefers shower 1 time per week in the morning or early afternoon. Review of Resident 45's Documentation Survey Report for bathing revealed documentation Resident 45 received a bath on the following dates: August 6; August 16th-10 days with no bath. August 20; August 23; September 3: 11 days with no bath. September 10; September 20-10 days with no bath; September 27; October 8th-11 days with no bath; Bathing was marked NA on the following dates: (MONTH) 9 and 30; (MONTH) 6, 13, and 17; (MONTH) 4, 11, 18 and 25; and (MONTH) 1. Interview with RN-A (Registered Nurse) on 11/07/19 at 2:29 PM revealed baths should be given as the residents request. RN-A revealed the NA entries on the Documentation Survey Reports for bathing meant Not Applicable which indicated the resident did not receive a bath on those dates NA was marked. RN-A confirmed there was an issue with residents receiving baths. Interview with the facility Administrator on 11/07/2019 at 2:29 PM confirmed baths should be given per resident request. The Administrator also confirmed that if a resident refused a bath, the staff needed to try again later or the next day and not wait for the next scheduled bath day to try again. The Administrator revealed the facility bathing program needed to be revamped. Review of the facility policy Nursing Department Staff reviewed 1/3/2019 revealed the following: Residents shall have baths or showers at least once (1) times each week or more often if requested by the residents. F. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment took used in care planning) dated 10/30/19 revealed for Section C a BIMS (Brief Interview for Mental Status) score of 5 which indicates a severe cognitive impairment. Section G revealed for bathing that the activity itself did not occur. Review of the Progress Notes for Resident 12 revealed no documentation of Resident 12 refusing to take a bath. Review of the undated Care Plan for Resident 12 revealed the following interventions: - BATHING: The resident requires staff participation with bathing. Prefers to have a Whirlpool 1 times a week - BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of bathing documentation for Resident 12 revealed that the resident had a bath on 9/5/19 and the next bath was received 9/30/19. This was 24 days between baths. In (MONTH) Resident 12 received a bath on 10/3/19 and the next one was on 10/24/19. This was 20 days between baths. An interview on 11/07/19 at 3:00 PM with RN-A (Registered Nurse Consultant) revealed that bathing for Resident 12, had not been occurring routinely and per the residents plan of care.",2020-09-01
772,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,689,E,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b AND 12-006.18E4 Based on observation, interview, and record review; the facility staff failed to maintain the resident environment free of accident hazards by wheeling residents without wheelchair pedals (Residents 6, 21 and 32 ); failing to keep Resident 10's bed in a low position while they were in it; failing to ensure Resident 28's fall mat was in place; storing potentially hazardous chemicals in Resident 32's bathroom in reach of residents; and failing to implement new interventions after falls for Resident 12. This had the potential to affect 6 of 9 residents reviewed for accidents. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 6's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 10/23/2019 revealed an admission date of [DATE]. Resident 6 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 6 was cognitively intact. Walk in room and corridor did not occur. Resident 6 required extensive assistance of staff for locomotion on and off unit. Wheelchair was used for a mobility device. Functional impairment in range of motion for Resident 6 indicated a limitation on both sides of lower extremity. Observation of Resident 6 on 11/05/19 at 2:00 PM revealed AA-H (Activity Aide) pushed Resident 6 down the 400 hall to the activity room in their wheelchair without wheelchair pedals. Resident 6 was holding their feet up but they were barely off the floor. Observation of Resident 6 on 11/5/2019 at 2:02 PM revealed the Activity Director pushed Resident 6 in the wheelchair without wheelchair pedals in the activity room potentially placing Resident 6 at risk of being propelled out of the wheelchair onto the floor if they were unable to keep their feet elevated while they were being wheeled in the wheelchair. B. Review of Resident 21's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 21 had a BIMS score of 13 which indicated Resident 21 was cognitively intact. Resident 21 required limited assistance from staff for locomotion on and off the unit. Resident 21's functional limitation in range of motion indicated impairment on both sides of the lower extremity. Observation of Resident 21 on 11/04/19 at 9:12 AM revealed NA-I (Nurse Aide) pushing Resident 21 in a wheelchair down the hall without using the foot pedals. Resident 21 was holding their feet up and they had gripper socks on, potentially placing Resident 21 at risk of being propelled out of the wheelchair onto the floor if they were unable to keep their feet elevated while they were being wheeled in the wheelchair. C. Review of Resident 10's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 10 had a BIMS (Brief Interview for Mental Status) score of 7 which indicated severe cognitive impairment. Resident 10 required extensive assistance from staff for bed mobility and transfers and was dependent upon staff for locomotion on and off the unit. Walk in room and corridor did not occur. Observation of Resident 10 on 11/3/2019 at 3:00 PM, 11/05/19 at 2:05 PM revealed they were resting in bed. The bed was several feet off the floor in high position. Observation of Resident 10's bed on 11/05/19 at 2:11 PM with the facility DON (Director of Nursing) revealed the bed was in high position. Interview with the DON at this time revealed Resident 10's bed was up too high and should have been kept in low position. Interview with the DON on 11/05/19 at 2:17 PM revealed the facility did not have a specific policy for keeping the beds in low position. It was just something the staff should know. The DON confirmed that although Resident 10 required assistance with bed mobility, it was not worth the risk keeping their bed that high should Resident 10 fall out of it. Review of Resident 10's Care Plan dated 8/26/2019 revealed Resident 10 was at risk for falls and had a [MEDICAL CONDITION] disorder. Resident 10 required extensive assist of two staff for bed mobility. D. Review of Resident 28's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 28 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 28 required extensive assistance from staff for bed mobility and transfer. Resident 28 was dependent upon staff for locomotion off unit. Observation of Resident 28 on 11/05/19 at 1:53 PM, 11/5/19 at 3:43 PM, and 11/6/19 at 5:01 PM revealed they were resting in bed. A landing strip style fall mat (a beveled low profile mat placed on the floor by the bed to prevent potential injury in the event of a fall) was on the floor under their bed. Review of Resident 28's Care Plan dated 9/5/2017 revealed Resident 28 was at risk for fall related injury. Interview with the DON on 11/06/2019 at 1:30 PM revealed the fall mat was supposed to be on the floor beside Resident 28's bed, not under the bed. E. Review of Resident 32's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 32 had a BIMS score of 8 which indicated moderate cognitive impairment. Resident 32 required extensive assistance from staff for locomotion on and off the unit. A wheelchair was used for mobility. Walking in room and corridor did not occur. Resident 32 had a functional limitation in range of motion with impairment in upper and lower extremity on one side. Active [DIAGNOSES REDACTED]. Observation of Resident 32 on 11/03/19 at 5:49 PM revealed NA-I pushed Resident 32 into the dining room with no wheelchair pedals. Resident 32 was wearing gripper socks and was holding their feet up potentially placing Resident 32 at risk of being propelled out of the wheelchair onto the floor if they were unable to keep their feet elevated while they were being wheeled in the wheelchair. Review of Resident 32's Care Plan dated 1/12/2018 revealed Resident 32 was at risk for fall related injury due [MEDICAL CONDITION](stroke) with left sided weakness. Observation of Resident 32 on 11/06/19 at 1:26 PM revealed MA-D (Medication Aide) wheeled Resident 32 down the hall with no wheelchair pedals. Resident 32 had gripper socks on and was holding their legs up. MA-F then came and got Resident 32 from MA-D and wheeled Resident 32 to their room by wheeling them down the hall with no wheelchair pedals on. Resident 32 was holding their feet/ legs up. Observation of Resident 32's bathroom on 11/4/19 at 12:30 PM revealed a tub of MicroKill Bleach wipes on the sink in reach of residents. Review of the MSDS (Material Safety Data Sheet) for MicroKill Bleach Disinfectant revealed the following: Hazard Statements: causes eye irritation; causes serious eye damage; causes severe [MEDICAL CONDITION] eye damage. Interview with the DON on 11/06/2019 at 1:30 PM revealed the facility staff were supposed to put wheelchair pedals on the wheelchairs when they were wheeling residents unless the resident was using their feet to propel themselves. The staff were not to expect the residents to hold their legs/feet up. Fall mats were supposed to be on the floor beside the resident bed, not under the bed. The DON confirmed the staff were not to leave the disinfectant wipes on the sinks in the resident bathrooms and they should be kept out of reach of residents. E. Review of Resident 12's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 10/30/19 revealed an admission date of [DATE]. Resident 12 had a BIMS (Brief Interview for Mental Status) score of 5 which indicated sever cognitive impairment. Resident 12 required limited assistance with one person for transfers and personal hygiene. Required extensive assist with one person for toileting. Review of PN (Progress Notes) revealed the following documentation and interventions for falls: PN dated: 5/7/2019 at 3:43 PM Resident slid out of wheelchair while sleeping, resident did not get hurt or hit head. Intervention: Dycem to be applied to wheelchair and recliner. PN dated: 5/12/2019 at 10:18 AM Resident found on floor in room at 7:00 this am. Sitting by recliner on bottom. Denies hitting head. Assist to feet x two assist. Intervention: Make sure call light was within reach. Encouraged resident to call for assist. PN dated: 5/24/2019 at 11:10 PM Nurse hears resident calling for help and went into residents' room and resident was on the floor in front of the recliner. When resident was asked what resident was doing, resident said, I was going to my wheelchair. Resident had just had the oxygen saturation level checked prior to the fall. Intervention: Dycem in recliner, and when awakened for procedure make sure resident was awake and not confused. PN dated: 8/12/2019 at 10:24 PM Staff heard resident fall into the wall, entered room and found resident sitting on the floor next to the recliner. Resident does not always call for assistance and does not lock brakes on the wheelchair when transferring. Intervention: Ensure resident locks the wheelchair when transferring and needs to call for assistance. Review of the Incident Reports dated: 5/7/2019; 5/12/2019; 5/24/2019 and 8/12/2019 revealed that the interventions listed in the Progress Notes are the same listed on the incident report. Remembering that Resident 12 had a BIMS score of 5. Review of Resident 12's undated Care Plan revealed no new person centered interventions were implemented to prevent falls with potential injury for this resident. Review of Resident 12's [DIAGNOSES REDACTED]. An interview on 11/07/19 at 2:23 PM with RN-A (Registered Nurse Consultant) revealed the interventions were not put into place after each fall taking into consideration Resident 12's cognitive deficit. When a resident had a severe cognitive deficit reminding them to do something would not be an appropriate intervention.",2020-09-01
773,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,725,F,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on interview and record review; the facility failed to ensure they had enough staff to provide ADL (Activities of Daily Living) assistance to the residents. This affected Residents 2, 4, 20, 37, and 45 and had the potential to affect all of the facility residents. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Review of Resident 2's Quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 2 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 2 required extensive assistance from 1 staff person for bathing. Interview with Resident 2 on 11/04/19 at 1:13 PM revealed they were supposed to get 2 baths a week. Resident 2 revealed they didn't receive a bath at all this past week because the facility has been short of help. Review of Resident 2's Documentation Survey Report for bathing revealed Resident 2 received a bath on the following dates for 2019: June 17; June 27th-10 days with no bath; July 4; July 11th-7 days with no bath; July 18th-7 days with no bath; July 25th-7 days with no bath; August 1; August 8th- 7 days with no bath; August 26th-18 days with no bath. August 29; September 5; September 19th-14 days with no bath; September 26th-7 days with no bath; October 3; October 10th-7 days with no bath; October 24th-14 days with no bath; November 5th-12 days with no bath. Bathing was marked R, or refused on (MONTH) 6th. Bathing was marked NA on (MONTH) 8, (MONTH) 15 and 19; (MONTH) 9, 12, 23, and 30; (MONTH) 14, and (MONTH) 4. B. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 had a BIMS score of 15 which indicated Resident 4 was cognitively intact. Resident 4 was dependent upon staff for bathing. Interview with Resident 4 on 11/04/19 at 2:26 PM revealed they were supposed to get a bath on Mondays and Thursdays and sometimes they didn't get a bath; Resident 4 revealed sometimes they did not even receive at least one bath a week because the facility didn't have enough help. Review of Resident 4's Care Plan dated 1/3/2018 revealed the following: Bathing assist total of one. Prefers bed bath in the early morning 2 times week. Review of Resident 4's Documentation Survey Report for bathing for 2019 revealed the following baths were documented: July 15; July 25th-10 days with no bath; August 1st-7 days with no bath; August 8th-7 days with no bath; August 15th-7 days with no bath; August 26th-11 days with no bath; September 12th-17 days with no bath; September 19th-7 days with no bath; September 26th-7 days with no bath; October 10th-14 days with no bath; October 24th-10 days with no bath; November 4th-11 days with no bath. Bathing was marked R on (MONTH) 8 and (MONTH) 29. Bathing was marked NA on (MONTH) 29; (MONTH) 19 and 22; (MONTH) 2, 5, 23, and 30; and (MONTH) 17. C. Review of Resident 20's Annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 20 had a BIMS score of 15. Resident 20 required extensive assistance from staff for bathing. Interview with Resident 20 on 11/04/19 at 10:24 AM revealed they were supposed to get 2 baths a week but sometimes they only got one because the facility was short on staff. Review of Resident 20's Documentation Survey Report for bathing for 2019 revealed documentation Resident 20 received a bath on the following dates: June 4; June 11th-7 days with no bath; July 2; July 19th- 17 days with no bath; July 23; July 26; July 30th; August 23rd- 24 days with no bath; September 3rd- 11 days with no bath. October 29th- 56 days with no bath. Bathing was marked NA on (MONTH) 7; (MONTH) 2, 9, 20, and 30; (MONTH) 6, 24, and 27; (MONTH) 4, 11, 18, 22, and 25; and (MONTH) 1. Review of Resident 20's Care Plan dated 9/4/2018 revealed the following: Prefers a shower in the afternoon 1 time per week D. Review of Resident 37's admission MDS dated [DATE] revealed an admission date of [DATE]. Resident 37 had a BIMS score of 15. Resident 37 required limited assistance from staff for transfers and locomotion. Bathing did not occur during the 7 day MDS look back period. Interview with Resident 37 on 11/04/19 at 1:31 PM revealed they were supposed to get 2 baths a week. Resident 37 revealed sometimes they did not even get one bath a week because the facility did not have enough staff. Review of Resident 37's Documentation Survey Report for bathing for 2019 revealed documentation Resident 37 received a bath on the following days: There was no documentation resident received a bath in (MONTH) or September. Resident 37 was out of the facility from 8/30 to 9/9. From the admitted ,[DATE] to Resident 37's discharge date of ,[DATE] Resident 37 went 21 days with no bath; When Resident 37 returned on 9/9 they went from 9/9 to 10/14 with no bath or 36 days without a bath; Resident 37 received a bath on (MONTH) 14 and (MONTH) 1 (18 days with no bath). Bathing was marked NA on Resident 37's Documentation Survey Report for bathing on (MONTH) 9 and 27, (MONTH) 6, 10, 13, 17, and 27; and (MONTH) 4, 11, 18, 25, and 29. R was marked on (MONTH) 20. Resident 37 was marked out of the facility on (MONTH) 30 and (MONTH) 3. Review of Resident 37's Care Plan dated 8/28/2019 revealed the following: Resident prefers a bath in the morning 1 time per week E. Review of Resident 45's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 45 had a BIMS score of 15. Resident 45 required extensive assistance from staff for bathing. Review of Resident 45's Care Plan dated 4/19/2018 revealed Resident 45 required bathing assist of extensive to total assist of one. Prefers shower 1 time per week in the morning or early afternoon. Review of Resident 45's Documentation Survey Report for bathing revealed documentation Resident 45 received a bath on the following dates: August 6; August 16th-10 days with no bath. August 20; August 23; September 3: 11 days with no bath. September 10; September 20-10 days with no bath; September 27; October 8th-11 days with no bath; Bathing was marked NA on the following dates: (MONTH) 9 and 30; (MONTH) 6, 13, and 17; (MONTH) 4, 11, 18 and 25; and (MONTH) 1. Interview with RN-A (Registered Nurse) on 11/07/19 at 2:29 PM revealed baths should be given as the residents request. RN-A revealed the NA entries on the Documentation Survey Reports for bathing meant Not Applicable which indicated the resident did not receive a bath on those dates NA was marked. RN-A confirmed there was an issue with residents receiving baths. Interview with the facility Administrator on 11/07/2019 at 2:29 PM confirmed baths should be given per resident request. The Administrator also confirmed that if a resident refused a bath, the staff needed to try again later or the next day and not wait for the next scheduled bath day to try again. The Administrator revealed the facility bathing program needed to be revamped. Review of the facility policy Nursing Department Staff reviewed 1/3/2019 revealed the following: Residents shall have baths or showers at least once (1) times each week or more often if requested by the residents.",2020-09-01
774,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,758,D,0,1,VSU711,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review the facility staff failed to monitor Resident 30 for adverse effects of antipsychotic medication (medication used to treat behavioral disorders). This affected 1 of 6 residents reviewed for unnecessary medications. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 30's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/11/2019 revealed an admission date of [DATE]. Resident 30 had no BIMS score as Resident 30 was rarely/never understood. Antipsychotic medication was received 7 days of the 7 days MDS look back period. Review of Resident 30's Order Summary Report dated 11/7/2019 revealed an order for [REDACTED]. Review of Resident 30's AIMS (Abnormal Involuntary Movement Scale-an assessment used to monitor for adverse side effects of antipsychotic medication) dated 9/25/2019 was marked that Resident 30 was not receiving antipsychotic medication so it was not completed. Interview with RN-A (Registered Nurse) on 11/07/19 at 5:22 PM confirmed Resident 30's AIMS assessment should have been marked yes they received antipsychotic medication and the reviewer should have proceeded with the assessment.,2020-09-01
775,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,759,E,0,1,VSU711,"**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 staff failed to maintain a medication error rate below 5%. The facility staff had 5 errors out of 25 opportunities resulting in a medication error rate of 20%. This affected 4 of 4 residents observed for medication administration. The facility identified a census of 52 at the time of survey. Findings are: [NAME] Observation of Resident 10 on 11/06/19 at 8:30 AM revealed they were in the dining room eating a breakfast of hot cereal, supplement, juice. MA-D (Medication Aide) administered the following medications to Resident 10 labeled as such: [MEDICATION NAME] ([MEDICAL CONDITION] medication) 125 mcg (micrograms) 1 PO (by mouth) on an empty stomach at least 30 minutes prior to meal. Review of Resident 10's Order Summary Report dated 11/7/2019 revealed orders for the following: [MEDICATION NAME] Sodium Tablet Give 125 mcg by mouth in the morning related to [MEDICAL CONDITION]. Observation of Resident 10 on 11/06/19 at 8:31 AM revealed they had eaten all of the hot cereal, supplement, and 1 glass of juice. Resident 10 was in the process of finishing the other glass of juice. Review of Resident 10's (MONTH) MAR (Medication Administration Record) revealed the [MEDICATION NAME] was scheduled at 7:30 AM. B. Observation of Resident 5 on 11/06/19 at 8:31 AM revealed they were walking from the dining room down the hall to their room. Observation of MA-D on 11/06/19 at 8:37 AM revealed they administered the following medication to Resident 5 labeled as such: Levothyroxin 75 mcg 1 tab PO QD (every day) on an empty stomach at least 30 minutes prior to the meal. Interview with Resident 5 on 11/06/19 at 8:38 AM confirmed they had already eaten breakfast and they just now got the medications and they had taken them. Review of Resident 5's Order Summary Report dated 11/7/2019 revealed the following order: [MEDICATION NAME] Tablet 75 MCG ([MEDICATION NAME] Sodium) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Review of Resident 5's (MONTH) MAR indicated [REDACTED]. Review of the Nursing2018 Drug Handbook revealed the following: [MEDICATION NAME] ([MEDICATION NAME]): Give medication at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. C. Observation of RN-E (Registered Nurse) on 11/6/2019 at 4:44 PM revealed RN-E administered 5 units of [MEDICATION NAME]to Resident 45. RN-E did not offer to open one of the snacks on Resident 45's table or encourage Resident 45 to eat anything. Observation of Resident 45 on 11/6/2019 at 5:43 PM revealed they were sitting in their wheelchair in their room. The snacks had been untouched and they were now out of reach. Interview with Resident 45 at this time revealed they had not had anything to eat since they had received their insulin at 4:44 PM. Resident 45 revealed they wheeled themselves to the dining room for supper around 5:55 PM. Observation of Resident 45 on 11/6/19 at 5:51 PM revealed they were sitting in their wheelchair in their room. Resident 45 did not have any food. Observation of Resident 45 on 11/6/19 at 5:55 PM revealed they were wheeling themselves down the hall toward the dining room. They did not have any food, 61 minutes after receiving the insulin. Review of Resident 45's Order Summary Report dated 11/7/2019 revealed the following: Humalog Solution 100 UNIT/ML (milliliter) (Insulin [MEDICATION NAME](Human)) Inject as per sliding scale (give the amount of insulin corresponding to the blood sugar reading)subcutaneously before meals related to Type 2 Diabetes Mellitus: if Blood Sugar 150 - 200 = give 5 units; 201 - 250 = 8 units; 251 - 300 = 11 units; 301 -350 = 14 units; 351 - 400 = 17 units; 401 - 450 = 20 units Above 450 call doctor or under 60 call Dr. D. Observation of RN-E on 11/6/19 at 5:10 PM revealed RN-E administered 8 units of [MEDICATION NAME]to Resident 10 into their right arm using an insulin [MEDICATION NAME]. RN-E did not prime the [MEDICATION NAME] prior to dialing the dose and administering the insulin to Resident 10 and RN-E did not offer Resident 10 a snack or juice/milk. Observation of Resident 10 on 11/6/2019 at 5:25 PM revealed they were sitting in their wheelchair in the hall. They did not have any food. Observation of Resident 10 on 11/6/2019 at 5:44 PM, 11/6/19 at 5:52 PM, and 11/6/19 5:55 PM revealed they were sitting in the dining room at the table. There was no food, juice, or milk, 45 minutes after receiving the insulin. Review of Resident 10's Order Summary Report dated 11/7/2019 revealed orders for the following: [MEDICATION NAME] Solution 100 UNIT/ML (Insulin [MEDICATION NAME]) Inject as per sliding scale subcutaneously four times a day related to Type 2 diabetes mellitus: if 0 - 200 = Hold provide for [DIAGNOSES REDACTED] as needed; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units. BS>(over)400 notify physician. E. Observation of Resident 25 on 11/6/19 at 5:21 PM revealed RN-E administered [MEDICATION NAME]5 units from an insulin vial into Resident 25's left arm. Resident 25 was sitting in their wheelchair in their room. RN-E did not offer Resident 25 a snack or any food or juice/milk. There was no food in Resident 25's reach in their room. Observation of Resident 25 on 11/6/2019 at 5:45 PM they were in their room sitting in their wheelchair receiving a breathing treatment through a mask covering their mouth and nose. Resident 25 did not have any food. Observation of Resident 25 on 11/6/19 at 5:52 PM and 5:55 PM revealed they were sitting in their room in their wheelchair. Resident 25 did not have any food, 34 minutes after receiving the insulin. Review of Resident 25's Order Summary Report dated 11/7/2019 revealed the following orders: [MEDICATION NAME] Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION NAME]) Inject 5 unit subcutaneously before meals related to Type 1 Diabetes Mellitus. Review of the Nursing2018 Drug Handbook revealed the following: Action: Lowers blood glucose (sugar) level by stimulating peripheral glucose uptake by binding to insulin receptors on skeletal muscle and in fat cells. Onset of action of [MEDICATION NAME] and [MEDICATION NAME] is 15 minutes. For [MEDICATION NAME], give immediately (5 to 10 minutes) before a meal. For [MEDICATION NAME], give within 15 minutes before a meal or immediately after a meal. Interview with RN-A on 11/6/2019 at 6:02 PM revealed RN-E should have primed the insulin [MEDICATION NAME] and medications should have been given per manufacturer's guidelines in regards to food. Review of the facility Meal Times revealed breakfast was served at 8:00 AM, Lunch at 12:00 PM, and Supper at 6:00 PM. Review of the facility policy Medication Administration dated 5/2017 revealed the following: Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR before administering. Review of the facility policy Using the [MEDICATION NAME] Insulin Competency revealed the following instructions for priming the insulin [MEDICATION NAME] prior to administering the insulin: Dial a test dose of 2 units. Hold the pen upright and tap to bring any bubbles to the top. Press the INJECT button all the way and check that the insulin has come out of the needle. The dial will return to 0 if this occurs. This step may be repeated up to 6 times to ensure priming. If unable to prime after 6 attempts, replace pen. Once primed, check the window is reading 0.",2020-09-01
776,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,880,D,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B; 12-006.17D Based on observation, interview, and record review; the facility staff failed to perform hand hygiene with restorative care; failed to clean the glucometer (a machine to check blood sugar levels) between residents; and failed to store a bed pan off the floor to prevent potential cross contamination. This affected 3 of 3 residents (Residents 45, 5, and 20). The facility identified a census of 52 at the time of survey. Findings are: [NAME] Observation of Resident 45 on 11/06/19 at 10:14 AM revealed MA-D (Medication Aide) assisted Resident 45 with restorative care with range of motion of the arms, hands, fingers, leg raises, and feet marches. When Resident 45 did leg raises MA-D raised their hands in front of Resident 45's legs and had the resident touch the shoes to MA-D's hands. MA-D did not perform hand hygiene after Resident 45's shoes touched MA-D's hands. MA-D then put Resident 45's pillows back around Resident 45 in the recliner and gave Resident 45 the call light which Resident 45 handled after MA-D touched it. MA-D also touched Resident 45's chair control which Resident 45 then used to readjust the chair. Review of the facility policy Infection Prevention and Control Program dated 5/2017 revealed the following: All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE (personal protective equipment-gloves, gowns, masks) removal, before/after eating, before/after toileting, and before going off duty. B. Observation of RN-E on 11/6/2019 at 4:36 PM revealed they used a glucometer to check Resident 45's blood sugar. Interview with RN-E on 11/6/2019 at 4:37 PM revealed the glucometers were used for all of the residents. The residents shared the glucometer so they had to clean the glucometers in between residents. RN-E was not observed cleaning the glucometer after checking Resident 45's blood sugar. RN-E left the glucometer on top of the med cart. Observation of RN-E on 11/6/2019 at 5:14 PM revealed RN-E wiped the glucometer off very briefly (3 seconds) with a MicroKill wipe and the glucometer was dry immediately. RN-E then took the glucometer in to Resident 5's room and checked Resident 5's blood sugar. Review of Resident 5's Order Summary Report dated 11/7/2019 revealed there was no order to check a blood sugar. Interview with LPN- K (Licensed Practical Nurse) on 11/06/19 at 10:08 AM revealed the facility glucometers were shared between residents. The cleaning procedure was to wrap the glucometer with a disinfectant wipe and let it sit for the wet set time to disinfect it. Interview with RN-A on 11/6/19 at 6:02 PM confirmed RN-E should have cleaned the glucometer per cleaning instructions. Review of the facility policy Glucometer Disinfection dated 5/2017 revealed the following: Cleanse the glucometer with the disinfectant wipe. Allow device to dry for minimum of five (5) minutes or per manufacturer recommendations. Review of the manufacturer's recommendations for MicroKill Bleach Wipes revealed the minimum kill time ((i.e. contact time) for a disinfectant is the amount of time a surface must remain wet with the product to achieve disinfection) was 30 seconds. The kill time for [MEDICAL CONDITION] spores was 3 minutes. Ensure that the surface remains wet for the entire contact time. C. Observation of Resident 20's room on 11/04/19 at 12:30 PM revealed a bed pan on the floor in the bathroom with no cover on or around it. Observation of Resident 20's room on 11/07/19 at 3:31 PM with the DON (Director of Nursing) present revealed the bed pan was still on the floor in the bathroom. Interview with the DON at this time confirmed the bed pan was not supposed to be on the floor. The DON revealed the facility staff were supposed to store the bed pans in a bag off the floor. Review of the facility policy Infection Prevention and Control program dated 5/2017 revealed the following: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.",2020-09-01
777,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,909,D,0,1,VSU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility failed to ensure a program was in place to monitor resident beds for potential entrapment hazards. This affected 1 of 24 residents whose beds were evaluated (Resident 28). The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 28's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/4/2019 revealed an admission date of [DATE]. Resident 28 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 28 required extensive assistance from staff for bed mobility and transfer. Resident 28 was dependent upon staff for locomotion off unit. Observation of Resident 28's bed on 11/05/19 at 8:56 AM and 11/06/19 at 1:31 PM revealed the bed was up against the wall and the mattress was not secured to the bed. The mattress could be slid away from the wall creating a potential entrapment hazard due to the gap between the mattress and the wall. Review of Resident 28's Care Plan dated 9/5/2017 revealed Resident 28 was at risk for fall related injury. Interview with the facility Administrator on 11/06/19 at 11:00 AM revealed the housekeeping staff checked the beds with the deep clean but it was not specifically documented if the mattresses were secure, if there were no gaps in side rails, if the side rails were not loose, etc. There was no documentation they were checking the beds for safety issues.",2020-09-01
778,EMERALD NURSING & REHAB COZAD,285093,318 WEST 18TH STREET,COZAD,NE,69130,2019-11-07,921,E,0,1,VSU711,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observation and interview the facility failed to maintain a maintenance services to repair fixtures and walls for 4 residents (Resident 36, Resident 43, Resident 30, and Resident 32) of 24 sampled residents. The facility census was 52 at the time of the survey. Findings are: [NAME] On 11/4/19 at 11:55 AM an observation of the room occupied by Resident 36 revealed the sink in the bathroom had a very slow drain which could overflow into the floor. B. On 11/4/19 at 11:55 AM an observation of the room occupied by Resident 43 revealed the sink in the bathroom had a very slow drain which could overflow into the floor. C. On 11/5/19 at 9:49 AM an observation of the room occupied by Resident 30 revealed the wallpaper was peeling in the bathroom. D. On 11/5/19 at 9:03 AM an observation of the room occupied by Resident 32 revealed the corner of the wall by the closet was marred and soiled with brown stains, the bathroom faucet was corroded and chipped and the bathroom door frame was marred. Interviews conducted during the survey with the 24 residents selected for the initial pool revealed there were no complaints about the environment for bugs or room temperature. An interview on 11/07/19 at 9:48 AM with the MS (Maintenance Supervisor) confirmed the issues with the slow draining sink, the peeling wallpaper with marred walls in the bathrooms, and the corroded and chipped faucet. An interview on 11/07/19 at 9:48 AM with the MS (Maintenance Supervisor) regarding the maintenance program and issues with pest revealed Orkin pest control had been by monthly and were due for a revisit. There had been a problem with beetles and Orkin had made an extra visit between (MONTH) and October. Also Orkin was due to come out monthly until cold weather sets in due needing extra control of the pest situation.",2020-09-01
779,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,165,E,0,1,EUUX11,"Licensure Reference Number 175 NAC 12-006.06A Based on observations, record review and interviews; the facility failed to 1) ensure that complaint/grievance forms were accessible for residents, families and visitors to utilize without asking staff members for them and 2) failed to identify a grievance officer on the complaint/grievance procedure. The facility census was 50 with the potential to affect more than an isolated number of residents. Findings are: [NAME] Interview on 1/23/17 at 3:00 PM with a family representative, who requested to remain anonymous, revealed was not aware of how to file a written complaint or grievance with the facility. The family representative stated that would like to utilize a written grievance form as verbally expressing concerns to the staff was not always effective. Interview on 1/24/17 at 12:20 PM with a family representative, who requested to remain anonymous, revealed was not aware of how to file a written complaint or grievance with the facility. The family representative stated that verbally expressing concerns to staff was not always effective or there was no follow up or resolution with ongoing concerns. Observations throughout the facility on 1/25/17 at 7:30 AM revealed no grievance forms available for residents, families or visitors to utilize without asking a staff member for them. Interview on 1/25/17 at 7:40 AM with the Social Services Director revealed that grievance forms were available in the Social Services office or at the Nurses Station. Further interview confirmed that grievance forms were not accessible to residents, families or visitors without requesting them from staff members. B. Review of the facility Complaints/Grievance Procedure, dated 12/8/08, revealed no staff member was designated as the grievance officer as required. Review of the Grievance Tracking Log revealed no written grievances were filed since 10/5/16. Interview with the Administrator on 1/25/17 at 8:00 AM confirmed that complaint/grievance forms were not accessible for residents, families and visitors without asking for them. Further interview confirmed that a grievance officer was not identified on the facility policy and procedure as required.",2020-09-01
780,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,205,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide one sampled resident (Resident 39) and/or the resident's family representative with written information of the facility bed hold policy at the time of transfer to the hospital. Sample size included 3 resident family interviews. Facility census was 50. Findings are: Interview with Resident 39's family representative on 1/24/17 at 12:37 p.m. revealed the resident was transferred to the hospital in (MONTH) of (YEAR) for pneumonia. When questioned if the resident or representative was notified of the facility bed hold policy (policy describing holding the resident's bed during the hospital stay for an agreed pay arrangement), the representative responded that the resident and representative hadn't receive any notices of such. Interview with the facility Business Office Manager on 1/25/17 at 11:08 a.m. confirmed Resident 39 was transferred to the hospital on [DATE] and returned from the hospital on [DATE]. The Business Office Manager verified that the Resident's room was held for the resident during the stay in the hospital and the resident was billed for the room per facility bed hold agreement. The Business Office Manager stated the facility SSD (Social Services Director) was responsible for obtaining the bed hold policy forms and filing them. Record review of Resident 39's chart and medical records revealed the resident's representative signed a form entitled Bed Hold Policy on 10/26/12 and another form entitled Bed Hold Policy and Authorization signed by the resident on 12/12/16. Further review of the records revealed there was no bed hold policy forms received or signed by the resident or representative at the time of transfer to the hospital on [DATE]. Interview with the facility SSD (Social Service Director) on 1/26/17 at 8:12 a.m. verified neither Resident 39 nor the resident's family representative were given written notice of the facility bed hold policy when the resident transferred to the hospital on [DATE] and there was no authorization or declination decision made by the resident or representative at the time of transfer as to whether or not to hold the resident's bed and charge the private pay arrangement fee.",2020-09-01
781,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,241,D,0,1,EUUX11,"Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interviews, the facility failed to ensure that gait belts (a canvas belt applied around the resident's waist to aid staff in assisting residents to safely ambulate) were removed after use in the dining room to promote dignity for two sampled residents (Resident 13 and 32). The facility census was 50 with 17 current sampled residents. Findings are: [NAME] Observations of the dining room on 1/23/17 at 12:45 PM revealed Resident 32 seated in the dining room wearing a gait belt. Further observations revealed the resident ambulated, without assistance, out of the dining room while wearing the gait belt. B. Observations of the dining room on 1/25/17 from 9:00 AM - 9:30 AM revealed Resident 13 seated at the table wearing a gait belt. Interview with the Director of Nursing on 1/26/17 at 10:00 AM confirmed that the staff should remove the gait belts after use to promote the residents' dignity in the dining room.",2020-09-01
782,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,242,E,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(4) Based on observations, interviews and record reviews; the facility failed to ensure that 2 sampled residents, Resident 4 and 89, had choices for the number of baths per week and two sampled residents (Resident 90 and 66) were given choices regarding being allowed to sleep through the night without being awakened. Sampled size was 17 with 2 closed records. The facility census was 50. Findings are: [NAME] Interview on 1/23/17 at 3:28 PM with Resident 4 revealed that the resident used to take 3 baths per week at home and now gets 1 bath a week sometimes. Further interview revealed that the last bath the resident received was 1 1/2 weeks ago. Review of the Data Collection Tool dated 10/28/16 for Resident 4 revealed preferences of bathing to be biweekly. Further review of an additional tool dated 10/31/16 revealed preferences of biweekly bathing. Review of the Bathing Schedule with no date, revealed that Resident 4 was scheduled for Wednesdays and Saturdays for bathing twice a week. Review of the Bathing Flow Sheet dated 10/28/17 through 1/12/17 revealed that Resident 4 received bathing the 1 time/week during the week of 10/30 through 11/5, 1 time during the week 11/6 through 11/12, 1 time during the week of 11/13 through 11/19, 1 time the week of 11/20 through 11/26, 1 time the week 12/11 thru 12/17, 1 time the week of 1/1/17 through 1/7, 1 time the week of 1/8 thru 1/14, then from 1/15 through 1/23 there was no written documentation to support baths given per resident's preferences. Interview on 1/25/17 at 6:00 AM with (Bathing Assistant) BA - A revealed that Resident 4 preferences was 2 baths a week. Continued interview verified that BA - A had been out with an illness and the other scheduled Bathing Aide was also gone with an injury. Interview on 1/26/19 at 2:25 PM with the Administrator, the DON and a Nurse Consultant verified that Resident 4's preferences for bathing was for biweekly. Further interview confirmed that Resident 4 had not received biweekly baths per preferences. B. Review of the Resident Face Sheet revealed that Resident 89 was admitted to the facility on [DATE]. Interview with the resident's family member on 1/23/17 at 3:15 PM revealed that the resident was used to bathing at least two times a week before admission to the facility. Further interview revealed that two baths a week were requested and had not been provided since admission. Review of the bathing record revealed that the resident had a bath on 1/3/17, 1/10/17 and 1/22/17. Interview with BA - A on 1/25/17 at 7:30 AM revealed that the resident was to receive a bath two times a week but wasn't done because of staff illness. Interview with the Director of Nursing on 1/26/17 at 7:45 AM confirmed that the resident received three baths since admission as documented on the bathing sheet. Further interview confirmed that the residents choice for two baths a week was not honored. C. During an interview with Resident 90 on 1/23/17 at 4:00 p.m., the resident was asked if the facility allowed the resident a choice as to when to awaken in the morning. The resident responded no and explained this was due to being told by staff the resident had to be weighed early in the morning. The resident was questioned what time this occurred and how often and the resident responded the weighing occurred every night as early as 3 a.m. and most often around 4 a.m. or 5 a.m. The resident was asked what the resident's routines were before being admitted and the resident stated having liked to sleep in in the mornings sometimes around noon. Observation of Resident 90 revealed the following: - On 1/25/17 at 4:00 a.m. Resident 90's door to the room was closed. At 4:30 a.m. NA-B and NA-N were observed bringing the mechanical lift scale to Resident 90's room and knocking on the door. There was no response from the resident. NA-B opened the door and called out Nursing and turned on the lights to the room. Resident 90 was observed sleeping and had not responded. NA-B and NA-N then shook the resident's shoulders and announced it was time to weigh the resident and the resident responded, blinking at the lit room. NA-B and NA-N then assisted the resident into the mechanical lift and proceeded to weight the resident. When completed, NA-B asked how the procedure went and the resident responded It would be better if it were done at least 6:30 (a.m.) After returning the resident to the bed and delivering fresh water, the resident stated would try to go back to sleep. Interview with NA-B on 1/25/17 R 4:20 a.m. confirmed Resident 90 was weighed on the night shift every night usually between 4 a.m. and 5 a.m. per being assigned the task by the licensed nurses. Record review of Resident 90's Medication and Treatment records for (MONTH) of (YEAR) revealed the resident's weights were done and recorded daily with an ordered time of 5:30 a.m. D. Interview with Resident 66 on 1/24/17 at 10:33 a.m. revealed the resident's condition had improved. The resident stated after being admitted to the facility in (MONTH) of (YEAR), the resident required mechanical lift assistance with transfers but now was capable of getting up without assistance. When questioned if the resident was allowed choices for when to awaken, the resident stated no that the staff told the resident the resident they needed to weigh the resident every morning and would wake the resident up to weigh per mechanical lifting procedures. The resident stated this occurred every night around 4 a.m. until the resident no longer needed the lift for weighing. Interview with LPN-C on 1/25/17 at 5:00 a.m. confirmed the night shift was assigned to obtain residents with daily weight orders and that in the three years LPN-C was on staff these weights were always obtained at night between 4 a.m. and 5 a.m.",2020-09-01
783,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,258,D,0,1,EUUX11,"Licensure Reference Number: 175 NAC 12-006.18A (3) Based on observations and interviews, the facility failed to avoid vacuuming in the hallways in the morning when residents were still sleeping. This noise affected two sampled residents (Resident 90 and 66). Sample size was 22 residents interviewed. Facility census was 50. Findings are: [NAME] Interview with Resident 90 1/23/17 at 4:07 p.m. revealed the resident had problems with the noise levels outside the room. The resident described the vacuuming is done in the hallway outside the room in the mornings prior to seven a.m. and the noise often awakens the resident from sleep. B. Interview with Resident 66 on 1/24/17 at 10:33 a.m. revealed the resident had concerns about choices of when to get up in the mornings. The resident explained that the staff vacuum the hallway every morning around 6:30 a.m. before the resident is awake and this disturbed the resident's sleep. Observation on 1/25/17 revealed Housekeeper-X vacuumed the hallway by Resident 90 and Resident 66's rooms from 6:41 a.m. to 6:50 a.m. Both Resident 90 and 66 were observed sleeping in their rooms prior to the procedure. Interview with Housekeeper-X on 1/25/17 at 9:34 a.m. confirmed the housekeeping staff are assigned to vacuum hallways daily and this procedure was done around 6:30 a.m. every day. During an interview with the Administrator on 1/25/17 at 12:40 p.m. the concerns from Resident 90 and 66 of early morning vacuuming was discussed along with the observed procedure. The Administrator agreed hallway vacuuming times should be changed to times when the residents were not still sleeping and could be done at breakfast time when residents were awake and out of their rooms.",2020-09-01
784,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,272,D,0,1,EUUX11,"Licensure Reference Number 175 NAC 12-006.09B (10) Based on observations, record reviews and interviews; the facility failed to complete a comprehensive assessment of dental status for one sampled resident (Resident 47). The facility census was 50 with 17 current sampled residents and two closed records. Findings are: Observations of Resident 47 on 1/23/17 at 2:30 PM revealed several missing and broken teeth. Review of the Significant Change MDS (Minimum Data Set, a federally mandated comprehensive assessment used for care planning), reference date 1/9/17, Section L Oral/Dental Status, revealed no broken natural teeth. Review of the Data Collection Tool, dated 1/2/16 (confirmed with the Director of Nursing on 1/26/17 at 8:15 AM that the correct date was 1/2/17), revealed that the resident had own teeth and some were missing and some were broken. Interview with RN (Registered Nurse) - D, MDS Coordinator, on 1/26/17 at 9:30 AM revealed that a complete oral assessment was not done for this resident to include the condition of the resident's teeth.",2020-09-01
785,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,278,D,0,1,EUUX11,"Licensure Reference Number 175 NAC 12-006.09B (10) Based on observations, record reviews and interviews; the facility failed to accurately code the dental status on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) for one sampled resident (Resident 47). The facility census was 50 with 17 current sampled residents and two closed records. Findings are: Observations of Resident 47 on 1/23/17 at 2:30 PM revealed several missing and broken teeth. Review of the Data Collection Tool, dated 1/2/16 (confirmed with the Director of Nursing on 1/26/17 at 8:15 AM that the correct date was 1/2/17), revealed that the resident had own teeth and some were missing and some were broken. Review of the Significant Change MDS, reference date 1/9/17, Section L Oral/Dental Status, revealed that Z None of the above were present, including D Obvious or likely cavity or broken natural teeth. Interview with RN (Registered Nurse) - D, MDS Coordinator, on 1/26/17 at 9:30 AM confirmed that the resident's dental status was not coded accurately on the MDS. Interview with the Director of Nursing on 1/26/17 at 8:15 AM confirmed that the MDS needed to be coded accurately to trigger care planning for dental care.",2020-09-01
786,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,279,E,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1b Based on observations, record reviews and interviews; the facility failed to develop care plans to address 1) dental status, contractures (a condition of fixed high resistance to passive stretch of a muscle) and bruising for one sampled resident (Resident 47), 2) skin condition for one sampled resident (Resident 90) and 3) the implementation of contact isolation for one sampled resident (Resident 79). The facility census was 50 with 17 current sampled residents and two closed records. Findings are: [NAME] Observations of Resident 47 on 1/23/17 at 2:30 PM revealed several missing and broken teeth, multiple bruising at various stages of healing on upper extremities and contractured fingers on both hands. Interview with the resident on 1/23/17 at 2:30 PM revealed that the resident had no problems chewing or swallowing, received bruises from intravenous therapy and blood draws during recent hospitalization and couldn't bend the the last three fingers on each hand due to arthritis. Review of the Data Collection Tool, dated 1/2/16 (confirmed with the Director of Nursing on 1/26/17 at 8:15 AM that the correct date was 1/2/17), revealed that the resident had own teeth and some were missing and some were broken. Review of the Admission/Readmission Skin Review, dated 1/2/17, revealed multiple bruises on both upper extremities. Interview with the DON (Director of Nursing) on 1/23/17 at 1:00 PM revealed that the resident had contractures of fingers on each hand due to arthritis. Review of the Care Plan, edited on 1/12/17, revealed no care plan to address the resident's dental status, contractures or bruising. Interview with the DON on 1/26/17 at 7:45 AM confirmed that the care plan had not been developed to address the resident's dental status, contractures or bruising. B. During an interview with Resident 90 on 1/23/17 at 4:00 p.m., the resident described [MEDICAL CONDITION] on the top of the head and on the nose were diagnosed as [MEDICAL CONDITIONS]. Observation of Resident 90 during the interview on 1/23/17 at 4:00 p.m. revealed the resident had scabbed [MEDICAL CONDITION] above the left temple, top of the head, above the right temple, and on the tip of the nose. Record review of Resident 90's Admission/Readmission Skin Review form dated 12/27/16 revealed documentation describing Ca (cancer) sites on the resident's nose, left temple, right temple, and top of the head. Record review of Resident 90's Care Plan with long term goal target dates of 4/13/17 revealed there were no problems, goals, or approaches developed on the resident's care plan to address the presence of [MEDICAL CONDITIONS]. Interview with the Director of Nursing on 1/26/17 at noon confirmed Resident 90's care plan was not developed to address the presence of [MEDICAL CONDITIONS], approaches to treat the [MEDICAL CONDITION], or goals for the problem. C. Interview with the charge nurse, RN (Registered Nurse)-L on 1/23/17 during the initial tour of the facility conducted between 10:44 a.m. and 11:00 a.m. revealed Resident 79 was being treated for [REDACTED]. Record review of Resident 79's Urine Culture report form dated 1/15/17 revealed the culture identified the resident's urine contained Extended Spectrum Beta Lactamase (a multi-drug resistant infectious organism). Observation 1/25/17 at 7:00 a.m. revealed NA-R and NA-S provided morning care assistance to Resident 79. Prior to entering the room, NA-R and NA-S applied disposable gowns, disposable gloves, and disposable masks. NA-R and NA-S then proceeded to help the resident get dressed, emptied the resident's urinary catheter bag, assisted the resident onto the toilet, and assisted the resident to provide personal cares. Interviews with NA-R and NA-S after the procedures on 1/25/17 at 7:15 a.m. revealed they gowned, gloved, and used the disposable masks when assisting Resident 79 due to the resident's being on isolation for a urinary infection. When questioned if they were to use splash guards to prevent urinary splashing, NA-R and NA-S said they weren't certain. When questioned if staff were to use any type of specialty bags for soiled linens or clothing, NA-R and NA-S said they weren't certain. Record review of Resident 79's Care Plan with goal target dates through 2/16/17 revealed there was nothing developed on the resident's care plan identifying a problem related to the initiation of contact isolation precautions, approaches on how to deliver care using contact isolation precautions, or goals pertaining to the isolation. Interview with the Director of Nursing on 1/26/17 at noon confirmed that Resident 79's urine culture exam on 1/15/17 was found positive for the organism of Extended Spectrum Beta Lactamase. The Director of Nursing stated after receiving the report on 1/15/17 the resident was placed on contact isolation procedures. The Director of Nursing verified the initiation of contact isolation procedures, approaches and directions for providing contact isolation, and goals pertaining to the infection were not developed on the resident's care plan.",2020-09-01
787,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,280,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on observations, interviews and record reviews the facility failed to ensure that care plans had been updated to include; 1) the current activities of daily living and functional activities for one sampled resident (Resident 4) and 2) a sore throat/earache for one sampled resident (Resident 1). The sample size was 17 with 2 closed records. The facility census was 50. Findings are: [NAME] Review of the Resident Face Sheet for Resident 4 revealed an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the MDS(Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) submitted on 12/26/17 as a 60-day scheduled assessment revealed a decrease or change from the previous MDS data submitted on 11/28/16. Further review revealed a change or increase in amount of help required in bed mobility, transferring, from independent to supervision, and locomotion on the unit and dressing from independent to extensive assistance for Resident 4. Review of the Care Plan for Resident 4 dated as edited on 11/1/16 revealed ADL(activities of daily living) Functional/Rehabilitation revealed that Resident 4 needed assistance with selfcare abilities related to [MEDICAL CONDITION]. Further review revealed interventions of extensive assistance with ADL's to no assistance required with ADL's. Observation on 1/23/17 at 2:00 PM of Resident 4 assisted from the recliner to the bed to rest. Observation on 1/25/17 at 5:22 AM of (Nursing Assistant) NA - B while cares provided for Resident 4. During this time the resident was assisted to a standing position, dressing, peri-cares and getting into bed. Further observation revealed that the resident had shortness of breath and weakness. Interview on 1/25/17 at 5:23 AM with (Licensed Practical Nurse) LPN - C on 1/25/17 revealed that when the resident was admitted so was admitted with respiratory issues and shortness of breath. Further interview revealed that the resident did at times try to be independent with ADL's but was encouraged to call for assistance due to weakness and shortness of breath at times. Interview on 1/26/17 at 10:00 AM with the (MDS Coordinator) MDS/C- D verified that the care plan had not been updated or revised for Resident 4 as it did not reflect the residents' current ADL status. Further interview verified changes had been made to the care plan and the existing information was not accurate for the resident and had not been taken off the care plan. Interview with the Administrator, the Director of Nursing and the Nurse Consultant on 1/26/17 at 2:20 PM confirmed that the care plan interventions for Resident 4 had not been reviewed and revised to reflect the current level of ADL assistance required by Resident 4. B. Interview with Resident 1 on 1/24/17 at 11:00 AM revealed that the resident had a bad sore throat, earache and cough. The resident stated that it hurts really bad to swallow and would like the doctor called to get something to help. Observations of the resident in the dining room on 1/24/17 at 12:00 PM revealed the resident taking sips of hot fluids. The resident stated that it hurt to swallow anything but hot drinks. Interview with the resident on 1/25/17 at 12:00 PM and on 1/26/17 at 8:45 AM revealed that throat was still sore, hurts to swallow, and ear still hurts. Review of the Routine Medications, dated (MONTH) (YEAR), revealed an order, dated 1/9/17, for [MEDICATION NAME] (antibiotic) daily for 10 days. Review of the Nurses Notes, dated 1/18/17 at 2:50 PM, revealed that the resident continued on the antibiotic related to a sinus infection. Further review at 11:50 PM revealed that the last dose of antibiotic was given at supper. Review of the Care Plan, target date 4/30/17, revealed no care plan to address the sinus infection, sore throat or earache. Interview with the Director of Nursing on 1/26/17 at 12:00 PM confirmed that the care plan was not updated to reflect the resident's sinus infection or current sore throat or earache.",2020-09-01
788,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,282,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C Based on record reviews, observation, and interviews; the facility failed to implement care plan approaches identified to address problematic [MEDICAL CONDITION] for one sampled resident (Resident 90). Sample size included 17 current residents and reviews of 2 closed records. Facility census was 50. Findings are: Record review of Resident 90's Resident Face Sheet form revealed the resident was admitted to the facility on [DATE]. Record review of Resident 90's Care plan revealed a problem identified [MEDICAL CONDITION] dated 1/16/17. The Long Term Goal for the problem was identified as: I will be able to sleep the amount of hours of my choice. Approaches to the problem included instructions for staff to not schedule inhalation treatments at bedtime if possible, and I do not want to be awakened for VS (vital signs) during the night. Interview with Resident 90 on 1/23/17 revealed the resident was not satisfied at being allowed a choice with sleeping throughout the night describing that the staff awakened the resident every night as early as 3 a.m. and most often between 4 a.m. and 5 a.m. The resident stated staff explained the weights had to be taken every night at this time. Observation on 1/25/17 at 4:30 a.m. revealed NA (Nurse Aide)-A and NA-N aroused the Resident from sleeping to perform a mechanical lift weighing procedure. Interview with NA-B on 1/25/17 at 4:20 a.m. confirmed the staff weighed Resident 90 every night on the night shift usually between 4 a.m. and 5 a.m. Interview with the Director of Nursing on 1/26/17 at noon confirmed Resident 90's care plan identified a problem of [MEDICAL CONDITION] with the goal to allow the resident to sleep the amount of hours per resident choice. The Director of Nursing also verified among the approaches on the care plan were directions not to awaken the resident for procedures during the night. The Director of Nursing verified Resident 90 was being awakened for daily weighing on the night shift and that the care plan approaches were not being implemented by the staff to address the resident's [MEDICAL CONDITION] problem.",2020-09-01
789,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,283,E,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C3a Based on record reviews and interview, the facility failed to complete discharge summaries summarizing the condition and stay for 3 sampled residents (Residents 69, 82, and 87) with anticipated discharges from the facility. Sample size included 19 closed record reviews. Facility census was 50. Findings are: [NAME] Closed medical record file review for Resident 69 revealed a Discharge Summary/Post Discharge Plan of Care form with a discharge date recorded on the form was 12/14/16. The discharge status recorded the resident was discharged to an Assisted Living and recorded the resident was initially admitted to the facility on [DATE]. Further review of the form revealed sections for discharge diagnosis, discharge medications, date of last physical exam, physician discharge orders, Nursing Summary/discharge instructions, Nutrition/Dietary Summary/Discharge instructions, Recreation/Healthy Generation Summary/Discharge instructions, and Rehabilitation Summary/Discharge instructions were not completed, signed, or dated. In addition there was no resident signature obtained on the provided line on the last page of the document. B. Closed medical record file review for Resident 82 revealed a Discharge Summary/Post Discharge Plan of Care form with a discharge date recorded on the form was 11/28/16. The discharge status recorded the resident was discharged to an Assisted Living and recorded the resident was initially admitted to the facility on [DATE]. Further review of the form revealed sections for discharge diagnosis, discharge medications, date of last physical exam, physician discharge orders, Nursing Summary/discharge instructions, Nutrition/Dietary Summary/Discharge instructions, Recreation/Healthy Generation Summary/Discharge instructions, and Rehabilitation Summary/Discharge instructions were not completed, signed, or dated. In addition there was no resident signature obtained on the provided line on the last page of the document. C. Closed medical record file review for Resident 87 revealed a Discharge Summary/Post Discharge Plan of Care form with a discharge date recorded on the form was 1/4/17. The discharge status recorded the resident was discharged to own home and recorded the resident was initially admitted to the facility on [DATE]. Further review of the form revealed sections for discharge diagnosis, discharge medications, date of last physical exam, physician discharge orders, Nursing Summary/discharge instructions, Nutrition/Dietary Summary/Discharge instructions, Recreation/Healthy Generation Summary/Discharge instructions, and Rehabilitation Summary/Discharge instructions were not completed, signed, or dated. In addition there was no resident signature obtained on the provided line on the last page of the document. Interview with the Administrator on 1/26/17 at 9:00 a.m. confirmed the discharge summaries included in the closed medical records [REDACTED].",2020-09-01
790,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,309,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, record review and interview; the facility failed to assess, provide cares and follow up with complaints of pain related to an ongoing sore throat and earache for one sampled resident (Resident 1). The facility census was 50 with 17 current sampled residents and two closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan with atarget goal date of 4/30/17, revealed that the resident had sadness and anxiety related to depression due to loss of vision and hearing and was nearly blind related to [MEDICAL CONDITION]. Review of the Routine Medications, dated (MONTH) (YEAR), revealed an order, dated 1/9/17, for [MEDICATION NAME] (antibiotic) daily for 10 days. Review of the Nurses Notes revealed the following: - 1/18/17 at 2:50 PM, the resident continued on the antibiotic related to a sinus infection and at 11:50 PM the last dose of antibiotic was given at supper; - 1/22/17 at 4:20 PM, the resident complained of an earache on the right side for two days, cotton ball was placed in the right ear per the resident's request and yesterday the family brought in earache drops which were not given. The doctor was faxed for recommendations, will continue to monitor; - 1/24/17 at 9:35 AM, facsimile was received to [MEDICATION NAME](antibiotic) drops to the right ear twice a day for seven days. Further review revealed no further documentation, including an assessment of the resident's ongoing sore throat or earache or vital signs, until 1/26/17 at 9:20 AM, per the request of the Director of Nursing. Observation of the resident on 1/24/17 at 11:00 AM revealed the resident seated in the wheelchair in room with head in hands and eyes closed. Interview with the resident on 1/24/17 at 11:00 AM revealed that the resident had a bad sore throat, earache and cough. The resident stated that it hurts really badly to swallow and would like the doctor called to get something to help since this had been going on for a couple of days and wasn't feeling any better. Interview on 1/24/17 at 11:15 AM with LPN (Licensed Practical Nurse) - K, Charge Nurse, revealed LPN-K would contact the clinic to evaluate the resident's sore throat and earache. Observations of the resident in the dining room on 1/24/17 at 12:00 PM revealed the resident taking sips of hot liquids. The resident stated that it hurt too bad to swallow anything but hot drinks. The resident stated that the resident had some hot cereal for breakfast but it hurt too bad to swallow that also. Interview with the resident on 1/25/17 at 12:00 PM and on 1/26/17 at 8:45 AM revealed that the resident continued to have a throat that was sore and it still hurt to swallow anything but sips of hot liquids. The resident also stated that the resident's ear still hurt. Interview with the Director of Nursing on 1/26/17 at 8:45 AM revealed that the nurses should have completed and documented an assessment of the resident's sore throat and earache, vital signs, care provided to relieve the ongoing pain, and follow up to ensure that the resident's needs were met.",2020-09-01
791,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,312,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, record reviews and interviews; the facility failed to ensure that oral care was offered for one sampled resident (Resident 47) dependent on staff for assistance. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 47 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, edited on 1/12/17, revealed that the resident required assistance with activities of daily living related to weakness and immobility. Observations on 1/25/17 at 6:30 AM revealed MA (Medication Aide) - [NAME] and NA (Nursing Assistant) - F assisted the resident with morning cares. Further observations revealed that oral care was not offered with the morning cares. Interview with the resident on 1/25/17 at 10:30 AM revealed that didn't remember having oral cares done the last few days. The resident stated liked to brush teeth in the morning but toothbrush and tooth paste weren't on the table. Interview with MA - [NAME] on 1/25/17 at 10:40 AM revealed that the resident's oral care supplies were kept in the cupboard in the bathroom above the toilet and the resident did not have access to them. MA - [NAME] confirmed that the toothbrush was dry and the toothpaste was still in the box and hadn't been used. Review of the nursing assistant activities of daily documentation forms revealed that oral care was not specifically listed. Interview with LPN (Licensed Practical Nurse) - K, Charge Nurse, on 1/25/17 at 9:00 AM revealed that routine oral care was not included in the daily nursing assistant care form. Further interview confirmed that the resident was dependent on the staff to set up supplies and assist with routine oral cares. Review of the facility policy and procedure Morning Care, dated 1/1/01, revealed the following including: Purpose To facilitate resident's overall comfort, cleanliness, grooming and well-being and Procedure . 10. Encourage/assist the resident with oral hygiene and provide a fresh glass of water. Interview with the Director of Nursing on 1/26/17 at 8:15 AM confirmed that the staff were to offer, set up and assist the resident with routine oral care.",2020-09-01
792,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,315,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 Based on observations, record reviews and interviews; the facility failed to ensure that care was provided to manage urinary incontinence for two sampled residents (Residents 89 and 39) dependent on staff for assistance. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: [NAME] Review of the Resident Face Sheet revealed that Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 1/20/17, revealed that the resident was incontinent of bladder and required assistance with toileting. Approaches included toilet/check/change resident upon rising in the morning, before and after meals, at bedtime and every two hours during the night. Observations on 1/23/17 at 3:00 PM revealed the resident seated in the wheelchair with wet slacks and a urine smell. Interview with a family representative on 1/23/17 at 3:00 PM revealed that the resident needed assistance to the bathroom and was not always getting assistance or changed when needed. The family representative stated that the resident needed to be checked more frequently for incontinence care. Interview with LPN (Licensed Practical Nurse) - H on 1/24/17 at 9:25 PM revealed that the resident was incontinent of urine and needed to be toileted every two hours. Interview with NA (Nursing Assistant) - M on 1/24/17 at 9:30 PM revealed that the resident was usually incontinent of urine and didn't call for assistance to the bathroom. Interview with NA - B on 1/25/17 at 4:15 AM revealed that the resident was incontinent of bladder. NA - B stated that during the night, residents were checked and changed at 12:30 AM rounds and at 3:00 AM rounds. NA - B stated that the resident was changed at 12:30 due to incontinence and was dry at 3:00 AM but not toileted. Observations on 1/25/17 at 4:30 AM, 5:30 AM, 6:00 AM and 7:00 AM revealed the resident sleeping in bed and not checked for incontinence. Observations on 1/25/17 at 6:00 AM revealed NA - B (night shift) was on shift rounds with NA - F (day shift). Further observations revealed that the resident was not checked for incontinence. Observations on 1/25/17 at 7:15 AM revealed MA - [NAME] awakened the resident for morning cares. Further observations revealed that the resident was incontinent of urine, MA- [NAME] toileted the resident and the resident voided. MA - [NAME] completed the morning cares and the resident was taken to the lobby area per wheelchair at 7:35 AM. Observations on 1/25/17 revealed the following: - 7:45 AM revealed the resident in the dining room for breakfast; - - 9:30 AM the resident was still in the dining room; - 10:00 AM the resident was taken out of the dining room and to the lobby area for a current events activity; - 11:05 AM the resident was taken to the activity room for exercise; - 11:30 AM the resident was seated in the lobby area with eyes closed; - 11:40 AM the resident was seated in the dining room. Interview on 1/25/17 at 11:40 AM with the RA (Restorative Aide) - O revealed that the resident was not toileted this morning until 11:30 AM. RA - O stated that the resident was not incontinent and did not void at that time. B. Review of the Resident Face Sheet revealed that Resident 39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 1/20/17, revealed that the resident was incontinent of bladder and bowel at times and approaches included offer toileting every morning, before and after meals and as needed. Interview with a family representative on 1/24/17 at 12:30 PM revealed that often found the resident wet and the staff were not always getting the resident's disposable brief changed. Interview with LPN (Licensed Practical Nurse) - H on 1/24/17 at 9:25 PM revealed that the resident was incontinent of urine and needed to be toileted every two hours. Interview with NA (Nursing Assistant) - M on 1/24/17 at 9:30 PM revealed that the resident was usually incontinent of urine and didn't call for assistance to the bathroom. Interview with NA - B on 1/25/17 at 4:15 AM revealed that the resident was incontinent of bladder. NA - B stated that during the night, residents were checked and changed at 12:30 AM rounds and at 3:00 AM rounds. NA - B stated that the resident went to bed around 11:00 PM last night, was checked and changed at 12:30 AM rounds due to incontinence and was not incontinent/or toileted at 3:00 AM. Observations of the resident on 1/25/17 at 4:30 AM, 5:30 AM, 6:00 AM and 7:00 AM revealed the resident sleeping in the same position in bed. Observations on 1/25/17 at 6:00 AM revealed NA - B (night shift) was on shift rounds with NA - F (day shift). Further observations revealed that the resident was not checked for incontinence. Observations on 1/25/17 at 8:20 AM revealed MA - [NAME] awakened the resident for morning cares. Further observations revealed that the resident was incontinent of urine in the disposable brief. MA - [NAME] and NA - F completed morning cares and did not offer toileting. Interview with the Director of Nursing on 1/26/17 at 7:30 AM confirmed that the residents were to be toileted or checked and changed as directed on the care plan to manage urinary incontinence and to promote comfort for the residents.",2020-09-01
793,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,318,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D4 Based on observations, record reviews and interviews; the facility failed to assess finger contractures (a condition of fixed high resistance to passive stretch of a muscle) and provide care to maintain function or to prevent further loss of function for one sampled resident (Resident 47). The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 47 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) on 1/23/17 at 1:00 PM revealed that the resident had contractures of fingers on each hand. Observations of the resident on 1/23/17 at 2:30 PM revealed contractures of the middle, ring and small fingers on both hands. Interview with the resident on 1/23/17 at 2:30 PM revealed that can't bend those fingers or use them anymore because they are still. The resident stated did not wear splints on hands and didn't have exercises for those fingers. The resident stated sometimes tried to move them and exercise on own. Interview with LPN (Licensed Practical Nurse) - P, Restorative Nurse, on 1/25/17 at 8:00 AM revealed that the resident was not on a restorative program. Interview with COTA (Certified Occupation Therapy Assistant) - Q on 1/25/17 at 10:10 AM revealed that the resident was on skilled occupational therapy to maintain prior status or improve the functional status for the thumb and forefinger. Further interview confirmed that occupational therapy was not working with the contracted fingers. COTA - Q confirmed that an assessment of the resident's contractures was not completed to determine baseline and no program was developed to address the contractures for skilled therapy or restorative care. Review of the Interdisciplinary Rehabilitation Screening Form, dated 1/25/17, signed by the Occupational Therapist, revealed level 2 contractures of fingers 3,4,5 on both hands. Further review revealed that the resident had fixed contractures secondary to joint deformity from arthritis and had functional use of the thumb and index fingers. Interview with the DON on 1/26/17 at 7:30 AM confirmed that the resident's finger contractures were not assessed and a plan was not in place to maintain functional status and/or prevent further decline in functional status.",2020-09-01
794,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,328,G,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, record reviews and interviews; the facility failed to ensure that oxygen was in place and administered as ordered and that respiratory status was monitored for one sampled resident (Resident 39) who frequently removed oxygen resulting in low oxygen blood levels. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, edited 1/20/17, revealed that the resident was at risk for impaired gas exchange related to chronic [MEDICAL CONDITION]. Approaches included administer oxygen per nasal cannula, assess and record signs of impaired gas exchange (confusion, restlessness, irritability), resident refuses to wear oxygen frequently, monitor oxygen saturation as ordered and monitor and document respiratory status as needed with changes in respiratory status. Interview with a family representative on 1/24/17 at 12:30 PM revealed they often found the resident without oxygen. Further interview revealed that the resident was more confused, restless and agitated when the oxygen wasn't kept on which made it even more difficult to get the resident to keep the oxygen in place. Observations on 1/24/17 at 8:45 PM revealed the resident seated in the wheelchair in room with oxygen cannula (tubing placed in the nose to administer supplemental oxygen) on the floor. Further observations revealed NA (Nursing Assistant) - M attempted to place the oxygen on the resident and the resident refused. NA - M reported to LPN (Licensed Practical Nurse)- H, Charge Nurse, that the resident refused the oxygen and was agitated. LPN - H entered the room and encouraged the resident to use the oxygen and the resident complied. LPN - H checked the resident's oxygen saturation which was 79% (normal oxygen saturation is greater than 90%). LPN - H encouraged the resident to take deep breaths and after several minutes the oxygen saturation was 80%. At 9:15 PM, LPN - H reported that a respiratory treatment was administered and then the resident's oxygen saturation rate was 90%. Observations of the resident on 1/24/17 at 9:45 PM revealed that the resident's oxygen was off and the cannula was draped over the arm of the wheelchair. Interview on 1/24/17 at 10:00 PM with NA - M revealed that the resident continued to refuse to get ready for bed. Observations on 1/25/17 at 4:30 AM, 5:30 AM and 6:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Interview with RN (Registered Nurse) - L on 1/25/17 at 6:05 AM revealed that RN-L was not aware that the resident's oxygen had been off this morning. RN - L checked the oxygen saturation which was reported to be 86%. Observations on 1/25/17 at 7:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Observations on 1/25/17 at 8:20 AM revealed MA (Medication Aide) - [NAME] awakened the resident for morning cares. MA - [NAME] shut the oxygen concentrator off. Further observations revealed that the resident did not have oxygen on during the morning cares. MA - [NAME] applied the oxygen for the resident at 8:50 AM. Review of the Nurses Notes revealed no notes after 1/11/17 which stated that the resident was off Medicare A skilled nursing services. There was no documentation of the resident's refusal to use oxygen as ordered, restlessness and agitation or low oxygen saturation levels. Review of the Treatments, dated (MONTH) (YEAR), revealed an order, dated 12/12/16, for oxygen at 2 liters per minute per nasal cannula continuously. Review of the Routine Medications, dated (MONTH) (YEAR), revealed an order, dated 12/12/16 for respiratory treatments four times a day. Review of the Respiratory Assessment Flow Sheet, dated (MONTH) (YEAR), revealed an assessment completed daily after a respiratory treatment which showed oxygen saturation levels of 94% - 98%, and lungs clear. Interview with the DON (Director of Nursing) on 1/26/17 at 8:30 AM confirmed that the nurses should monitor and document the resident's respiratory status, in addition to the daily assessment, as the resident was at risk for low oxygen saturation levels, increased restlessness, agitation and discomfort when the oxygen was removed.",2020-09-01
795,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,332,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.10D Based on observations, record reviews, and interviews; the facility staff failed to: 1) administer a scheduled aerosol (inhaled medication) medication for one sampled resident (Resident 90); and 2) administer a scheduled dose of an antidepressant medication for one sampled resident (Resident 52). The omissions resulted in a facility medication error rate of 8% (2 errors in 25 opportunities for medication errors). Sample included observations of 10 residents receiving medications from facility staff. Facility census was 50. Findings are: [NAME] Observation on 1/23/17 at 2:55 p.m. revealed LPN (Licensed Practical Nurse)-T was administering medications on the evening shift. LPN-T was observed noting that Resident 90 had a scheduled aerosol medication ordered four times daily and the record indicated the medication was due at dinner. LPN-T was observed unable to find the medication on the cart and did not administer a dose of the medication. Interview with LPN-T on 1/23/17 at 2:55 p.m. during the observation stated the time on the resident Medication Record was incorrectly written as dinner but that the resident requested it afternoon which is why the medication was normally given around 3 p.m. LPN-T verified the medication would be omitted and not given as ordered due to not being able to find the medication on the medication cart as it was re-ordered but had not arrived. LPN-T described having to circle and initial the medication scheduled for the dinner dose because the medication dose was being omitted. Record review of Resident 90's Home medications (a list of physician orders [REDACTED]. Record review of Resident 90's Medication Administration Record [REDACTED]. The instructions for administration were to administer the medication QID (four times daily) with doses scheduled at breakfast, lunch, dinner, and bedtime. Further review of Resident 90's record verified LPN-T had circled and initialed the dose scheduled for dinner with a handwritten notation on the back of the form that read: [MEDICATION NAME] unavailable from pharmacy. Has been ordered. B. Observation on 1/24/17 at 9:50 p.m. revealed LPN-H was administering medications to Resident 52. LPN-H discovered Resident 52's bedtime dose of [MEDICATION NAME] (an antidepressant medication) was not available for administration and the medication was omitted. Record review of Resident 52's Medication Administration Record [REDACTED]. Further inspection of the form revealed LPN-H had initialed and circled the scheduled dosage time and recorded on the back of the form that the [MEDICATION NAME] 100 mg (milligrams) was not available. Record review of Resident 52's chart revealed a faxed form document from the physician on 12/9/16 which provided an order for [REDACTED]. Record review of a facility policy entitled Medication Administration Variance Reporting dated 1/1/01 defined a type of Medication Variance as Medication not administered as ordered . omitted, including medications 'unavailable' from pharmacy or family. Interview with the Director of Nursing on 1/25/17 at 11:40 a.m. verified the observations that Resident 90 was not administered the [MEDICATION NAME] respiratory treatment on 1/23/17 scheduled for dinner and Resident 52 had not been administered the bedtime dose of [MEDICATION NAME] on 1/24/17 which constituted omission medication variances (another term meaning medication errors).",2020-09-01
796,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,353,D,0,1,EUUX11,"License Reference Number 175 NAC 12-006.04C Based on observations, interviews and record reviews; the facility failed to ensure sufficient staffing to meet the needs for 6 sampled residents (Resident 53, 19, 89, 39, 4, and 90) as evidenced by not providing the assistance needed for toileting, meal delivery and meal assistance, slow response to calls for assistance, and not providing assistance when requested to go to bed . Current sample size was 17 with 2 closed record reviews. The facility census at the time of survey was 50 . Findings are: [NAME] Interview on 1/23/17 at 2:56 PM with Resident 53 revealed that the resident felt that there was not enough staff and could use more staff to help with supper. B. Interview on 1/23/17 at 4:12 PM with a family member and Resident 19 revealed that there was not enough staff to assist with the residents cares, as the resident was dependent on using a sit to stand with transfers and sometimes had to wait 20-40 minutes or longer for staff to provide assistance with toileting. Review of the Care Plan for Resident 19 dated 9/1/16 revealed that the resident was assistance with all transfers and ADL's(Activities of Daily Living) and transfers using the sit-to-stand lift with one to two person assist. C. Interview on 1/23/17 at 7:51 PM with the family member of Resident 89 revealed that the family member did not feel that there was enough staff on the evening shift to get the work done and provide the care that her mom needs. Refer to Federal Licensure Tag F 315 for more information. D. Interview on 1/24/17 at 12:28 PM with the family member of Resident 39 revealed that the family member did not feel that there was enough staff to help in the mornings, and the resident was not always getting assistance with the room tray. Refer to Federal Licensure tags F 315, F 328 and F 364 for further information. E. Interview on 1/24/17 at 2:32 PM with Resident 4 revealed that there was not enough staff to provide resident cares as the resident sometimes has to wait a long time before the call light is answered. Further interview revealed that the resident was to get 2 baths a week, is only getting one, and has now went 1 1/2 weeks without a bath. Refer to Federal Licensure Tag F242 for more information. Interview on 1/25/17 at 5:22 AM with (Licensed Practical Nurse) LPN - C revealed that Resident 4 is supposed to call for assistance with transferring but does not always do so. Further interview revealed that at times the resident is confused and also wears oxygen with shortness of breath and weakness. Observation on 1/25/17 at 5:23 AM of Resident 4 in the bathroom, unassisted, and then returned to the bed without calling for assistance. Further observation revealed that the brief was laying on the bathroom floor, was soaked and the resident had removed the resident's brief and pants and returned to the bed and was short of breath. Interview on 1/24/17 at 8:56 PM with NA - B revealed that the NA works the night shift, and revealed that the NA did not feel that there was enough staff to meet the resident's needs. This NA reported that, sometimes the call lights are on for over 45 minutes. This NA was working extra on the evening and night shift. Interview on 1/24/17 at 9:04 PM with NA - G revealed that this NA worked evening shifts and was currently working over her shift which ended at 8:00 AM to assist with getting residents to bed. Further interview revealed that the staffing available for this shift is more than it usually was. Interview on 1/24/17 at 9:08 PM with LPN - H revealed that staffing lately has been consistent but feels that more staff in the evenings would be beneficial as this LPN did not feel that the, needs of the residents are meet, because there are not enough staff. Interview on 1/24/17 at 9:15 PM with NA - I revealed that sometimes on the evening shift there are just 2 NA's. Further interview revealed that the staff number during this time frame is not usual. Interview on 1/24/17 at 9:20 PM with NA - J revealed that the NA had worked nights and at times there was only 1 NA scheduled if someone called in. This NA did report that sometimes on evening shifts from 2-6 there is only 1 CNA scheduled. This NA felt that at times the staffing was dangerous and the residents were not getting all the cares ordered for them. Review of the Nursing Assistant Schedule for (YEAR) and the Nursing Assignment sheets revealed that the records do not match and confusing to review as changes have not been made to the original master schedule to correlate with the assignment sheet. Review of the Nursing Assignment sheets dated 1/13/17 revealed: - 1 scheduled NA from 2:00 PM to 4:00 PM for 51 residents per the posting, - 1 scheduled NA from 2:00 PM to 4:00 PM for 50 residents per the positing, - 1 RN added to help answer lights as no CNA available on the floor from 2:00 PM to 4:00 PM due to call in for 50 residents per posting. Interview on 1/26/17 at 3:00 PM with the Administrator, the Director of Nursing, and the Nurse Consultant to address staffing issues. Further interview revealed that the facility did not recognize or feel that there was staffing issues. Staffing issues were identified through the survey process with observations, resident interviews, family interviews, staff interviews, and record review of the of the Nursing Assignment and the posting. Further interview revealed numerous Quality Care Issues that had not been identified. F. Interview with Resident 90 on 1/23/17 at 4:17 p.m. revealed the resident had been admitted to the facility in early (MONTH) of (YEAR). The resident was questioned if the resident felt there were enough staff available to make sure the resident received the care and assistance required or requested without waiting a long time. The resident responded to the question no and went on to explain that every evening there would often be only two nurse aides available and the resident required two staff to assist with a mechanical lift. The resident stated when requesting to go to bed it will take up to two hours between the request and the time staff attend to the request. The resident attributed this to staff needing a second person to assist with the lift. The resident felt they needed more staff because of the time it took to respond to a bedtime request while the staff find an additional staff person to help transfer to bed. Observation on 1/24/17 at 8:45 p.m. revealed Resident 90 activated the call light which was responded to by LPN (Licensed Practical Nurse)-C. The resident requested to go to bed. LPN-C acknowledged the request, turned off the call light and returned to other tasks. At 9:23 p.m. two staff members, NA (Nurse Aide)-B and NA-F entered the resident room, obtained a mechanical lift and assisted the resident to bed. Interview with Resident 90 on 1/24/17 at 9:30 p.m. after the resident was assisted to bed, the resident confirmed having requested to go to bed at 8:45 p.m. and the staff had not responded to the request until 9:23 p.m., 38 minutes after the request.",2020-09-01
797,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,364,E,0,1,EUUX11,"Licensure Reference Number 175 NAC 12-006.11D Based on observations, record reviews and interviews; the facility failed to ensure that 1) refrigerated desserts were not served until residents were present in the dining room and 2) a breakfast plate of food was not served until one sampled resident (Resident 39) was in the dining room. The facility census was 50 and this had the potential to affect the majority of the residents but not all residents as an average of ten residents received meal trays in their rooms . Findings are: [NAME] Observations of the dining room on 1/23/17 at 11:35 AM revealed ice water and dishes of chocolate pudding on the residents tables with no residents in the dining room. Further observation revealed a poster which stated that lunch was served at 12:00 PM. Observations of the dining room on 1/24/17 at 11:30 AM revealed dishes of refrigerated grapes and canned peaches placed on the tables. Interview on 1/25/17 at 11:45 AM with DA (Dietary Aide) - U and DA - V revealed that they routinely placed the desserts on the tables as they were setting up the tables for lunch. Further interview revealed that they usually started setting the tables about 11:30 AM. Interview with the Dietary Manager on 1/25/17 at 11:50 AM confirmed that the temperature of the refrigerated desserts would not be maintained at room temperature for that length of time (20 - 30 minutes or more) to keep the temperatures cold enough to ensure the palatability of the foods. B. Observations on 1/25/17 at 8:50 AM revealed Resident 39 brought into the dining room per wheelchair. Further observation revealed a covered plate of food and juice at the table. Interview at 8:50 AM with DA - U revealed that the breakfast was served for the resident and would verify the food temperatures on the plate. DA - U removed the plate of food and the juice and obtained the temperature of the scrambled eggs was 64 degrees F. (Fahrenheit), the toast and bacon were 60 degrees F. and the juice was 50 degrees F. DA - U prepared another plate of food and poured a fresh glass of juice for the resident. Review of the Daily Food Temperature Sheet, dated 1/25/17, revealed that at 7:45 AM the temperature of the scrambled eggs was 180 degrees F. and the juice was 40 degrees F. The bacon and toast temperatures were not recorded. Interview with the Dietary Manager on 1/25/17 at 11:50 AM confirmed that food should not be served and left on the table before the residents were in the dining room to ensure palatable food temperatures.",2020-09-01
798,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,371,F,0,1,EUUX11,"Licensure Reference Number 175 NAC 12-006.11 E Based on observations, record reviews and interviews; the facility failed to ensure that 1) the sugar and flour storage containers were labled, 2) refrigerator and freezer temperatures were monitored and documented twice a day as scheduled, 3) hair restraints completely covered dietary staff's hair while in the kitchen and 4) potentially contaminated disposable gloves were not used for handling ready to eat foods. The facility census was 50 with the potential risk of food borne illness for all of the residents. Findings are: [NAME] Observations on 1/23/17 at 10:45 AM, during the initial walk through of the kitchen, revealed that the storage containers for the bulk sugar and the flour were not labeled. B. Review of the Refrigeration Temperature Log, dated (MONTH) (YEAR), revealed that the refrigerator and freezer temperatures were to be taken and documented every morning and afternoon. Further review revealed no documentation of the refrigerator or freezer on the afternoon shift on 1/1, 1/4, 1/7, 1/8, 1/14, 1/15, 1/21, 1/22 and 1/23. Interview on 1/23/17 at 10:45 AM with the DM (Dietary Manager) confirmed that the containers needed to be labeled. Further interview confirmed that the refrigerator and freezer temperatures were to be checked and documented on the log two times a day to ensure proper temperatures were maintained for food storage. C. Observations in the kitchen on 1/23/17 at 10:45 AM revealed DA (Dietary Assistant) - V and DA - W wore hair nets that didn't completely cover their hair. Further observations in the kitchen on 1/25/17 at at 11:45 AM revealed DA - U wore a hair net that didn't completely cover hair. Interview with the DM on 1/25/17 at 11:50 AM confirmed that the staff were to be sure that their hair nets completely covered their hair to reduce the risk of cross contamination. D. Observations in the kitchenette in the main dining room on 1/25/17 at 12:00 PM revealed DA - U wearing disposable gloves separating the dinner rolls. Further observations revealed DA - U, wearing the same gloves, picked up the tray of dinner rolls and placed it on the counter area, rearranged the dinner rolls on the tray, picked up a box of foil sheets and placed foil coverings over the dinner rolls without removing the disposable gloves. Interview on 1/25/17 at 12:10 PM with the DM confirmed that the disposable gloves should have been removed immediately after handling the dinner rolls and new gloves applied to rearrange the dinner rolls to reduce the risk of cross contamination. Review of the 7/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used for an authoritative reference for food service sanitation practices, revealed the following: 3-602.11 The common name of the food, or absent a common name, in adequately descriptive identity statement . Temperature and Time Control 3-501.11 Stored frozen foods shall be maintained frozen. 3-501.12 Under refrigeration that maintains the food temperature of 41 degrees Fahrenheit. 3-402.11 Hair restraints worn to effectively keep hair from contacting exposed food. 3-304.15 Single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food and discarded when interruptions occur in the operation.",2020-09-01
799,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,411,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to offer routine dental services for one sampled resident (Resident 47) with missing and broken teeth. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 47 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was admitted to the facility on [DATE]. Observations of the resident on 1/23/17 at 2:30 PM revealed several missing and broken teeth. Interview with the resident on 1/23/17 at 2:30 PM revealed no discomfort with teeth or difficulty chewing. Interview with the Social Services Director on 1/26/17 at 9:20 AM revealed that the resident was on skilled Medicare services at this time. The Social Services Director stated that there was no record that the resident had been to a dentist since admission. Further interview revealed that routine dental appointments were not offered to the resident for preventative care or cleaning.",2020-09-01
800,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,425,D,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12 Based on observations, record reviews, and interviews; the facility failed to: 1) ensure a regularly scheduled inhalation medication was obtained and available for administration as ordered for one sampled resident (Resident 90); and 2) ensure a regularly scheduled antidepressant medication was obtained and available for administration as ordered for one sampled resident (Resident 52). Sample size included 10 residents observed receiving medications from the staff. Facility census was 50. Findings are: [NAME] Observation on 1/23/17 at 2:55 p.m. revealed LPN (Licensed Practical Nurse)-T was administering medications on the evening shift. LPN-T was observed noting that Resident 90 had a scheduled nebulizer (a machine producing an aerosol mist to deliver inhalation medication) treatment ordered four times daily due at dinner time. LPN-T was observed unable to find the medication on the cart and did not administer a dose of the medication. Interview with LPN-T on 1/23/17 at 2:55 p.m. during the observation stated the time on the resident Medication Record was incorrectly written as dinner but that the resident requested it afternoon which is why the medication was normally given around 3 p.m. LPN-T verified the medication would be omitted and not given as ordered due to not being able to find the medication on the medication cart as it was re-ordered but had not arrived. LPN-T described having to circle and initial the medication scheduled for the dinner dose because the medication dose was being omitted. LPN-T explained the pharmacy was across state and the medication would not be available until the next morning. Record review of Resident 90's Home medications (a list of physician orders [REDACTED]. Record review of Resident 90's Medication Administration Record [REDACTED]. The instructions for administration were to administer the medication QID (four times daily) with doses scheduled at breakfast, lunch, dinner, and bedtime. Further review of Resident 90's record revealed the resident's last dose of Duoneb was administered on 1/23/17 at breakfast and the lunch, dinner, and bedtime doses were omitted with documentation on the Nurse's Medication notes on the back of the form recording the Duoneb treatments were not administered at lunch, dinner, and bedtime due to the medication being unavailable from the pharmacy. Further review of the record revealed the medication was re-initiated on 1/24/17 at breakfast. B. Observation on 1/24/17 at 9:50 p.m. revealed LPN-H was administering medications to Resident 52. LPN-H discovered Resident 52's bedtime dose of Zoloft (an antidepressant medication) was not available for administration and the medication was omitted. Record review of Resident 52's chart revealed a faxed form document from the physician on 12/9/16 which provided an order for [REDACTED]. Record review of Resident 52's Medication Administration Record [REDACTED]. Further inspection of the form revealed the resident received the Zoloft at bedtime on 1/21/17 but the bedtime doses on 1/22/17, 1/23/17, and 1/24/17 were omitted with documentation on the Nurse's Medication Notes portion on the back of the form recording the medication was omitted due to not available. Interview with the Director of Nursing on 1/25/17 at 11:40 a.m. verified Resident 90 missed three doses of the scheduled Duoneb breathing treatment on 1/23/17 and Resident 52 missed three scheduled bedtime doses of Zoloft on 1/22/17; 1/23/17; and 1/24/17 due to the medications being unavailable from the pharmacy.",2020-09-01
801,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,441,E,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.17B Based on observations and interviews, the facility failed to ensure that 1) an oxygen cannula was kept off of the floor and replaced when potentially contaminated for one sampled resident (Resident 39), 2) respiratory equipment was cleaned and covered after use for two sampled residents (Residents 39 and 47), 3) personal care items were not stored on the bathroom floor and a bar of hand soap by the bathroom sink was labeled for two sampled residents who shared a bathroom (Residents 53 and 28), 4) a bottle of periwash was labeled in a bathroom shared by two residents (Residents 51 and 74), 5) a soiled bedpan was not placed on the floor and was emptied and cleaned promptly for one sampled resident (Resident 47) and 6) an uncovered catheter drainage bag was not placed directly on the floor for one sampled resident (Resident 79) to reduce the risk of cross contamination. The facility census was 50 and the current sample was 17 residents. Findings are: [NAME] Observations of Resident 39 on 1/24/17 at 8:45 PM revealed the resident seated in the wheelchair in room with oxygen cannula (tubing placed in the nose to administer supplemental oxygen) on the floor. Further observations revealed NA (Nursing Assistant) - M attempted to place the oxygen on the resident and the resident refused. NA - M placed the cannula on the resident's lap and left to report that the resident refused the oxygen and was agitated. LPN (Licensed Practical Nurse)- H, Charge Nurse, entered the room to check the resident and encourage the resident to use the oxygen. Interview with LPN - H revealed was not aware that the oxygen cannula was previously on the floor and needed to be replaced. LPN - H replaced the contaminated oxygen cannula. B. Observations of Resident 39's bathroom on 1/24/17 at 7:20 AM and on 1/25/17 at 6:30 AM revealed respiratory treatment equipment including reservoir for nebulizer (an apparatus for producing a fine spray or mist) medication, mouth piece and mask uncovered in a basket located on a shelf above the toilet. Observations of Resident 47's room on 1/24/17 at 7:20 AM and on 1/25/17 at 6:30 AM revealed the BiPap (a type of continuous positive airway pressure utilized to assist residents with difficulty breathing while sleeping) mask uncovered on the resident's dresser. Further observations revealed respiratory equipment used for nebulizer treatments, including the mouth piece, uncovered on the resident's dresser. C. Observations of the bathroom for room [ROOM NUMBER] (Residents 53 and 28) on 1/24/17 at 7:20 AM and on 1/25/17 at 6:30 AM revealed two packages of disposable briefs stored on the floor and an unlabeled bar of hand soap in a dish by the bathroom sink. D. Observations of the bathroom for room [ROOM NUMBER] (Residents 51 and 74) on 1/24/17 at 7:20 AM and on 1/25/17 at 6:30 AM revealed an unlabeled and opened spray bottle of periwash on the bathroom shelf. E. Observations of Resident 47's room on 1/25/17 at 9:45 AM revealed a strong smell of feces and urine. Further observations revealed a soiled uncovered bed pan which contained feces and urine on the floor by the resident's bed. Interview with MA (Medication Aide) - [NAME] on 1/25/17 at 9:50 AM revealed that the resident used the bed pan earlier and forgot to empty and clean it before leaving the room. Interview with the DON (Director of Nursing), Infection Control Nurse, on 1/26/17 at 7:30 AM confirmed that the staff should have reported the contaminated oxygen cannula right away so it would be replaced before the resident used it. Further interview confirmed that the respiratory equipment needed to be cleaned and stored covered after use, personal care items should not be stored on the floor and hand soap and periwash should be labeled for residents who share bathrooms to reduce the risk of cross contamination. The DON confirmed that bedpans should not be placed on the floor to reduce the risk of cross contamination and should be emptied and cleaned promptly. E. Record review of Resident 79's Resident Face Sheet revealed the resident was admitted to the facility on [DATE] and among the resident's medical [DIAGNOSES REDACTED]. Interview with charge nurse, RN (Registered Nurse)-L on 1/23/17 during an initial tour of the facility conducted between 10:44 a.m. and 11:00 a.m. revealed Resident 79 was being treated for [REDACTED]. Record review of Resident 79's Urine Culture report form dated 1/15/17 revealed the culture identified the resident's urine contained Extended Spectrum Beta Lacatamase (a multi-drug resistant infectious organism). Record review of Resident 79's Care plan with Long Term Goal Target Date of 2/16/17 revealed a problem identifying the resident had a foley (catheter device inserted into the bladder for urinary drainage). Approaches and instructions to the staff for the care of the resident's catheter recorded the resident Requires extensive assistance with toileting. Observations of Resident 79 revealed the following: - 1/25/17 at 4:30 a.m. the resident was asleep in a low bed and was observed with the resident's catheter bag outside of a protective cover and in direct contact with the floor. - 1/25/17 at 5:30 a.m. observation with the Director of Nursing revealed the resident was asleep in a low bed and the catheter bag was positioned outside of a protective cover and in direct contact with the floor. 1/25/17 at 5:30 a.m. an interview with the Director of Nursing confirmed Resident 79's catheter bag was not covered and was positioned in direct contact with the floor resulting in a potential source of cross contamination to the resident's catheter. Observation of morning cares delivered to Resident 79 by NA (Nurse Aide)-R and NA-S on 1/25/17 beginning at 7:00 a.m. revealed the staff assisting the resident to get dressed and transfer by mechanical lift to the bathroom. During the pivot transfer to sit at the edge of the bed to position in the lift, the resident's catheter bag was placed by NA-S directly on the floor while the resident was positioned and lifted. Following the transfer into the wheelchair, NA-S then placed the catheter bag into a cover bag on the wheelchair. Interview with the Director of Nursing on 1/26/17 at noon revealed the Director of Nursing also functions as the interim Infection Control Practitioner for the facility. The Director of Nursing confirmed that during cares and positioning, residents with catheters should not have the drainage bags come in contact with the floor as this was a potential source of cross contamination that could potentially result in an infection.",2020-09-01
802,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,463,E,0,1,EUUX11,"Licensure Reference Number: 175 NAC 12-007.04G Based on observations and interviews, the facility failed to ensure bathroom call lights were functional in rooms occupied by 3 sampled residents (Residents 24, 19, and 29). Sample size included 30 residents. Facility census was 50. Findings are: [NAME] Observation of Resident 24's room on 1/23/17 at 1:22 p.m. revealed the call light in the bathroom was broken and unable to activate the visual or auditory signal when pulled. B. Observation of Resident 19's room on 1/23/17 at 1:22 p.m. revealed the call light in the bathroom was broken and unable to activate the visual or auditory signal when pulled. C. Observation of Resident 29's room on 1/23/17 at 2:10 p.m. revealed the call light in the bathroom was broken and unable to activate the visual or auditory signal when pulled. Observations with the Director of Nursing on 1/23/17 at 4:40 p.m. revealed the bathroom call lights in rooms occupied by Residents 24, 19, and 29 were not functional and unable to activate the visual or auditory signal when pulled. Interview with the Director of Nursing on 1/23/17 at 4:40 p.m. confirmed the bathroom call lights in rooms occupied by Residents 24, 19, and 29 were not functional and unable to activate the visual or auditory signals and that they needed to be replaced.",2020-09-01
803,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,514,E,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.16B Based on record review and interviews; the facility failed to ensure that the MAR's(Medication Administration Records) and the TAR's(Treatment Administration Records) contained written completion of documentation for 4 sampled residents (Resident 19, 21, 23 and 40). The current census sample was 17 with 2 closed record reviews. The facility census at the time of survey was 50. Findings are: [NAME] Review of the Routine Medications sheet of MAR for Resident 21 dated for (MONTH) (YEAR) revealed no written documentation on: - 1/13 and 1/16, 1/20, and 1/21 for pain assessments completed for the day shift, - 1/16, 1/21 and 1/22 for the evening shifts pain assessments, - 1/12 for the administration of [MEDICATION NAME] on the evening shift, - 1/12 no written documentation for the evening dose of [MEDICATION NAME], - 1/12 no written documentation of the HS(bedtime) snack supplement offered, - 1/12/17 of the [MEDICATION NAME] administered daily, - 1/12 for the bedtime dose of [MEDICATION NAME], - 1/19 and 1/20 for the dose of [MEDICATION NAME] for the AM morning shifts. Review of the Treatments Sheets or TAR for Resident 21 dated for (MONTH) (YEAR) revealed no written documentation on: - 1/20 the day shift for the Geri gloves on at all times for the AM shift, - 1/20, 1/21/ and 1/22 on the evening shifts for the Geri gloves on at all time, - 1/17, and 1/20 for the leg protectors on at all times for the day shifts, the evening shifts on 1/5, 1/7, 1/8, 1/12 and the night shifts on 1/19, 1/20, 1/21, and 1/22, - 1/21 for the day shift to check the wandergaurd on the walker every shift for function and for the PM shift on 1/8, 1/9, 1/12 and the night shifts on 1/20, 1/21 and 1/22. Further review revealed no written documentation of the oxygen tubing changed, concentrator filters washed, or to wipe down concentrator every Saturday 1/21. B. Review of the MAR for Resident 23 dated (MONTH) (YEAR) revealed no written documentation on: - 1/8/17 and 1/17/17 of PM pain rating to be done every shift, - 1/5/17 the [MEDICATION NAME] dose at bedtime, - 1/5/17, 1/18/17 for the doses of [MEDICATION NAME] at bedtime, - 1/13/17 Med plus 240 ml (milliliters) twice a day. Review of the (TAR) for Resident 23 dated (MONTH) (YEAR) revealed no written documentation on: - 1/20/16 of monitoring the Right elbow skin tear daily until healed and monitoring the right outer leg abrasion daily until healed. C. Review of the MAR indicated [REDACTED] - 1/20 of the AM pain or on 1/16 of the PM pain score to be completed every shift, - 1/16 of the [MEDICATION NAME] administered to be administered at supper, - 1/8 of the Microsulfron to be administered, - 1/24 of [MEDICATION NAME] to be administered daily, - 1/6 of offering HS snack, - 1/8 of a [MEDICATION NAME] ordered to be changed, - 1/19 and 1/20 on the day shift to check placement of the [MEDICATION NAME] every shift., - 1/22 of checking the [MEDICATION NAME] for placement. Review of the TAR for Resident 19 dated (YEAR) revealed no written documentation on monitoring a bruise daily 1/17 and 1/20. D. Review of the MAR indicated [REDACTED] - 1/8 of the [MEDICATION NAME] administered at bedtime, - 1/13, 1/20 and 1/21 of the AM pain score completion, - 1/16 of the PM pain score and, - 1/5 of the HS snack offered. Interview on 1/26/17 at 11:00 AM with (Registered Nurse) RN - L revealed that written documentation should be completed on the MAR's and TAR's directly following the administration of medication or treatment provided to the resident. Interview on 1/27/17 at 2:30 PM with the Administrator, the Director of Nursing and the Nurse Consultant verified that the MAR's and TAR's for Residents 19, 21, 23 and 40 did have holes and areas that did not have written documentation of completion. Further interview verified that the MAR's and TAR's are to be completed upon administration of the medication or treatment for [REDACTED].",2020-09-01
804,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2017-01-26,520,F,0,1,EUUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.07 Based on record review and interviews; the facility failed to re-evaluate prior plans of correction to correct and maintain correction for previously cited deficient practice related to: privacy and dignity for the residents in commons areas, reviewing and revising care plans with changes for residents to include current ADL's (Activities of Daily Living), or changes in condition regarding sore throat/earache and a change in respiratory care issues, provision of care to include assessments not completed, interventions and evaluation no in place to ensure that the needs for a resident with signs and symptoms of an infection were met, residents dependent on ADL's provided assistance with dental cares, management and cares provided for urinary incontinence, proper food storage regarding monitoring the temperatures of the refrigerators and freezers with food items, that medications were available from the pharmacy, measures taken to prevent the potential for cross-contamination of respiratory care equipment, oxygen cannula and personal care items. This had the potential to affect all 50 of the residents. The facility census was 50 at the time of survey. Findings are: Record review of the previous complaints, and annual survey deficiencies for the facility revealed the following: - F 164 Privacy- medical records kept private, and skin not exposed to others for injections, and vital signs in commons areas. - F 241 Dignity- gait belt in the commons and diningroom area, - F 279 Development of care plans to include [MEDICAL TREATMENT] and access site cares, - F 280 Review and revise care plans to include liquid consistencies, - F 309 Provide care/treatment and monitoring for [MEDICAL TREATMENT] resident and bruising of another resident - F 312 Residents dependent on ADL's received bathing, and soiled clothing changed, - F 315 Restore bladder function, monitor catheter and bladder assessments completed - F 323 Oxygen concentrators turned off while residents out of rooms, - F 371 Sanitation and food storage to include the proper storage of bowls to prevent the potential for cross-contamination - F 441 Infection control with disposal of gloves, injections, and hand washing after wearing gloves, - F 463 Call lights not operational - F 514 Holes in the Medication and Treatment Administration records for insulin administration, blood sugar readings and blood pressure readings. Additional tags cited this survey include: F 165, F 205, F 242, F 258, F 272, F 278, F 282, F 283, F 318, F328, F 332, F 353, F 364 and F 411. Interview on 1/26/17 at 3:30 PM with the Quality Assurance Coordinator/Administrator, the Director of Nursing and the Nursing Consultant revealed the facility had not corrected the issues of: privacy for the residents in regards to exposure of skin, oxygen concentrators left on while the residents were not in the room, operational call lights and holes for completion of the Medication and Treatment Administration records.",2020-09-01
805,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-02-05,609,D,1,0,R49311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on record reviews and interview, the facility failed to ensure that an investigation report was successfully transmitted to the State Agency per facsimile as required for one current sampled resident (Resident 1). The facility census was 53 with eight current sampled residents and three closed records reviewed. Findings are: Review of the facility Investigation Report Template, dated 10/4/18, revealed that Resident 1 fell on [DATE] and sustained a [MEDICAL CONDITION] and the investigation was completed on 10/4/18. Further review of the Facsimile Cover Sheet revealed that the document was not successfully transmitted to the State Agency on 10/5/18 at 10:27 and TX FAILURE NOTICE. Interview with the Director of Nursing on 2/5/19 at 1:15 PM confirmed that the investigation report was not successfully submitted to the State Agency for review as required.",2020-09-01
806,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-02-05,880,D,1,0,R49311,"> Licensure Reference Number 175 NAC 12-006.10A2 Based on observations, record review and interview; the facility failed to ensure that nurses administered an injection in a manner to reduce the risk of cross contamination for one current sampled resident (Resident 11). The facility census was 53 with four sampled residents observed for medication administration. Findings are: Observations on 2/5/19 at 11:45 AM revealed LPN (Licensed Practical Nurse) - C prepared to administer an insulin injection for Resident 11. LPN - C donned disposable gloves at the medication cart, prepared the insulin injection, placed the medication into the medication cart and closed the computer on the medication cart. Further observations revealed LPN - C knocked on the resident's door, adjusted the resident's sleeve, prepped the resident's skin with an alcohol wipe and administered the injection into the resident's left arm while wearing the same disposable gloves. LPN - C removed the disposable gloves, applied hand gel and returned to the medication cart. Review of the facility policy Guidance for Using Insulin Products, dated (MONTH) (YEAR), revealed the following including: 4. Administration Techniques a. Have all necessary equipment ready and available. b. Wash your hand prior to each injection. Interview with the Director of Nursing on 2/5/19 at 1:15 PM confirmed that the nurses were to administer injections in a manner to reduce the risk of cross contamination, including hand washing prior to the injection.",2020-09-01
807,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,637,D,0,1,DM7M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B1 (7) Based on record reviews and interviews, the facility failed to determine if changes in resident conditions required considerations in performing Significant Change MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments for two sampled residents (Residents 7 and 19). Facility census was 50. Sample size included 29 current residents. Findings are: [NAME] Record review of Resident 7's Admission Record printed on 4/13/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 7's MDS records revealed quarterly MDS assessments were completed on 11/24/17 and 2/9/18. Comparisons of these assessments revealed the following declines or changes: - BIMS (Brief Interview of Mental Status, a test to determine cognitive memory impairments). Declined from a score of 13 (cognitively intact) in (MONTH) to a score of 11 (moderately impaired) in February. - Bed mobility (ability to move in bed) declined from independent with no help in (MONTH) to Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance with the help of one staff member in February. - Dressing (ability to put on and remove clothing) declined from independent with no help in (MONTH) to Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance with the help of one staff member in February. - Personal hygiene (ability to comb hair, brush teeth, shave, wash/dry face) declined from independent with no help in (MONTH) to Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance with the help of one staff member in February. - The pain assessment of the MDS records revealed the resident experienced no pain in (MONTH) and occasional pain that was severe at times in February. Record review of Resident 7's electronic medical record revealed no documentation the facility Interdisciplinary team noted the changes between the (MONTH) (YEAR) and (MONTH) (YEAR) quarterly MDS assessments, nor if the team considered whether or not to proceed with a comprehensive Significant Change in Status MDS assessment. B. Record review of Resident 19's Admission Record printed on 4/13/18 revealed the resident was admitted to the facility initially on 10/13/16 with the current admitted recorded 6/10/17. Review of Resident 19's MDS records revealed the resident had quarterly assessments completed on 12/8/18 and 3/2/18. Comparison of these assessments revealed the following declines or changes: - BIMS score dropped from 13 (cognitively intact) in (MONTH) to a score of 99 (unable to complete interview) in June. - Bed mobility declined from Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance to Extensive Assistance- resident involved in activity, staff provide weight-bearing support. - Transfer ability (moving between surfaces, chair to bed, bed to wheelchair, etc.) declined from Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance to Extensive Assistance- resident involved in activity, staff provide weight-bearing support. - Dressing ability declined from Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance to Extensive Assistance- resident involved in activity, staff provide weight-bearing support. - Personal hygiene declined from Limited Assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance to Extensive Assistance- resident involved in activity, staff provide weight-bearing support. - Bladder incontinence declined from Occasionally incontinent (less than 7 episodes in 7 days) to Frequently incontinent (7 or more episodes of urinary incontinence but at least one episode of continent voiding). Record review of Resident 19's electronic medical record revealed no documentation the facility Interdisciplinary team noted the changes between the (MONTH) (YEAR) and (MONTH) (YEAR) quarterly MDS assessments, nor if the team considered whether or not to proceed with a comprehensive Significant Change in Status MDS assessment. Interview with the MDS Coordinator, RN (Registered Nurse)-C on 4/17/18 at 1:45 p.m. confirmed Res 7 had declines in BIMS score, bed mobility, dressing, hygiene, and presence of pain between the (MONTH) (YEAR) quarterly MDS and the (MONTH) (YEAR) quarterly MDS. RN-C also verified Resident 19 declined in BIMS score, bed mobility, transfer ability, dressing, personal hygiene and bladder incontinence between the (MONTH) (YEAR) and (MONTH) (YEAR) Quarterly MDS reviews. RN-C confirmed there was no documentation to support the Interdisciplinary Team had noted the changes and considered whether or not to proceed with a comprehensive Significant Change in Status MDS assessment. Source: Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual (regulatory requirement instructions on how to perform and transmit MDS assessments) Version 1.14 revised (MONTH) (YEAR). When a resident's status changes and it is not clear whether the resident meets the SCSA (Significant Change in Status Assessment) guidelines, the nursing home may take up to 14 days to determine whether the criteria are met. After the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record. A Significant change is a decline or improvement in a resident's status that . Impacts more than one area of the resident's health status . A SCSA is appropriate when: - there is a determination that a significant change . has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments. - The final decision regarding what constitutes a significant change in status must be based upon the judgment of the IDT . However, staff must note these transient changes in the resident's status in the resident's record .",2020-09-01
808,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,657,E,0,1,DM7M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure a Nursing Assistant was included in the Interdisciplinary Team in the development, revision, and review of resident care plans for three current residents (Residents 19, 28, and 296). Facility census was 50. Sample size included 29 current residents. Findings are: [NAME] Record review of Resident 19's Admission Record printed on 4/13/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 19's Plan of Care Conference Summary form dated 3/8/18 revealed from the Attendees Plan of Care Conference section of the form that a Nursing Assistant was not included in the conference summary. There was no documentation in the resident's record that a Nursing Assistant was involved in reviewing, developing, and revision of the resident's care plan. B. Record review of Resident 28's Admission Record printed on 4/13/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 28's Plan of Care Conference Summary form dated 3/15/18 revealed from the Attendees Plan of Care Conference section of the form that a Nursing Assistant was not included in the conference summary. There was no documentation in the resident's record that a Nursing Assistant was involved in reviewing, developing, and revision of the resident's care plan. C. Record review of Resident 296's Admission Record printed on 4/13/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 296's Plan of Care Conference Summary form dated 4/11/18 revealed from the Attendees Plan of Care Conference section of the form that a Nursing Assistant was not included in the conference summary. There was no documentation in the resident's record that a Nursing Assistant was involved in reviewing, developing, and revision of the resident's care plan. Interview with RN (Registered Nurse)-C, the facility MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator confirmed the Interdisciplinary Team attending care plan conferences for Resident 19 on 3/8/18; Resident 28 on 3/15/18; and Resident 296 on 4/11/18 had not included a Nursing Assistant. RN-C also verified there was nothing in Resident's 19, 28, and 296 medical records that a Nursing Assistant had been included in the development, revision, or review of resident care plans.",2020-09-01
809,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,689,D,1,1,DM7M11,"> Licensure Reference Number: 175 NAC 12-006.09D7a Based on record reviews and interviews, the facility failed to ensure the circumstances and condition of the resident was assessed and documented following an incident with a resident being found on the floor for one sampled resident (Resident 51). Facility census was 50. Sample size was 29 current residents and 3 closed records. Findings are: Record review of a facility Investigation Report completed on 4/10/18 revealed the facility investigated an Injury Unknown Origin event involving Resident 51 on 4/4/18. The investigation recorded that on 4/4/18 at 2:00 p.m. the resident was found lying on the back in an unwitnessed event. The resident was assessed and no significant change or injury was noted at the time. Later in the evening after supper, a staff member was behind the nurse's station and heard another resident state Resident 51 was going to fall and came out from the nurse's station and saw Resident 51 sitting on the floor. Employee Interviews in the investigation revealed the following: - NA (Nurse Aide)-D stated seeing the resident on carpet area in front of nurse's station away from the wall sitting up. NA-D saw RN (Registered Nurse)-E by the medication cart next to the Activity room. NA-D reported the resident was on the floor in front of the nurse's station and that NA-D assisted in getting the resident up in the wheelchair. NA-D stated RN-E had not assessed the resident while on the floor because the staff had picked the resident up and placed the resident in the wheelchair. - LPN (Licensed Practical Nurse)-F reported seeing Resident 51 on the floor and witnessed RN-E going toward the resident who had fallen by the desk. - RN-E stated the resident crawled out of bed earlier in the day and RN-E obtained vital signs once for the resident during the shift around 9:00 p.m. RN-E stated not being made aware the resident had fallen by the nurse's station. RN-E stated hearing another resident alert staff Resident 51 was going to fall and NA-D responded. RN-E stated asking NA-D if the resident fell and NA-D said no. RN-E then obtained the resident's vital signs much later then that time. RN-E stated never witnessing the resident falling and when went to check the resident the resident was in the wheelchair. - NA-G stated having worked with Resident 51 on 4/4/18. When asked if aware of any falls, NA-G stated other staff reported the resident fell while putting phone on nursing station. NA-G reported helping put the resident back in the wheelchair but not being aware of what occurred before or after the resident was on the floor. Record review of Resident 51's Progress Notes revealed there was no entry recorded regarding the resident being found on the floor by the nurse's station after supper on 4/4/18. There was no assessment of the resident's condition following the incident or description of what occurred. Interview with the DON (Director of Nursing), ADON (Assistant Director of Nursing), and Corporate Nurse Consultant on 4/16/18 at 3:20 p.m. confirmed Resident 51 experienced an incident sometime after supper on 4/4/18 in which the resident was discovered by the staff on the floor by the nurse's station. The Nurse Aides assisted the resident up into the wheelchair without waiting for the charge nurse to assess the resident's condition. The DON stated there was some mis-communication between the Nurse Aides and the charge nurse, RN-E, as to whether the resident had fallen or not. RN-E reported believing the resident hadn't fallen and did not follow up with assessment of condition, circumstances of the fall, or resident vital signs due to this. The NA's on duty and another nurse LPN-F saw RN-E getting a blood pressure cuff and assumed RN-E was responding to the incident. The DON confirmed the staff had not followed facility policies when finding a resident on the floor by waiting for the charge nurse to assess the resident before moving or getting the resident up. In addition, the DON confirmed the staff had not ensured the resident's fall was reported to the charge nurse for additional follow up assessments and notifications of physician and family.",2020-09-01
810,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,812,F,0,1,DM7M11,"Licensure Reference Number: 175 NAC 12- E Based on observations and interviews the facility failed to repair cracking, peaeling paint and plaster from the ceiling located around the large vent in the main dining room and failed to clean the dirt and debris on vents and the ceiling throughout the large dining room. All residents could be affected. Facility census was 50. 04/11/18 at 12:00 p.m. Large Dining Room observation revealed cracking, peeling paint and plaster from the ceiling located around the large vent above resident tables. Ceiling vents and the ceiling located throughout the large dining room had dirt and debris located on them. 04/16/18 at 12:00 p.m. Large Dining Room observation revealed cracking, peeling paint and plaster from the ceiling located around the large vent above resident tables. Ceiling vents and the ceiling located throughout the large dining room had dirt and debris located on them. 04/17/18 at 8:15 a.m. Large Dining Room observation revealed cracking, peeling paint and plaster from the ceiling located around the large vent above resident tables. Ceiling vents and the ceiling located throughout the large dining room had dirt and debris located on them. 04/17/18 at 8:51 a.m. - interview with the Dietary Manager and Administrator verified the cracking, peeling paint and plaster from the ceiling located around the large vent in the main dining room needed repaired and also verified the dirt and debris on vents and ceilings throughout the dining room required cleaning. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 6-201.11 Except as specified under 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and EASILY CLEANABLE, 6-201.16(A) Wall and Ceiling covering materials shall be attached so that they are EASILY CLEANABLE.",2020-09-01
811,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,842,E,0,1,DM7M11,"Regulation Licensure Number 175 NAC 12-006.16B Based on observation, record review, and interview the facility failed to maintain complete and accurately documented medication disposition records for 7 residents. Census: 50. Sample size: 29. On 04/16/18 at 11:30 AM observation of med destruction closet along with the review of the medication disposition records showed the following: [NAME] Medication disposition record revealed 1 entry on Resident #27's disposition record. It revealed no destroy date filled in for the medication; observation revealed the medication was not in the medication destroy storage closet. B. Medication disposition record revealed there were 23 entries on Resident #55's disposition record. It revealed there were no discontinue dates recorded, no initials for staff recording data were found, no destruction witness signatures, no destroy date(s) recorded; quantities of medications destroyed were not systematically recorded. The medications in pill/tablet form that were listed on the medication disposition record for Resident #55 were not in the medication destroy storage closet. C. Medication disposition record revealed there were 12 entries on Resident #53's disposition record. It revealed there were no discontinue date for medication due to be destroyed, no initials of staff recording date were found, no witness signatures and no destroy date were recorded. The medication in pill/tablet for that were listed in the medication disposition record for Resident #53 were not in the medication destroy storage closet. D. Medication disposition record revealed there were 2 entries on Resident #52's disposition record. It revealed that a destruction witness signature and destroy date was missing. E. Medication disposition record revealed there were 11 entries on Resident #54's disposition record. It revealed there were initial of staff that recorded data, no destruction witness signatures, and no destroy date were recorded. The medications that were listed on the disposition record for Resident #54 were not in the medication destroy storage closet. F. Medication disposition record revealed there were 4 entries on Resident #10's disposition record. It revealed there were no destroy dates recorded and was missing the second witness signature. The medications that were listed on the disposition record for Resident #10 were not in the medication destroy storage closet. [NAME] Medication disposition record revealed there were 3 entries on Resident #44's disposition record. It revealed there were no destroy dates recorded and destruction witness signatures were missing. The medications that were listed on the disposition record for Resident #44 were not in the destroy storage closet. On 04/16/18 11:30 AM an interview with the ADON confirmed medications that were listed on the medication disposition records and were not in the destroy storage closet had been destroyed and the disposition records didn't show accurate or complete documentation for medications that were destroyed, when they were destroyed, and who was present for the destruction. On 04/17/18 an interview with the Director of Nursing and the Administrator confirmed that medication disposition records didn't show complete or accurate documentation.",2020-09-01
812,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,880,F,0,1,DM7M11,"Licensure Reference Number: 175 NAC 12-006.17B Based on observations and interviews, the facility staff failed to ensure that 1) contaminated hands did not touch a clean dressing for one current sampled resident (Resident ) and 2) change the safety straps on the bathing chairs that were frayed and became non cleanable to reduce the risk of cross contamination. This had the potential to affect all residents. The facility census was 50 with 29 current sampled residents. Findings are: [NAME] Observation of a dressing change for Resident 37 on 4/16/18 at 10:30 AM by RN-A (Registered Nurse) performed a lathered hand wash for 20 seconds, rinsed, dried and applied gloves. RN-A took a washcloth off the bathroom rod, applied soap and turned the faucet on with the gloved hands. RN-A moved to the resident, uncovered the resident and performed catheter cares with the same gloved hands. RN-A did not change the gloves or perform hand hygiene during these steps. Interview with the Director of Nurses, Assistant Director of Nurses and Regional Nurse on 4/17/2018 at 9:50 AM revealed the wash cloth was contaminated once the gloved hands touched the soap dispenser and the water faucet with the wash cloth. B. Observation of the dressing change for Resident 44 on 4/16/2018 at 1:40 PM by RN-B, took the dressings into the room with the bare hands laid the dressings on the uncleaned overhead table then performed a lathered hand hygiene of the hands for 20 seconds, rinsed, dried and use a paper towel to turn off the faucet. RN-B put on gloves removed the old dressing and measured the wound with gloved hands. RN-B removed gloves washed hands for 20 seconds, rinsed, dried and used a paper towel to turn off the faucet. RN-B put on new gloves opened the dressing package that laid on the overhead table with gloved hands for iodine swab put on the wound then opened the dressing and with the gloved hand discarded the wrapper to the garbage. RN-B applied the dressing to the wound, removed the gloves and labeled the dressing. Interview with the Director of Nurses, Assistant Director of Nurses and the Regional Nurse on 4/17/2018 at 9:54 AM revealed gloved hands should not be worn to open dressing wraps then place the dressing on the wound with the same gloved hands. Review of the facility policy entitled Clean Dressing Change Technique, dated 6/1/17, revealed: -clear off area of overhead table, -assemble supplies, -carefully open all supplies needed, -apply clean gloves, -cleanse the wound, -remove gloves, -wash the hands, -apply the gloves, -dress the wound. C. Observation of the 2 bathing rooms found the safety belts on the bathing chairs frayed that were a non cleanable surface. Interview with the Administrator on 4/17/2018 at 3:00 PM confirmed the belts were frayed.",2020-09-01
813,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2018-04-17,925,F,0,1,DM7M11,"Licensure Reference Number: 175 NAC 12-006.18A(4) Based on observations and interviews, the facility failed to clean out two light fixtures of dead insects in the main kitchen. All residents could be affected. Facility census was 50. Findings are: 04/12/18 at 7:30 a.m. Large kitchen observation identified two light fixtures with dead insects inside the covers of the lights. The two light fixtures were located on the ceiling above the area of the three sink compartment area. 04/16/18 at 12:00 p.m. Large Kitchen observation identified two light fixtures with dead insects inside the covers of the lights. The two light fixtures were located on the ceiling above the area of the three sink compartment area. 04/17/18 at 7:30 a.m. Large Kitchen observation identified two light fixtures with dead insects inside the covers of the lights. The two light fixtures were located on the ceiling above the area of the three sink compartment area. 04/17/18 at 9:06 a.m. Staff interview with the Administrator and Dietary Manager verified the light fixtures in the large kitchen located in the area of the 3 sink compartment area had dead insects located inside the light covers. The administrator and Dietary Manager verified the light covers should have been cleaned out.",2020-09-01
814,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,551,D,1,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05 (4) Based on record reviews and interviews, the facility failed to include one sampled resident's (Resident 8) responsible party and legal Power of Attorney in decisions related to the use or discontinuation of [MEDICAL CONDITION] medications. Facility census was 46. Sample size was 16. Findings are: Record review of Resident 8's Admission Record printed on 6/6/19 revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Further examination of the document revealed under Contacts the resident's FM/POA (Family Member/Power of Attorney) was listed as the Responsible Party and POA- Care. Interview with Resident 8's FM/POA by phone on 6/5/19 at 10:01 a.m. and again in person on 6/5/19 at 1:15 p.m. revealed the FM/POA reported a concern that the facility was not consistent in including the FM/POA in decision making regarding the resident's health care decisions. The FM/POA stated the resident had been diagnosed with [REDACTED]. The FM expressed concern that the resident's [MEDICAL CONDITION] medications were changed or discontinued without the FM/POA being consulted or informed. The FM/POA was concerned that these changes may affect the resident's ongoing behavioral symptoms. The FM/POA stated the resident had been to a VA (Veteran's Administration) psychiatrist prior to admission at the facility and wondered if this should continue stating the facility primary physician for Resident 8 was managing and changing the psychoactive medications without psychiatric evaluations. The FM/POA stated that when discussing these things the facility reported to the FM/POA that the resident was competent to make own decisions and sign paperwork. Record review of a State of Nebraska Power of Attorney for Health Care form signed by the resident and notorized by a notary on 8th day of (MONTH) (YEAR) revealed the resident appointed and authorized the FM/POA to make health care decisions for me when I am determined to be incapable of making my own health care decisions . Record review of Resident 8's Preferred Intensity of Medical Care and Treatment form on 4/18/18 revealed the FM/POA had signed the form as the Resident Surrogate on admission including decisions to Do Not Resuscitate and permission to Hospitalize the resident. The resident's signature was not on the form indicating the FM/POA made this health care decision. Record reviews of Resident 8's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed the resident's BIMS (Brief Interview of Mental Status, a test to determine resident cognitive/memory abilities) scores were as follows: - on 10/11/18 the resident scored a 6 (0-7 score indicated severe impairment) on the BIMS exam. - on 1/4/19, the resident scored a 7 on the BIMS exam. - on 3/22/19 the resident scored an 8 (8-12 score indicated moderately impaired) on the BIMS exam. The 10/11/18 MDS assessed the resident had fluctuating inattention (difficulty focusing attention, easily distractible, difficulty keeping track of what was said) and fluctuating disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. Further review of the 3/22/19 exam revealed the resident could not identify the year missing this by greater than 5 years or no answer, missed the month by greater than one month or no answer, and gave an incorrect answer when asked to identify the day of the week. Record review of Resident 8's care plan (undated) revealed the resident was identified with a focus problem of alteration in mood d/t (due to) depression. The care plan indicated the resident enjoys smoking and the interventions included: The resident requires SUPERVISION while smoking. The care plan also identified a focus problem of alteration in cognitive status r/t (related to) [MEDICAL CONDITION]. The interventions included the use of a Wanderguard (an alarm bracelet preventing the resident from leaving the facility unattended). Record review of Resident 8's Psychiatry Consult signed by the psychiatrist on 12/21/2017 (prior to facility admission) revealed the resident was referred for increasing behaviors and cognitive issues. The resident's history was gathered at the exam from the resident's FM/POA who was with the patient. The exam recorded the resident had a brain scan in (YEAR) showing further progression of vascular issues. The Legal History portion of the document revealed the FM/POA reports being the power of attorney for health care. The Assessment by the psychiatrist diagnosed the resident with Major neurocognitive disorder secondary to vascular disease with behavior component along with a Mood disorder. The psychiatric plan for the resident included a discussion with the FM/POA regarding medication management and long term care placement. The FM/POA reported wishing to continue the [MEDICATION NAME] (an anti-psychotic medication to treat [MEDICAL CONDITION] and behaviors) despite the risks covered during the appointment. The psychiatrist ordered to continue [MEDICATION NAME] at 0.5 milligrams twice a day. Record review of a 6/11/18 VA (Veteran's Administration) clinic office visit with a psychiatrist revealed MEDICATION ORDERS FOR [REDACTED]. Additional orders were given for Cognitive Behavioral Therapy Appointments at VA clinic. Record review of Resident 8's Progress Notes revealed the following entries: - 3/7/19 at 9:19 a.m. the Psychoactive med (medication) team met and reviewed meds. Resident is on Rispideral (sic) 0.5 mg (milligrams) at hs (bedtime). No behaviors. Discontinuing the Risperidal since (the resident) is not having any behaviors. Will continue to monitor. - 4/5/19 at 12:51 p.m. signed consultation report received with orders to decrease Trazadone to 12.5 mg q HS . - 5/16/19 at 10:12 a.m. verbal order given to increase [MEDICATION NAME] to 150 mg daily. There was no further documentation in the resident's medical record that the FM/POA was notified of these medication changes or involved in the decisions regarding changes in the resident's [MEDICAL CONDITION] medications for Resident 8. Record review of Resident 8's Informed Consent for Psychopharmacological Medication(s) form was signed by Resident 8 on 5/21/19 and there was no signature by the Responsible Party regarding the use of [MEDICAL CONDITION] medications and approval to use or not use them by the FM/PO[NAME] Interview with the facility SSD (Social Services Director) on 6/11/19 at 8:25 a.m. verified the resident was not seeing a VA psychiatrist routinely. Interview with the DON (Director of Nursing) and Administrator on 6/11/19 at 10:00 a.m. confirmed the facility listed Resident 8's FM/POA and identified the FM/POA as Resident 8's responsible party and POA on the resident's Admission Record. The DON confirmed there was no documentation in the resident's medical record that the FM/POA was involved in or notified of decisions to discontinue the [MEDICATION NAME] on 3/7/19; changes in Trazadone dosage on 4/5/19; or increase in [MEDICATION NAME] on 5/16/19. The DON verified the resident had signed the Informed Consent for Psychopharmacological Medication(s) form on 5/21/19 but the FM/POA had not been involved in reviewing or signing this form. The DON verified the last psychiatry visit to the VA was on 6/11/18 and the psychiatrist was not involved in the discontinuation of the resident's [MEDICATION NAME] or changes in the resident's Trazadone and [MEDICATION NAME].",2020-09-01
815,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,580,D,1,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on interviews and record reviews, the facility failed to notify one sampled resident's (Resident 8) responsible party of medication changes. Facility census was 46. Sample size was 16. Findings are: Record review of Resident 8's Admission Record printed on 6/6/19 revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Further examination of the document revealed under Contacts the resident's FM/POA (Family Member/Power of Attorney) was listed as the Responsible Party and POA- Care. Interview with Resident 8's FM/POA by phone on 6/5/19 at 10:01 a.m. and again in person on 6/5/19 at 1:15 p.m. revealed the FM/POA reported a concern that the facility was not consistent in including the FM/POA in being notified when changes occurred regarding the resident's health status and medication changes. The FM/POA stated the resident had been diagnosed with [REDACTED]. Record review of a State of Nebraska Power of Attorney for Health Care form signed by the resident and notorized by a notary on 8th day of (MONTH) (YEAR) revealed the resident appointed and authorized the FM/POA to make health care decisions for me when I am determined to be incapable of making my own health care decisions . Record review of Resident 8's Progress Notes revealed the following entries: - 3/7/19 at 9:19 a.m. the Psychoactive med (medication) team met and reviewed meds. Resident is on Rispideral (sic) 0.5 mg (milligrams) at hs (bedtime). No behaviors. Discontinuing the [MEDICATION NAME] since (the resident) is not having any behaviors. Will continue to monitor. - 3/22/19 at 10:15 a.m. signed fax back with orders (for the resident) for [MEDICATION NAME] (oral medication)swish and spit 5 ml (milliliters) BID (twice daily) 14 days. - 4/5/19 at 12:51 p.m. signed consultation report received with orders to decrease Trazadone to 12.5 mg q HS . -5/8/19 at 1:47 p.m. signed consultation report received with order to DC (discontinue) [MEDICATION NAME] (medication) cream . - 5/16/19 at 10:12 a.m. verbal order given to increase [MEDICATION NAME] to 150 mg daily. - 5/23/19 at 10:11 a.m. (name of physician) in and seen resident made changes to (the resident's) [MEDICATION NAME] (stool softener) and senna (laxative) medications. There was no further documentation in the resident's medical record that the FM/POA was notified of these medication changes for Resident 8. Interview with the DON (Director of Nursing) and Administrator on 6/11/19 at 10:00 a.m. confirmed the facility listed Resident 8's FM/POA and identified the FM/POA as Resident 8's responsible party and POA on the resident's Admission Record. The DON confirmed there was no documentation in the resident's medical record that the FM/POA was notified of medication changes on 3/7; 3/22; 4/5; 5/8; 5/16; and 5/23/19.",2020-09-01
816,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,623,E,0,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the Resident and legal representative of in writing of the facility initiated transfer for 5 sampled residents ( Resident 11, , 21, 39, 16 , and 4). Sample size was 16 current residents. Facility census was 46. Findings are: [NAME] 06/05/19 at 8:27 a.m. Resident 11 interview revealed the resident had a recent hospitalization but Resident 11 could not recall exactly what the dates of the hospitalization were. Record review Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) identified Resident 11's discharge to hospital on [DATE] returned to the facility on [DATE]. Record review progress note dated on 3-9-19 Resident was found unresponsive in the bathroom sitting on the toilet seat. Resident unable to communicate. Resident sent to the emergency room . Physician contacted and family contacted. Record review progress note on dated on 3-12-19 Resident was transferred back to the facility and it was identified resident had a PE (Pulmonary Emboli). 6/6/19 Record review identified there was no copy of a letter or written notice in Resident 39's medical record regarding a facility initiated transfer/discharge to the hospital, which would have notified Resident 11's family or representative 6/6/19 at 7:51 a.m. Resident interview Resident 11 revealed a recent hospitalization but could not recall receiving any written form of notice regarding the hospital transfer. 6/6/19 at 9:00 a.m. Staff interview with Administrative Assistant, Social Services Director, and Administrator verified there was a facility initiated hospital transfer on 3/9/19. Social Services Director confirmed there was no written communication to Resident 11's family/representative regarding the facility initiated transfer to the Hospital. B. 6/4/19 at 3:41 p.m. Resident 21 interview revealed the resident had a recent hospitalization recently but the resident was unable to recall what the dates of the hospitalization were. 6/6/19 at 9:28 a.m. Resident 21 interview Resident confirmed not being able to recall the dates of hospitalization and confirmed not being able to recall if a written notice regarding the hospital transfer was provided to the family/family representative. 6/6/19 Record review identified there was no copy of a letter or written notice in Resident 39's medical record regarding a facility initiated transfer/discharge to the hospital, which would have notified Resident 21's family or representative. 6/6/19 Record review Resident 21's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) identified Resident 21's discharge to the hospital on [DATE] returned to facility on 4/1/19. 6/6/19 at 9:00 a.m. Staff interview with Administrative Assistant, Social Services Director, and Administrator verified there was a facility initiated hospital transfer on 3/28/19. Social Services Director along with the Administrator confirmed there was no written communication to Resident 21's family/representative regarding the facility initiated transfer to the Hospital. C. 6/4/19 at 4:45 p.m. Resident 39 interview revealed the resident had a recent hospitalization but Resident 39 could not recall what all was going on and could not recall the time frames. 6/6/19 Record review Resident 39's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) identified Resident 29's discharge to hospital on [DATE] and returned to facility on 5/8/19. 6/6/19 Record review identified there was no copy of a letter or written notice in Resident 39's medical record regarding a facility initiated transfer/discharge to the hospital, which would have notified Resident 39's family or representative. 6/6/19 at 9:00 a.m. Staff interview with Administrative Assistant, Social Services Director, and Administrator verified there was a facility initiated hospital transfer on 5/4/19. Social Services Director along with the Administrator confirmed there was no written communication to Resident 39's family/representative regarding the facility initiated transfer to the Hospital. D. Record review of Resident 16's discharge MDS (Minimum Data Set, a federally mandated assessment and tracking tool) dated 2/18/19 revealed the resident's original admitted to the facility was on 11/6/2017. The MDS recorded the resident was discharged to an acute hospital setting on 2//18/19. A re-entry MDS revealed the resident was readmitted to the facility from the hospital on [DATE]. Record review of Resident 16's Progress Notes revealed an entry on 2/18/19 at 5:39 a.m. indicating the resident was symptomatic with left sided weakness. The facility contacted the physician and obtained an order to send the resident to the emergency room at the hospital. Review of Resident 16's medical record revealed there was no written communication provided to the resident and/or responsible party regarding the facility-initiated hospital discharge. Interview with the facility Administrator and DON (Director of Nursing) on 6/11/19 at 10:00 a.m. verified the facility had not provided a written notice to Resident 16 or the resident's responsible party regarding the facility initiated hospital discharge on 2/18/19. E. Record review of the admission record for Resident #4 revealed the residents original admitted to the facility was on 6/16/18. Record review of the MDS (Minimum Date Set, a federally mandated assessment and tracking tool) revealed the resident was discharged to an acute hospital setting on 2/1/19 and 2/21/19. Re-entry MDS revealed the resident was readmitted to the facility from the hospital on [DATE] and 3/5/19 respectively. Record review of the Progress Notes for Resident #4 revealed an entry on 2/1/19 at 2204 revealed the resident had been sent to the hospital with respiratory arrest. Record review of the Progress Notes for Resident #4 revealed an entry on 2/21/19 revealed the resident was admitted to the hospital for respiratory distress. Review of the medical record for Resident #4 revealed there was no written communication provided to the resident and/or responsible party regarding the facility-initiated hospital discharges dated 2/1/19 and 2/21/19. On 06/11/19 at 02:07 PM an interview with the Social Services confirmed there was no written notification provided to Resident #4 or the residents responsible party regarding the facility-initiated hospital discharges dated 2/1/19 and 2/21/19. On 06/11/19 at 12:08 PM an interview with the facility Administrator and Director of Nursing verified the facility had not provided written notification to Resident #4 or the residents responsible party regarding the facility-initiated hospital discharges dated 2/1/19 and 2/21/19.",2020-09-01
817,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,625,E,0,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the resident and legal representative of the bed hold policy in writing within 24 hours of transfer/discharge to the hospital for 4 sampled Residents ( Residents 11, 21, 39, and 4). Sample size was 16 current residents. Facility census was 46. Findings are: [NAME] 06/05/19 at 8:27 a.m. Resident 11 interview revealed the resident had a recent hospitalization but Resident 11 could not recall exactly what the dates of the hospitalization were. Record review Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) identified Resident 11's discharge to hospital on [DATE] returned to the facility on [DATE]. Record review progress note dated on 3-9-19 Resident was found unresponsive in the bathroom sitting on the toilet seat. Resident unable to communicate. Resident sent to the emergency room . Physician contacted and family contacted. Record review progress note on dated on 3-12-19 Resident was transferred back to the facility and it was identified resident had a PE (Pulmonary Emboli). 6/6/19 Record review identified the bed hold policy letter for Resident 11 was not provided to the family or representative within 24 hours. 6/6/19 at 7:51 a.m. Resident interview Resident 11 revealed a recent hospitalization but could not recall receiving the bed hold policy within 24 hours of transfer/discharge to the hospital. 6/6/19 at 9:00 a.m. Staff interview with Administrative Assistant, Social Services Director, and Administrator verified there was a facility initiated hospital transfer on 3/9/19. Administrative Assistant and Administrator confirmed they did not provide the written bed hold policy within 24 hours to family/representative. B. 6/4/19 at 3:41 p.m. Resident 21 interview revealed the resident had a recent hospitalization recently but the resident was unable to recall what the dates of the hospitalization were. 6/6/19 at 9:28 a.m. Resident 21 interview Resident confirmed not being able to recall the dates of hospitalization and confirmed not being able to recall if a written bed hold policy was provided within 24 hour to the family/representative. 6/6/19 Record review identified the bed hold policy for Resident 21 was not provided to the family or representative within 24 hours and that they only had been notified by phone. It was not until 4/10/19 that the family/representative was notified in writing to hold the bed until the resident was DC from the hospital. 6/6/19 Record review Resident 21's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) identified Resident 21's discharge to the hospital on [DATE] returned to facility on 4/1/19. 6/6/19 at 9:00 a.m. Staff interview with Administrative Assistant, Social Services Director, and Administrator verified there was a facility initiated hospital transfer on 3/28/19. Administrative Assistant along with the Administrator confirmed there was no written bed hold policy provided within 24 hours to the family/Representative after resident 21 had been discharged /transferred to the hospital. C. 6/4/19 at 4:45 p.m. Resident 39 interview revealed the resident had a recent hospitalization but Resident 39 could not recall what all was going on and could not recall the time frames. 6/6/19 Record review Resident 39's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) identified Resident 29's discharge to hospital on [DATE] and returned to facility on 5/8/19. 6/6/19 Record review identified that Resident 39's family was not given the bed hold policy in writing within 24 hours of transfer or discharge to the hospital. The notification of the bed hold Authorization/Policy identified that the family received telephone notification only. 6/6/19 at 9:00 a.m. Staff interview with Administrative Assistant, Social Services Director, and Administrator verified there was a facility initiated hospital transfer on 3/28/19. Administrative Assistant along with the Administrator confirmed there was no written bed hold policy provided within 24 hours to the family/Representative after Resident 39 had been discharged /transferred to the hospital. D. A review of the admission record for Resident #4 revealed the residents original admitted to the facility was on 6/16/18. Record review of the MDS (Minimum Data Set, a federally mandated assessment and tracking tool) revealed the resident was discharged to an acute hospital setting on 2/1/19 and 2/21/19. Re-entry MDS revealed the resident was readmitted to the facility from the hospital on [DATE] and 3/5/19 respectively. Record review of the Progress Notes for Resident #4 revealed an entry on 2/1/19 at 2204 documented the resident had been sent to the hospital with respiratory arrest. The review of the Progress Notes for Resident #4 revealed and entry on 2/21/19 at 1108 AM documented the resident was admitted to the hospital for respiratory distress. Review of the medical record for Resident #4 revealed the Bed Hold Policy was not provided in writing to Resident #4 or the residents respresentative within 24 hours of the facility initiated transfers/discharges dated 2/1/19 and 2/21/19 resepectively. On 6/11/19 at 12:08 PM an interview the the Director of Nursing and facility Administrator confirmed the bed hold policy was not provided to Resident #4 or the residents representative in 24 hours of transfer/discharge as required. On 06/11/19 at 02:07 PM an interview with Social Services confirmed no written notification had been made to Resident #4 or the residents responsible party in relation to facility initiated transfers/discharges dated 2/1/19 and 2/21/19, respectively.",2020-09-01
818,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,644,D,0,1,N26811,"**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 Resient Review) had been requested, after the facility discovered 1 resident (Resident 39) sampled with a newly evident [DIAGNOSES REDACTED]. Sample size was 16 residents. Facility census was 46. Findings are: Record review of the electronic medical record for Resident 39 revealed that Resident 39 was admitted on [DATE]/ . Resident 39 did not have a [DIAGNOSES REDACTED]. Record review 6/4/19 Resident 39 was diagnosed with [REDACTED]. The Delusional Disorders [DIAGNOSES REDACTED]. No new PASARR was requested at the time of the new Mental Illness diagnosis. Record review 6/4/19 of the 7/6/18 PASARR Level 1 completed identified no further level 1 screening was required, unless individual was later suspected or found to have a mental illness or intellectual disability screening. Record review 6/5/19 of Diagnosis - F22 T DELUSIONAL DISORDERS Medical Management 9/13/2018 Other [DIAGNOSES REDACTED]. view F03.90 T UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE Medical Management 9/13/2018 Other [DIAGNOSES REDACTED]. No new PASARR was initiated as to identify if a Level 2 PASARR needed to be completed with these new diagnosis. Record review of MEDICATION ORDERS FOR [REDACTED] Give 1 tablet by mouth at bedtime related to DELUSIONAL DISORDERS (F22). Staff interview on 6/5/19 at 2:55 p.m. to 3:15 p.m. Director of Nursing, Social Services Director and Administrator verified that a new PASARR was not requested to be completed after Resident 39 had a change in [DIAGNOSES REDACTED].",2020-09-01
819,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,656,D,1,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C Based on observations, record reviews, and interviews, the facility failed to implement care plan interventions pertaining to one sampled resident's (Resident 8) Restorative Nursing program. Facility census was 46. Sample size was 16. Findings are: Record review of Res 8's Admission Record printed on 6/6/19 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Interviews with Resident 8's FM (Family Member and Power of Attorney) on 6/5/19 at 10:01 a.m. by phone and again in person on 6/5/19 at 1:15 p.m. During the interview, the FM expressed a concern of the resident not walking as well as when first admitted to the facility. The FM stated the resident was walking to meals in the past and now was not walking at all to meals but depending on the wheelchair to take self to the dining room. The FM stated having requested several times that the facility needed to walk the resident to meals and was told (by unidentified staff members) they (the facility) couldn't do so because of not having enough staff to consistently walk the resident. The FM was concerned that the resident may lose the ability to walk and transfer if not being regularly assisted in walking. Record review of Resident 8's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed the resident had quarterly MDS assessments done on 3/22/19 and 1/10/19 and a significant change MDS completed on 10/1/18. Each of these assessments assessed the resident's ability to walk in the room and corridor as requiring limited assistance- resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance and staff provided the assistance of one staff member for the task. The (MONTH) and (MONTH) assessments had recorded the resident had not received any Restorative Nursing programs for walking during their reference periods (prior 7 days) while the (MONTH) assessment recorded the resident received a walking Restorative Nursing program on 3 of the 7 days during the reference period. Record review of Resident 8's Care Plan (undated) revealed a problem for limitations in ability to perform ADLs (Activities of Daily Living) due to [MEDICAL CONDITION] and weakness. Interventions included: Walk to and from meals as resident allows. The care plan goes on to read the resident gets impatient and does not always wait for staff to take the resident to the dining room with a walker and forgets to go to meals before staff can come in and walk the resident. Record review of a NUR (Nursing) Functional Evaluation signed by the Restorative Nurse LPN (Licensed Practical Nurse) on 6/7/19 assessed the resident's balance as not steady but able to stabilize without staff assistance. and Walking as Not steady, but able to stabilize without staff assistance. The goal for the resident was to maintain ability to transfer independently with Restorative interventions for walking. Restorative program Documentation Survey Report(s) for (MONTH) and (MONTH) of 2019 reveal the resident's restorative program included: Restorative walking to and from meals. The documentation showed in (MONTH) the resident 23 times from 2-17 minutes. The documentation showed only one time a day for those 23 times. In addition the resident refused to walk on 4 of the days and was unavailable on 3 days. In (MONTH) 2019, the documentation showed the resident walked on one of 7 days for a total of two minutes, refused to walk five times, and was unavailable on one occasion. The documentation revealed the resident's program was only being offered once a day rather than at mealtimes three times a day. Observations of the resident revealed the following: - 6/4/19 at 6:00 p.m. the resident was in the dining room in a wheelchair, walker left in room. The resident was not walked to the dining room. -6/5/19 at 7:45 a.m. the resident was in a wheelchair, walker left in room. The resident was not walked to the dining room. -6/5/19 at 11:45 a.m. the resident was in a wheelchair, the resident's walker was in the resident's room and the resident was not walked to the dining room. -6/6/19 at 7:30 a.m. the resident was in a wheelchair, the walker left in room. The resident was not walked to the dining room. - 6/11/19 at 7:30 a.m. the resident was in a wheelchair, the walker left in the room. The resident was not walked to the dining room. Interview with the DON (Director of Nursing) on 6/10/19 at at 4:35 p.m. confirmed Resident 8's Restorative walking program and care plan called for walking to and from meals as the resident allowed. The DON verified the documentation does not indicate the staff are attempting to walk the resident as outlined on the care plan, but shows the resident is only being offered to walk once daily.",2020-09-01
820,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,689,E,0,1,N26811,"Based on observations and interviews, the facility failed to: 1) ensure room water temperatures were maintained to prevent the potential for burn injury for 12 sampled residents (Residents 4, 5, 8, 11, 14, 16, , 21, 20, 35, 37, 30 and 39); and 2) ensure bathing tub temperatures were maintained to prevent potential burn injury in the bathing room on the 500 unit utilized by 7 sampled residents (Residents 11, 14, 22, 29, 31, , 34, and 40) and 11 non-sampled residents (Residents 1, 3, 6, 10, 17, 18, 27, 38, 41, 43, and 45). Facility census was 46. Sample size included 16 current residents. Findings are: [NAME] Licensure Reference Number: 175 NAC 12-006.18E3a (2) Observations of initial room inspections on 6/4/19 revealed the following elevated room water temperatures. - Room occupied by Resident 4 at 5:45 p.m. revealed a water temperature of 123 degrees F (Fahrenheit). - Room occupied by Resident 5 at 5:45 p.m. revealed a water temperature of 123.4 degrees F. - Room occupied by Resident 8 at 5:45 p.m. revealed a water temperature of 123.8 degrees F. - Room occupied by Resident 11 at 4:24 p.m. revealed a water temperature of 123 degrees F. - Room occupied by Resident 14 at 5:45 p.m. revealed a water temperature of 124.3 degrees F. - Room occupied by Residents 16 and 21 at 3:34 p.m. revealed a water temperature of 124.2 degrees F. - Room occupied by Resident 20 at 3:53 p.m. revealed a water temperature of 122.7 degrees F. - Room occupied by Residents 35 and 37 at 5:45 p.m. revealed a water temperature of 123.9 degrees F. - Room occupied by Residents 30 and 39 at 4:31 p.m. revealed a water temperature of 123.5 degrees F. Second observation of rooms occupied by Residents 4, 5, 8, 11, 14, 16, , 21, 20, 35, 37, 30 and 39 on 6/15/19 at 8:15 a.m. revealed the water temperatures in these rooms ranged from 121.5 degrees F to 123.9 degrees F. Interview with the Administrator on 6/5/19 at 8:15 a.m. verified rooms occupied by Residents 4, 5, 8, 11, 14, 16, , 21, 20, 35, 37, 30 and 39 ranged from 121.5 degrees F to 123.9 degrees F. Source: : Professional Plumbing, Heating, Cooling and Piping Community. (MONTH) 15, 2019. What are safe hot water temperatures by Ron [NAME] Consulting Services, Chairman of the International Residential Plumbing & Mechanical Code Committee. I have served on working groups for several plumbing industry standards committees for temperature actuated mixing valves . and it is generally agreed that 120 degrees (Fahrenheit) is the maximum, safe hot water temperature . It is generally agreed that 120 degrees Fahrenheit is the maximum safe hot water temperature that should be delivered from a fixture. Therefore hot water above 120 degrees Fahrenheit can be considered hazardous . B. Licensure Reference Number: 175 NAC 12-006.18E3a(1) On 6/5/19 between 2:00 PM and 2:10 PM an observation of the 500 Hall tubroom revealed elevated whirlpool bathtub water temperature of 113.3 degrees F (Fahrenheit) on a handheld digital thermometer. The observation revealed the installed whirlpool digital temperature gauge showed 100 degrees F. The Director of Nursing confirmed both readings at that time. On 6/5/19 between 2:00 PM and 2:10 PM an interview with the Director of Nursing revealed the installed, digital thermometer is set to go no higher than 110 degrees F. On 6/5/19 at 2:15 PM an interview with the Administrator confirmed the water temperature in the 500 Hall tubroom whirlpool bathtub was 113.3 degrees F. On 6/6/19 at 08:35 AM a second observation of the 500 Hall tubroom whirlpool water temperature revealed the water temperature was 113.3 degrees F and was verified by RN-D (Registered Nurse). On 06/06/19 at 09:16 AM an interview with the Director of Nursing and the corporate nurse consultant confirmed there was no log for checking tub room water temperatures and there was no facility policy or procedure for checking water temperatures for resident bathing. On 6/6/19 at 09:40 AM a third observation of the whirlpool water temperature in the 500 Hall tubroom was made with the use of 3 hand held digital thermometers in the water at the same time, at the same level, for the same length of time. The Administrator assisted with holding the thermometers. The observation revealed the following: the first handheld thermometer revealed a temperature of 113.0 degrees F; the second handheld thermometer revealed a temperature of 112 degrees F; the third handheld thermometer revealed a temperature of 113.3 degrees F; the whirlpool digital thermometer revealed a temperature reading of 110 degrees F. On 6/6/19 at 11:30 AM a review of the bath list for the 500 Hall bathtub room provided by the Director of Nursing, revealed the whirlpool tub in the 500 Hall tubroom was utilized by 7 sampled residents (Residents #11, #14, #22, #29, #31, #34, and #40) and by 11 non-sampled residents (Residents #1, #3, #6, #10, #17, #18, #27, #38, #41, #43, and #45). Source: Tips for Safe Senior Bathing- Caregiver-Aid (MONTH) 16, (YEAR): Ideally experts say the ideal water temperature for bathing and showering should be only one or two degrees above the body temperature of 98.6 degrees Fahrenheit. So a temperature range of 98 degrees to 100 degrees is best. There are dangers for the elderly when bathing in extremely hot or extremely cold water. Bath water temperatures of 102 degrees F (Fahrenheit) and above are dangerous to elderly, especially those who have heart and cardiovascular problems . Caregivers should adjust the hot water tank to ensure that bath water will not be too hot . use a bath thermometer to check the water temperature in the bath or shower, so there is no guessing about safety.",2020-09-01
821,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,755,E,0,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12A Based on observations, record reviews, and interviews, the facility failed to: 1) ensure medications were available for administration for one sampled resident (Resident 34); 2) ensure medications were held according to the parameter directions pertaining to blood pressure medications for two sampled residents (Residents 35 and 45); and 3) ensure medication insulin labels were checked against the Medication Administration instructions to ensure accuracy prior to administration for one non-sampled resident (Resident 33). Facility census was 46. Sample size was 16. Findings are: [NAME] Record review of Resident 34's Admission Record revealed the resident was admitted to the facility on [DATE]. Among the resident's medical [DIAGNOSES REDACTED]. Record review of Resident 34's Progress Notes revealed the following entries: - 6/3/19 at 10:31 a.m. a note recorded the resident's [MEDICATION NAME] medication given for Major [MEDICAL CONDITION] was not administered to the resident due to waiting on delivery from pharmacy. - 6/3/19 at 10:32 a.m. a note recorded the resident's [MEDICATION NAME] given for Essential (Primary) Hypertension was not administered due to consistently waiting on delivery from pharmacy. - 6/3/19 at 10:32 a.m. a note recorded the resident's [MEDICATION NAME] given for Essential (Primary) Hypertension was not administered due to consistently waiting on delivery from pharmacy. Record review of Resident 34's Medication Administration Record for (MONTH) 2019 revealed on 6/3/19 the morning doses of [MEDICATION NAME], and [MEDICATION NAME] were not administered to the resident. Interview with the DON (Director of Nursing) on 6/6/19 at 10:37 a.m. verified Resident's [MEDICATION NAME], and [MEDICATION NAME] morning doses were not administered to the resident on 6/3/19 when scheduled due to being unavailable from the pharmacy. B. Record review of Resident 35's Admission Record printed on 6/6/19 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 35's Medication Administration Record for (MONTH) of 2019 revealed the following orders and documentation. - Order for [MEDICATION NAME] 200 milligrams daily for Essential (Primary) Hypertension. The original order date was 9/18/18. Additional instructions on the form indicated the medication was to be held if pulse - Order for Carvedilol 6.25 milligrams twice a day for Essential (Primary) Hypertension. The original order date was 9/18/18. Further review of the document revealed on 6/3/19 the medication was administered to the resident in the morning and the resident's recorded pulse rate was 54. Interview with the DON on 6/11/19 at 10:00 a.m. confirmed Resident 35's [MEDICATION NAME] and Carvedilol instructions, on the Medication Administration Record, were to hold the medications if the resident's pulse was less than 60 bpm (beats per minute). The DON verified on 6/5/19 the resident received both of these medications when the resident's pulse was only recorded at 54 bpm. C. On 6/10/19 at 06:26 PM an observation of LPN-E (Licensed Practical Nurse) preparing an insulin administration for Resident #33. LPN-E removed an insulin injection pen from an unlabeled basket in the top drawer of the medication cart. The insulin injection pen had a generic (non-pharmacy) white label secured to it with the first name and last initial of Resident #33. The date the insulin injection pen was first opened (6/5/19) was also hand written on the generic, non-pharmacy, white label. LPN-E checked the administration amount on the eMar (electronic medication administration record), primed the pen with 2 units of insulin, and turned the pen administration amount to the correct number (4units). LPN-E administered the insulin to Resident #33. After administering the insulin, LPN-E returned placed the insulin pen back into the unlabeled basket in the top drawer of the medication cart. An interview on 6/10/19 at 06:30PM with the Director of Nursing verified there was no pharmacy label on the insulin pen used to administer insulin to Resident #33. The Director of Nursing confirmed that without the pharmacy label, there was no way for LPN-E to perform required medication checks prior to the administration of the medication. D. On 6/10/19 a record review of the eMar (electronic medication administration record) for the month of (MONTH) 2019 for Resident #45 printed on 6/10/19 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. The record review revealed the following order and documentation: - Order for [MEDICATION NAME] Besy-[MEDICATION NAME] HCl capsule 5-20mg, Give 1 capsule by mouth one time a day related to hypertensive [MEDICAL CONDITION] without heart failure *hold if SBP (SBP=systolic blood pressure) The original order date was 5/15/19. Further review of the eMar for Resident #45 revealed the following: - 6/3/19 the medication was administered with a SBP of 108 - 6/9/10 the medication was administered with a SBP of 105 - 6/10/19 the medication was administered with a SBP of 106 A review of the pharmacy label on the card for medication administration revealed the following order: [MEDICATION NAME]-[MEDICATION NAME] 5mg-20mg capsule: give 1 capsule by mouth one time a day *hold if SBP On 6/10/19 at 08:30 AM an interview with the Director of Nursing and the Administrator confirmed the instructions on the eMar and the medication administration card regarding Resident #45's [MEDICATION NAME]-[MEDICATION NAME] were to hold the medication if the SBP was less than 110. The interview verified that the resident recieved the medication on 6/3/19, 6/9/19, and 6/10/19 when the residents SBP was 108, 105, and 106 respectively and that parameters set by the provider weren't followed.",2020-09-01
822,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,760,D,0,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.10D Based on observations, record reviews, and interviews, the facility failed to administer insulin as prescribed resulting in significant medication errors for 1 sampled residents (Resident 37). Facility census was 46. Sample size was 16 current residents. Findings are: [NAME] Record review of Resident 37's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed an admission MDS assessment was completed on 5/21/19. The assessment recorded the resident was admitted to the facility on [DATE] and among the medical [DIAGNOSES REDACTED]. The assessment recorded the Primary Medical Condition Category for the resident was Medically Complex Conditions. The assessment recorded the resident received daily injections of insulin. Record review of Resident 37's (MONTH) 2019 Treatment Administration Record revealed the following orders related to Resident 37's insulin administration: - an order for [REDACTED]. - an order for [REDACTED].=3 (units); 251-300=6; 301-350=9; 351-400=12; 401+=15 notify MD, subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH [MEDICAL CONDITION]. Record review of Resident 37's Progress Notes revealed an entry on 6/5/19 at 8:48 p.m. revealed the resident was given 80 units of [MEDICATION NAME] (a rapid acting insulin) instead of [MEDICATION NAME] (a long acting insulin). The note recorded the physician was contacted and advised the resident be taken to the emergency room for observation. Record review of a facility report entitled: Investigation Report Template completed on 6/7/19 revealed the facility's investigation of the insulin medication error occurring on 6/5/19 regarding Resident 37. The report recorded the resident was given 80 units of Humalog insulin (another rapid-acting insulin interchangeable with [MEDICATION NAME]) instead of 80 units of [MEDICATION NAME]. LPN (Licensed Practical Nurse)-C had used the wrong insulin pen to administer the insulin to Resident 37 and after administration realized the error. LPN-C then reported to the charge nurse, LPN-A and the physician was contacted and the resident sent to the emergency room . The resident was observed at the emergency room but was not admitted to the hospital and did not have any untoward effects from the medication error. The resident was returned to the facility after observation in the emergency room . The investigation determined the cause of the medication error was a result of LPN-C not following medication pass standards by checking the insulin label with the Treatment Administration Record prior to administration. Record review of a faciltiy policy entitled: Medication Incident Reporting effective 9/1/18 revealed definitions of a Medication Error: A discrepancy between what the physician has ordered and what the resident received. Interview with the DON (Director of Nursing) and Corporate Nurse Consultant on 6/6/19 from 9:30 a.m. to 9:45 a.m. confirmed Resident 37 received an excessive dose of a rapid-acting insulin ([MEDICATION NAME]) instead of the ordered long-acting insulin ([MEDICATION NAME]) on 6/5/19 resulting in a significant medication error which required observation at the emergency room .",2020-09-01
823,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,761,E,0,1,N26811,"Licensure Reference Number: 175 NAC 12-006.12E1b Based on record reviews, and interviews, the facility failed to ensure that facility staff accounting for narcotics during the change of shift immediately sign the accounting forms when the counting was completed to verify the narcotic count accuracy. The failure occurred on narcotics locked and stored on one of three facility medication carts (500 hall). Facility census was 46. Findings are: Record review of the narcotic record accounting forms on the 500 cart revealed at 3:30 p.m. the counting forms had only been signed by one staff member on 6/5/19. Interview with LPN (Licensed Practical Nurse)-A on 6/5/19 at 3:30 p.m. revealed LPN-A took over control of the 500 medication cart at noon on 6/5/19. LPN-A had counted the narcotics with the off-going nurse and received the keys to the medication cart at that time. LPN-A verified not signing the accounting forms when the count was completed stating had not had time yet to sign them. Record review of a facility policy entitled Medicaion Management Guidelines effective on 9/1/18 revealed a section entitled Narcotic Count. The instructions include: The controlled drug checklist is signed by the nurse reporting for duty AND the nurse going off duty to verify that the count is correct. Interview with the DON (Director of Nursing) and Corporate Nurse Consultant on 6/5/19 at 3:43 p.m. verified the 500 wing medication cart narcotics accounting forms had not been signed by the on-coming nurse on 6/5/19 when the count occurred at noon. The DON verified the facility policy is to immediately sign verification of count accuracy when the count is completed to ensure the security of narcotics.",2020-09-01
824,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,842,D,0,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04C3a (7) Based on observations, record reviews, and interviews, the facility failed to record resident and personal representative concerns related to a damaged denture for one sampled resident (Resident 8). Facility census was 46. Sample size was 16 current residents. Findings are: Record review of Resident 8's Admission Record printed on 6/6/19 revealed the resident was admitted to the facility on [DATE]. Observation on 6/5/19 at 7:44 a.m. revealed Resident 8 had an upper denture which was chipped. Interview with Resident 8's FM (Family Member and Power of Attorney for Health Care) on 6/5/19 at 9:59 a.m. revealed the FM had come in for a visit (could not recall exact date) and noticed the resident's upper denture sustained some damage and was chipped. The FM stated reporting this to nursing staff and the staff did not know how or when the damage occurred, nor were any staff members aware at the time of the damage to the resident's denture. Record review of Resident 8's Progress notes between 3/7/19 and 6/11/19 revealed no documentation in the resident's medical record of a nursing assessment of the damaged denture or how this may affect the resident. Interview with the SSD (Social Services Director) on 6/11/19 at 8:25 a.m. revealed the SSD was made aware Resident 8's denture was chipped after the resident's FM reported the damage to the staff. The SSD stated the resident could not recall how or when the damage occurred. Interview with the DMR (Director of Medical Records) on 6/11/19 at 8:40 a.m. confirmed the DMR was made aware by the nursing staff (could not recall who) that the resident had chipped a denture and needed a dental appointment. Interview with the DON (Director of Nursing on 6/11/19 at 10:00 a.m. confirmed Resident 8's denture sustained a chip and that there was nothing recorded in the resident's medical record identifying when nursing staff was made aware of the issue or any assessment of the resident's damaged denture or how the damage may affect the resident.",2020-09-01
825,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,880,E,0,1,N26811,"Licensure Reference Number 175 NAC 12.006.17D Based on observation and interview the facility failed to implement appropriate infection control practices when administering medications to 2 sampled residents (Resident #40 and Resident #22) and 1 non-sampled resident (Resident #13). Resident census: 46. Resident sample size: 16. Findings are: An observation on 6/5/19 at 08:20 AM revealed MA-G (medication aide) preparing medications to administer to Resident #13. MA-G opened the computer to the eMar (electronic medication administration record) for the resident; opened the medication cart, and removed medication cards for Resident #13. MA-G removed the medications from the cards into a small medication cup and returned the medication cards to the drawer of the medication cart. MA-G locked the medication cart and took the small medication cup to Resident #13. Resident #13 took the medications. MA-G returned to the medication cart and began preparing medications for the next resident. No hand hygiene was performed prior to MA-G preparing medications for Resident #13 and no hand hygiene was performed prior to preparing medications for administration to Resident #13. MA-G performed no hand hygiene after administering medications to Resident #13 and none was performed prior to preparing medications for administration to the following resident. An observation on 6/5/19 at 08:30 AM revealed MA-F preparing medications to administer to Resident #40. MA-F opened the computer to the eMar for the resident; opened the medication cart, removed medication cards for Resident #40 and began putting prescribed medications in a small medication cup for administration to the resident. MA-F took the medications to the room of Resident #40 where the resident took the medications. MA-F returned to the medication cart and began preparing medication for administration to Resident #22. MA-F prepared medications to administer to Resident #22; delivered medications to the resident in a small medication cup. Resident #22 took the medications and MA-F returned to the medication cart. No hand hygiene was performed by MA-F prior to preparing medication for Resident #40; no hand hygiene was performed after completing the administration to the resident and none was performed prior to or after administrating medications to Resident #22. On 6/05/19 at 09:30 AM an interview with the Director of Nursing confirmed there was no hand hygiene performed prior to or in between medication administration tasks as required. On 6/5/19 at 10:00 AM an interview with the facility Administrator confirmed there was no hand hygiene performed prior to or in between medication administration tasks as required.",2020-09-01
826,CENTENNIAL PARK RETIREMENT VILLAGE,285094,510 CENTENNIAL CIRCLE,NORTH PLATTE,NE,69101,2019-06-11,883,E,0,1,N26811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident and/or representatives were not provided risks/benefits information regarding influenza and pneumonia vaccinations or provide consent regarding administering or declining the vaccines for 3 sampled residents (Resident #37, #40, and #34) Resident census: 46; Resident sample size: 16 Findings are: On 6/11/19 a record review of the facility immunization records revealed Resident #37, #40, and #34 had no consent forms for receiving vaccinations, no doctors orders regarding vaccinations and no documentation informing the residents or their representatives of the risks and/or benefits regarding the influenza and pneumonia vaccinations. Further review revealed Resident #37 was originally admitted to the facility on [DATE]. There was an unsigned physician communication form related to immunizations in the immunization consent records. The review also revealed that the original admitted for Resident #40 was 5/15/19. There was white piece of paper with the residents name and hand written No consent in PCC - get consent get order. There was no consent form and no order for Resident #40. Continued review of the facility immunization records revealed the original admitted for Resident #34 was 2/16/19. Thwere was a white piece of paper with the residents name and hand written Nothing entered. There was no consent form and no order for Resident #40. On 6/11/19 at 11:40 AM an interview with the Director of Nursing and the facility Administrator verified the residents and/or their representatives were not provided the risks/benefits information regarding influenza and pneumonia vaccinations and were not provided consent regarding administerin or declining the vaccinations.",2020-09-01
827,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-01-09,600,D,1,0,DYMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on record reviews and interview, the facility failed to ensure interventions were in place to prevent recurrent episodes of resident to resident altercations for one current sampled resident (Resident 2) who had altercations with two current sampled residents (Residents 1 and 4). The facility census was 86 with four current sampled residents. Findings are: Review of Resident 2's Care Plan, goal date 4/9/19, revealed the resident had a [DIAGNOSES REDACTED]. Further review revealed the resident had altercations with other residents on 10/3/18, 11/8/18 and 11/27/18. Review of the facility Resident to Resident investigation report, dated 10/9/18, revealed on 10/3/18 at 6:25 PM, the resident hit Resident 4's arm. Review of the Progress Notes revealed the following including: - 11/8/18 at 9:15 AM the resident hit Resident 1; - 11/27/18 at 7:22 PM the resident shoved Resident 1. Interview with the Director of Nursing on 1/9/19 at 4:00 PM confirmed the resident had ongoing behaviors directed towards staff and other residents. Further interview confirmed the interventions in place were not effective to prevent recurrent altercations with other residents.",2020-09-01
828,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-01-09,729,E,1,0,DYMM11,"> Licensure Reference Number 175 NAC 12-006.04A1 Based on record reviews and interviews, the facility failed to verify a Nursing Assistant was active on the Nurse Aide Registry as required when hired and before working with residents. The facility census was 86 and the Nursing Assistant was assigned to work on one of the facility's five nursing units that consisted of 50 beds. Findings are: Review of NA (Nursing Assistant) A's employee file revealed the employee was hired on 6/22/18 and worked until 9/6/18. Further review revealed no documentation NA - A was active on the Nurse Aide Registry as required prior to employment. Interview with the Human Resources Director on 1/9/19 at 12:00 PM verified NA - A was not active on the Nurse Aide Registry while employed in the facility. Interview with LPN (Licensed Practical Nurse) - F, Assistant Director of Nursing, on 1/9/19 at 4:30 PM revealed NA - A was assigned to work on the 200 wing (one of five of the nursing units in the facility) which had 50 beds.",2020-09-01
829,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-02-26,689,D,1,0,GXHQ11,"> Licensure Reference Number 175 NAC 12-006.09D7a Based on observations, record reviews and interview; the facility failed to ensure that door alarms were functioning to reduce the risk for elopement for one current sampled resident (Resident 1) with a Wanderguard (alarm device). The facility census was 91 with 18 current sampled residents. Findings are: Observations on 2/22/19 at 11:00 AM, accompanied with LPN (Licensed Practical Nurse - C) revealed that the alarm on the 100 wing west door was not functioning to alert staff if a resident with a Wanderguard device opened the door and left the facility unaccompanied. Interview with the Administrator on 2/22/19 at 11:00 AM confirmed that Resident 1 wore a Wanderguard device and was at risk for potential elopement due to occasional verbalizations of wanting to leave the facility and move to another facility. The Administrator confirmed that the door alarm needed to be repaired to ensure that it functioned properly to protect the resident from a potential elopement and injuries.",2020-09-01
830,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-02-26,725,E,1,0,GXHQ11,"> Licensure Reference Number 175 NAC 12-006.04C Based on record reviews and interviews, the facility failed to ensure sufficient staff and supervision so that routine bathing was provided on the 200 wing per resident's preferences and as scheduled for six current sampled residents (Residents 1, 2, 3, 8, 9 and 12). The facility census was 91 with 34 residents residing on the 200 wing. Findings are: [NAME] Review of Resident 1's Care Plan, goal date 4/16/19, revealed that the resident required assistance with personal hygiene. Review of the 200 wing bathing schedule revealed that the resident was scheduled to have a bath one time a week on Tuesday evening. Review of the Weight and Bath Sheets revealed that the resident refused a bath on 1/12/19 and 1/16/19 and no baths were documented as provided for (MONTH) or (MONTH) 2019. Review of the Follow Up Question Report, dated 1/1/19 - 2/25/19, indicated that the resident had a bath on 1/1/19 and 1/29/19. B. Review of Resident 2's Care Plan, goal date 4/8/19, revealed that the resident required extensive assistance with activities of daily living and preferred to have a bath two times a week. Review of the 200 wing bathing schedule revealed that the resident was scheduled to have a bath on Tuesdays and Fridays. Review of the Weight and Bath Sheets, revealed that the resident had a bath on 1/10/19, 2/1/19 and 2/22/19. Review of the Follow Up Question Report, dated 1/1/19 - 2/25/19, indicated that the resident had a bath on 1/10/19, 2/1/19, 2/5/19 and 2/22/19. C. Review of Resident 3's Care Plan, goal date 5/1/19, revealed that the resident required extensive assistance with activities of daily living and was to have a bath two times a week. Review of 200 wing bathing schedule revealed that the resident was scheduled to have a bath on Tuesdays and Fridays. Review of the Weight and Bath Sheets revealed that the resident had a bath on 1/1/19, 2/12/19, 2/20/19 and 2/22/19. Review of the Follow Up Question Report, dated 1/1/19 - 2/25/19, indicated that the resident received a bath on 1/11/19, 1/20/19, 2/12/19 and 2/22/19. D. Review of Resident 8's Care Plan, goal date 4/16/19, revealed that the resident required extensive assistance with activities of daily living and preferred a bath two times a week in the evening. Review of the 200 wing bathing schedule revealed that the resident was scheduled to have a bath on Tuesday and Friday evenings. Review of the Weight and Bath Sheets revealed that the resident had a bath on 1/5, 1/8, 1/11, 2/12 and 2/19. Review of the Follow Up Question Report, dated 1/1/19 - 2/25/19, indicated that the resident had a bath on 2/12 and 2/19. Interview with the resident on 2/25/19 at 1:35 PM revealed that they had cut nursing staff and they work short most days so it's difficult for them to get their work done, the staff are very tired and I feel sorry for them. Further interview revealed that the resident noticed that there was no bath aide scheduled anymore so baths are not provided like they used to be, it takes longer to have the call light answered, bed linens aren't always changed when needed, beds aren't made every morning and fresh water isn't passed as often. The resident stated that they put the nurse on medication cart to pass medications, it takes longer to get medications because they get busy with other duties, the nurses seem to be rushed to get their work done and is concerned about the potential for medication errors. The resident stated that is aware of routine medications and checks them carefully to be sure that the nurses brought them accurately. E. Review of Resident 9's Care Plan, goal date 4/7/19, revealed that the resident required extensive assistance with activities of daily living and preferred to have a bath two times a week in the afternoon. Review of the 200 wing bathing schedule revealed the resident's name not on the list. Review of the Weights and Bath Sheets revealed that the resident received a bath on 1/3/19, 1/5/19, 1/8/19, 1/12/19, 1/26/19, 1/30/19 and refused a bath on 2/13/19. Review of the Follow Up Question Report, dated 1/1/19 - 2/25/19, indicated that the resident had a bath on 1/5/19, 1/12/19, 1/20/19, 1/26/19, 1/30/19 and 2/16/19. Interview with the resident on 2/15/19 at 1:20 PM revealed that they are very short staffed and there is no bath aide scheduled anymore so baths are not given as often as they used to, they don't have enough staff to get their work done even though they try to. The resident stated that now uses a manual wheelchair and doesn't have the strength to move very far so relies on the staff to assist and often has to wait for help because they are so busy with other residents. F. Review of Resident 12's Care Plan, goal date 5/14/19, revealed that the resident required set up assistance with activities of daily living and preferred to have a bath one time a week. Review of the 200 wing bathing scheduled revealed that the resident was scheduled to have a bath on Wednesdays. Review of the Weights and Bath Sheets revealed that the resident received a bath on 1/17/19 and refused a bath on 1/12/19 and 1/30/19. Review of the Follow UP Question Report, dated 1/1/19 - 2/25/19, showed no indication that the resident received a bath. Interview with the resident on 2/25/19 at 1:35 PM revealed that they don't have enough staff to get their work done. They cut the staff down with no bath aide or people to pass water, make the beds or change the bed sheets. I'm supposed to get a bath every week but not getting that. It also takes longer to get my medications from the nurses. Interviews were conducted on 2/25/19 from 9:45 AM - 11:30 AM with the nursing staff on the 200 wing who requested to not be identified for specific comments. The Licensed Nurses, Medication Aides and Nursing Assistants interviewed all reported that they work short staffed most days and are called in to work extra hours at times. The nursing staff stated that it is difficult to get their work done safely and accurately. The nursing staff stated that it is difficult to provide routine bathing as scheduled and they have to fit in the baths when they have time. The nursing staff also commented that they are called to assist staff on the other wings when they need assistance to take care of a resident who requires two staff for cares. Review of the Facility Assessment Tool, dated 8/15/18, revealed that the average census for the 200 wing was 35 residents. Review of the 200 wing nursing schedules for the 200 wing day shift for (MONTH) 2019 showed that there were positions for two nurses, two medication aides and four nursing assistants. Further review revealed only one nurse scheduled for most days and no more than three nursing assistants scheduled. There was no indication that a bath aide was scheduled. Review of the Direct Care Staffing Hours for (MONTH) 2019 showed that the nursing hours varied on the 200 Wing day shift and less than six staff were on duty on 2/1, 2/2, 2/3, 2/7, 2/8, 2/9, 2/10, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/22, 2/23 and 2/24. Interview with the DON (Director of Nursing) on 2/26/19 at 11:15 AM confirmed that there was no Bath Aide or Hospitality Aide positions on the 200 wing. The DON stated that nursing assignments were adjusted which placed one of the Medication Aides to work on the floor with residents and the Charge Nurse was responsible for passing medications for half of the unit. The Unit Manager was assigned when needed to be the Charge Nurse and pass medications. Further interview confirmed that the residents were to receive their baths as scheduled or preferred to meet their needs and nursing supervision needed to be provided to ensure that the resident's received care as directed on their care plans.",2020-09-01
831,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-02-26,908,E,1,0,GXHQ11,"> Licensure Reference Number 175 NAC 12-006.18 Based on observations and interviews, the facility failed to ensure that 1) a call light was repaired or replaced for one current sampled resident (Resident 7) and 2) the ceiling was repaired after a water leak on the 200 wing. The facility census 91 with 34 residents residing on the 200 wing. Findings are: [NAME] Observations on 2/25/19 at 11:30 AM revealed that Resident 7's call light did not light up or sound in the hallway outside of the room to alert staff when the resident needed assistance. Interview with the resident on 2/25/19 at 11:30 AM revealed that the call light had not worked for a long time and had a bell to ring when assistance was needed. The resident stated that it was difficult to keep ringing that bell, arm and hand got really tired ringing that bell and would just have to quit. The resident stated needed to have a good call light. Observations on 2/25/19 at 2:45 PM revealed the Administrator confirmed that the call light did not work and told the resident that an electrician would be called to fix the call light. Interview on 2/25/19 at 9:45 AM with Medication Aide - G revealed that the resident's call light had not been working for a long time and they tried to listen for the bell so they could assist the resident. Interview on 2/25/19 at 10:00 AM with Licensed Practical Nurse - [NAME] revealed that the resident's call light had not been working for a long time. Interview with the Administrator on 2/25/19 at 2:45 AM confirmed that the resident's call light needed to be repaired or replaced. B. Observations on 2/25/19 at 9:10 AM revealed ceiling damage, stains and peeling paint and loose ceiling material on the 200 wing west of the nurses station. Interview with the Administrator on 2/25/19 at 2:45 PM confirmed that the ceiling needed to be repaired. Further interview on 2/26/19 at 8:45 AM revealed that there was a pipe leak on 1/24/19 that caused the ceiling damage.",2020-09-01
832,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,550,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interview, the facility failed to ensure that a [MEDICAL CONDITION] (abdominal opening to collect feces) bag was covered to promote dignity in the dining room for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents and three residents (Residents 40, 84 and 13) seated at the dining room table with the resident. Findings are: Observations on 5/20/19 at 12:30 PM revealed Resident 42 seated in the dining room with a full [MEDICAL CONDITION] bag visible below the resident's shirt. Further observations revealed several staff members passed by or assisted the resident with the meal service and did not assist the resident to cover the [MEDICAL CONDITION] bag. Further observations revealed Residents 40, 84 and 13 were seated at the table with the resident. Interview with the Director of Nursing on 5/23/19 at 9:30 AM confirmed that the staff should have assisted the resident to cover the [MEDICAL CONDITION] bag to promote the resident's dignity in the dining room.",2020-09-01
833,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,576,E,0,1,3V0011,"Licensure Reference Number: 175 NAC 12-006.05(12) Based on interviews and record reviews, the facility failed to ensure residents received mail on Saturdays. affecting residents who could potentially receive mail on the weekend. Facility census was 85. Findings are: Interview with resident council members ( Residents 84, 71, 25, 13, 54, 38, and 80) during a meeting with the council on 5-21-19 at 1:25 p.m. revealed from the members that mail was not always being received on Saturdays. Interview with Administrative Assistant on 5/28/19 at 9:20 a.m. to 9:25 a.m. confirmed that mail does come to the facility on Saturdays from the post office, however it is unclear if the mail is delivered to the residents on Saturday. Interview with Social Services Assistant on 5/28/19 at 9:25 a.m. to 9:30 a.m. confirmed that mail is delivered to the facility on Saturdays but it is unclear as to who delivers the mail to the residents on Saturdays. Interview with Activities Director on 5/28/19 at 9:30 a.m. to 9:35 a.m. Confirmed that mail is delivered to the facility by the post office on Saturdays but it is unclear if the mail is delivered to the residents on Saturdays or not. Record review on 5/28/19 of the facility Resident Rights information provided to Residents revealed, the nursing facility must respect the Resident Right to personal privacy, including the right to send and receive unopened mail. Interview with the Administrator on 5/28/19 verified that mail was not being delivered to Residents on Saturdays.",2020-09-01
834,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,578,E,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure 3 licensed nurses maintained verification of current completion in BLS (Basic Life Support)/CPR (Cardiopulmonary Resuscitation) skills in the event of [MEDICAL CONDITION]. This failure could potentially affect 21 current residents (Residents 2, 17, 18, 22, 26, 30, 32, 37, 39, 43, 45, 46, 47, 48, 55, 58, 69, 73. 80, 82, and 139)requesting CPR initiation in the event of [MEDICAL CONDITION]. Facility census was 85. Sample included employee file reviews for three licensed nurses and a facility transportation aide. Findings are: Record reviews of employee files for verifications of valid BLS/CPR course completion revealed the following: - RN (Registered Nurse)-T revealed RN-T was hired on [DATE]. Review of RN-T's file revealed RN-T completed an American Heart Association BLS/CPR course on [DATE] and the certification expired in (MONTH) of (YEAR). - LPN (Licensed Practical Nurse)-U was hired on [DATE]. Review of LPN-U's file revealed LPN-U completed an American Heart Association BLS/CPR course on [DATE] and the certification expired in (MONTH) of 2019. - LPN-G was hired on [DATE]. Review of LPN-G's file revealed no documentation of LPN-V completing a BLS/CPR course. Record review of facility nursing schedules from (MONTH) 29th through (MONTH) 28th of 2019 revealed the following: - RN-T worked as the only licensed nurse on the 400 and 500 units from 6 p.m. to 6 a.m. on 16 separate days. - LPN-U worked as the only licensed nurse on the 100 unit from from 6 p.m. to 6 a.m. on 13 separate days. - LPN-G worked as the only licensed nurse on the 200 unit from 6 p.m. to 6 a.m. on 14 separate days. Interviews with the HR Director, Director of Nursing, and Administrator on [DATE] at 2:30 p.m. confirmed RN-T, LPN-U, and LPN-G all worked 12 hour shifts serving as charge nurses on their assigned units from 6 p.m. to 6 a.m. The HR Director, Director of Nursing, and Administrator confirmed there was no evidence of current BLS/CPR certification for these nurses ensuring competency in performing CPR to residents in the event of [MEDICAL CONDITION]. Record review of a list of residents requesting CPR in the event of [MEDICAL CONDITION] revealed 21 current residents (Residents 2, 17, 18, 22, 26, 30, 32, 37, 39, 43, 45, 46, 47, 48, 55, 58, 69, 73. 80, 82, and 139)with valid physician orders [REDACTED].",2020-09-01
835,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,583,D,0,1,3V0011,"Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interview, the facility failed to ensure that privacy was provided during personal cares to prevent unnecessary exposure of the resident's body for one current sampled resident (Resident 41). The facility census was 85 with 24 current sampled residents. Findings are: Observations on 5/22/19 at 5:20 AM revealed Resident 41 in bed with eyes closed. Further observations revealed MA (Medication Aide) - J and MA - K awakened the resident for personal cares. MA - J and MA - K removed the top linens off of the resident and placed them at the foot of the bed which exposed the resident from the waist down. MA - J and MA - K removed the front of the disposable brief, performed skin care, turned the resident from side to side to remove the disposable brief, provide skin care and then applied a new disposable brief. Further observations revealed no attempt to cover the resident during the procedure to promote privacy and comfort. Interview with the Director of Nursing on 5/23/19 at 8:15 AM confirmed that the staff should drape or cover the resident during personal cares to promote privacy and comfort and to prevent unnecessary exposure of the resident's body.",2020-09-01
836,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,584,E,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-12-006.18A(1) Based on observation and interview, the facility failed A) to ensure the call monitoring system was functioning and answered to the resident satisfaction, b)maintain the safety of the heating system with covers over the heater in the rooms and bathrooms, c) to make the resident's beds. Findings are: [NAME] On 5/23/2019 at 9:01 AM a review of the grievance/complaint log dated (MONTH) 2019 revealed a complaint call light not working in bathroom on 200 hall. In room [ROOM NUMBER] the resident was taken to the bathroom and left there for 2 hours in the bathroom. On 5/23/2019 at 9:01 AM a review of the grievance/complaint log dated (MONTH) 2019 revealed the resident in 108 complained the staff did not empty the commode for over 30 minutes. The call light would be answered and the staff would not return for over 30 minutes. During the Resident Council Meeting on 5/21/2019, held by a surveyor, revealed residents complained call lights were turned off and the issue not addressed. Eight Residents attended the resident council meeting. Observation of call lights on 5/23/2019 revealed a call light sounded from 7:29 AM to 7:42 AM in room [ROOM NUMBER], a total of 13 minutes. Interview with MA-E (Medication Aide), MA-O and NA-P (Nurse Aide) on 5/23/2019 at various times revealed the expectation was to answer the call light as soon as possible like in a minute. Meet the residents needs. If a nurse does not answer the call light the individual was to do what they can and if they can not meet the residents needs leave the light on for a nursing person to answer the call light. Interview with the Administrator on 5/23/2019 at 10:12 AM revealed the expectation was for the call lights to be answered in less that 5 minutes. If the census goes up then the employee ration goes up. The facility had no call light monitoring system. B. Equipment like the heaters in the resident rooms were falling apart: -room [ROOM NUMBER] the heater was falling apart in the bathroom, -room [ROOM NUMBER] the heater falling apart in room behind the bed, -room [ROOM NUMBER] the heater in the bathroom was missing a cover, -room [ROOM NUMBER] no plug in the sink drain, glue on the wall by the bed, -room [ROOM NUMBER] the molding loose by the doorway was loose, personal fan was covered with grey debris and the bathroom vent was covered with grey debris, -room [ROOM NUMBER] the bathroom heater was falling apart, -room [ROOM NUMBER] the toilet cover does not fit the back of the toilet, -room [ROOM NUMBER] the bathroom heater was falling apart, -room [ROOM NUMBER] duct tape covering the spaces of the window frame. Interview with the Maintenance Person on 5/23/2019 between 8-9 AM verified the heaters needed fixed, the sink drain needed a plug, the molding needed glued, the fans needed cleaned, the bathroom vent needed cleaned, the toilet needed a lid that fits the back of the toilet, and the duct tape needed removed from the window that covers the spaces of the window frame. C. Interview with Resident 2 on 5/22/2019 at 1:30 PM revealed the bed does not get made, the covers were just pulled up. Observation of the bed revealed the covers were just pulled. The bed had not been straightened and made. Interview with the DON on 5/23/2019 at 12:21 PM revealed the expectation was for the beds to be made. Interview with NA-A, MA-B and NA-C on 5/23/2019 at 12:42 PM revealed the expectation was for the beds to be made not just pull up the covers.",2020-09-01
837,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,600,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (9) Based on record reviews and interviews, the facility failed to ensure one sampled resident's (Resident 89) finances were protected. Facility census was 85. Sample size was 24 current residents and 3 closed records. Findings are: Record review of Resident 89's Admission Record printed on 5/8/2018 revealed the resident was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Record review of Resident 89's Admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on 4/19/18 revealed the resident's cognitive BIMS (Brief Interview for Mental Status) assessment scored at 99- unable to complete interview . gave a nonsensical response . A progress note recorded by the SSD (facility Social Services Director) on 4/13/18 revealed the resident's Sibling-A came to the office to discuss the resident's financial accounts. The note recorded the resident had no guardian or POA (Power of Attorney) to look over the resident's affairs. The SSD discussed options with Sibling-A and steps to set up trust and making the facility payee for the social security checks. The sibling explained a step child of the resident was taking care of the checks. There was no further documentation by the facility with regard to the Resident 89's social security checks and finances until a note on 10/24/18 at 11:37 a.m. The SSD recorded a different sibling, Sibling-B, stopped by the SSD office to discuss the resident's financial accounts. The SSD told Sibling-B the facility had no access to the resident's accounts. Sibling-B voiced being worried the resident has no guardian/POA to look over the resident's accounts and financial well-being. The SSD discussed options and steps to help set up a trust account at the facility and with talking to social security for the facility to become a rep. (representative) payee. Sibling-B thought the resident's step-child had been taking care of the resident and spouse's account. The SSD called the step-child with regards to setting up an account with no answer, awaiting call back. There was no further documentation in the resident's record pertaining to the resident's finances and social security check. Record review of a Resident Statement Landscape printed on 5/22/19 revealed an accounting spreadsheet of Resident 89's trust account. The accounting form indicated an account was opened for the resident on 9/5/18 and an allowance of $50 was deposited on 10/17/18. The first deposit of the resident's social security check into the account showed it was done on 12/26/18. Interview with the facility's SSD on 5/22/19 at 10:45 a.m. confirmed the resident was admitted to the facility in (MONTH) of (YEAR) without an enacted POA or guardianship and that the resident had advanced dementia with severe cognitive impairments and the inability to make decisions independently. The SSD stated the resident's financial account was in a joint account with the resident's spouse who passed away and that the resident's social security checks were being given to a step-child at the time of admission. The SSD stated no attempts were made by the facility, nor was Adult Protective Services contacted to ensure the resident's finances and social security checks were not being mishandled following concerns expressed by the resident's siblings at the time of admission and then again six months later in October. An interview with the facility Administrator on 5/22/19 from 2:15 p.m. to 2: 32 p.m. discussed the resident's issues. The Administrator verified the resident was admitted to the facility without an enacted POA or guardianship and that the resident had advanced dementia with severe cognitive impairments and inability to make decisions independently. The Administrator reviewed the progress notes from the SSD recording sibling concerns regarding the resident's finances expressed on admission in (MONTH) of (YEAR) and again in (MONTH) of (YEAR) and confirmed the facility had not made attempts or contacts with Adult Protective Services to ensure the resident's finances and social security checks were not being mishandled by an unauthorized step-child.",2020-09-01
838,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,622,D,1,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Monument Care and Rehab/[NAME]bluff F622 D Licensure Reference Number: 175 NAC 12-006.05 5e (3) Based on record reviews and interviews, the facility failed to document the circumstances of facility discharges for two sampled residents discharged from the facility (Residents 89 and 90). Facility census was 85. Sample included a review of 3 closed records. Findings are: [NAME] Record review of an Admission Record for Resident 89 printed on 5/8/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Discharge- return anticipated MDS (Minimum Data Set, a federally mandated assessment and tracking tool) completed on 1/29/19 revealed Resident 89 had been discharged to an Acute hospital on [DATE] and the facility expected the resident to return when stabilized. Record review of Resident 89's electronic Progress Notes revealed there were no progress notes or other documentation in the resident's medical record recording the circumstances of the resident being permanently discharged from the facility. Record review of Transfer and Discharge from the Facility Policy created (MONTH) (YEAR). In the section entitled Documentation recorded When the facility transfers or discharges a resident under any of the circumstances .the facility must ensure that the transfer or discharge is documented in the resident's medical record . Interview with the facility Administrator on 5/21/19 at 11:30 a.m. confirmed Resident 89 was admitted to the facility in (MONTH) of (YEAR) and resided in one of the locked Alzheimer's care units at the facility during the resident's stay. The Administrator verified the resident's behavioral episodes escalated and experienced nine episodes of aggression toward other residents in a short period of time. The facility attempted various interventions and involved both the resident's physician and psychiatrist in attempting to treat the resident. Due to failure in stabilizing the resident, the resident was EPC'd to an acute Behavioral Health facility on 1/29/19. The Administrator verified the facility determined it was not safe to allow the resident to return and the facility denied re-admission after the hospital had notified the facility the resident's condition stabilized and the resident was ready for discharge back to the facility. The Administrator verified the facility had no documentation in the resident's medical record regarding the resident's formal discharge from the facility or supporting documentation as to why the facility chose not to allow the resident to return. B. Record review of Resident 90's MDS assessments revealed an Admission MDS was completed on 1/24/19 and a discharge assessment was completed on 3/5/19. The assessments recorded the resident was admitted to the facility on [DATE] and was discharged on [DATE] with a return to the facility not anticipated. The discharge MDS recorded the resident discharged to the community (private home/apartment, board /care, assisted living, or group home) Closed medical record review of Resident 90's stay at the facility revealed no notes or documentation pertaining to the resident's condition or circumstances at the time of the resident's discharge/transfer to the Assisted Living Facility. Record review of Transfer and Discharge from the Facility Policy created (MONTH) (YEAR). In the section entitled Documentation recorded When the facility transfers or discharges a resident under any of the circumstances .the facility must ensure that the transfer or discharge is documented in the resident's medical record . Interview with the DON (Director of Nursing) on 5/23/19 at 8:00 a.m. confirmed the facility had not documented in the resident's medical record any notes pertaining to the resident's condition, transfer to the Assisted Living facility, or any other circumstances that occurred at the time of discharge from the facility.",2020-09-01
839,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,623,E,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05(5) Based on record reviews and interviews, the facility failed to follow their transfer/discharge policies for 6 sampled residents (Residents 89, 49, 73, 26. and 83). Facility census was 89. 7 residents with hospital stays were sampled. Findings are: [NAME] Record review of Resident 44's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and for admission/discharge tracking information) revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 3/6/19. Interview with Resident 44 on on 5/20/19 at 11:25 a.m. revealed the resident describing having fallen and sustaining a fracture in (MONTH) of 2019. The resident did not recall receiving written notice from the facility regarding the hospital stay initiated by the facility after the resident fell and was sent to the hospital. Record review of Resident 44's medical record revealed no evidence a written notice to the resident regarding circumstances for the facility-initiated hospitalization , nor any evidence the information was sent to the State Ombudsman. B. Record review of Resident 49's MDS records revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 1/28/19 and again on 3/6/19. Record review of Resident 49's medical record revealed no evidence a written notice to the resident or a resident representative regarding circumstances for the facility-initiated hospitalization , nor any evidence the information was sent to the State Ombudsman at the time of hospitalization s on 1/28/19 and 3/6/19. C. Record review of Resident 73's MDS records revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 4/23/19. Record review of Resident 73's medical record revealed no evidence a written notice a written notice to the resident or a resident representative regarding circumstances for the facility-initiated hospitalization nor any evidence the information was sent to the State Ombudsman at the time of hospitalization on [DATE]. Interview with the facility Administrator on 5/28/19 at 10:39 a.m. confirmed Residents 44, 49, and 73 were hospitalized following facility-initiated transfers. The Administrator verified the facility policy was not followed regarding providing written notification of the transfers to the residents or representatives, and the information was not forwarded to the State Ombudsman. D. Licensure Reference Number: 175 NAC 12-006.05 (5e) Record review of Resident 89's MDS records revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 1/29/19. Record review of a document dated 2/14/19 received by Certified Mail at the facility on 2/21/19 revealed a General Counsel attorney for the local hospital sent correspondence to the facility. The corresponding letter recorded Resident 89 was admitted to the hospital's Behavioral Health Unit at the request of the facility and law enforcement for short term care. The patient is now stabilized and ready for discharge back (to the facility). However when (the hospital) contacted (the facility) to make arrangements for discharge, we (the hospital) were advised by (the facility) that it would not accept the patient back from (the hospital) citing behavioral issues with the patient. The correspondence goes on stating: You (the facility) have advised on the telephone that you will not accept the patient back because of behavior issues . Also, have you served a notice of discharge on the resident or legal representative? If so, we (the hospital) request a copy . Interviews with the hospital General Counsel attorney were conducted in person on 5/21/19 at 1:05 p.m. and by phone on 5/22/19 at 11:00 a.m. The General Counsel attorney verified that Resident 89 was admitted for acute care following an EPC request from the facility on 1/29/19. The resident's condition was stabilized and the facility informed the facility the resident was ready for re-admission. The facility denied the re-admission stating issues with the resident's behavior. The attorney confirmed neither the hospital nor the resident received any notice of facility discharge from the facility. Record review of a facility policy entitled Transfer and Discharge from the Facility Policy created in (MONTH) of (YEAR) revealed the following policy statements: - Before a facility transfers or discharges a resident, the facility must-- (i) Notify the resident and a resident's representative of the transfer or discharge and the reasons's for the move in writing and in a language and manner they understand. - Timing of the notice . the notice of transfer or discharge . must be made by the facility at least 30 days before the resident is transferred or discharged . . The notice will include the reason, effective date, location of transfer, rights for appeal, agency numbers, how to appeal, title of facility staff and information r/t Ombudsman. - Documentation- Res physician and staff will document in the record- the resident's health status at the time of notice . reason that the services provided are no longer needed, document discharge needs and discharge plan, date notice received, copy sent to Ombudsman, date notice sent to representative, date of formal discharge planning meeting and appeal rights. Interview with the facility Administrator on 5/28/19 at 10:39 a.m. confirmed Resident 89 was admitted to an acute care hospital on [DATE]. At the time of the hospitalization , the Administrator verified the resident or a representative of the resident was not notified in writing regarding a facility-imitated transfer of Resident 89 to the hospital. The Administrator also confirmed there was no 30 day notice to the resident or a representative of the resident or to the State Ombudsman regarding the facility decision to not re-admit the resident to the facility resulting in discharge from the facility. E. Family interview on 5/20/19 at 4:55 p.m. Resident 26's daughter reported the resident had been sent to the hospital recently but was unclear as to why Resident 26 was sent to the hospital. Record review on 5/21/19 Nursing progress note dated 5/1/19 at 22:13 identified Resident 26 was in the progressive care unit (PCU) at Regional West Medical Center. Record review on 5/21/19 Nursing progress note dated 5/3/19 at 15:25 Resident 26 resident was being discharged from Regional West Medical Center this afternoon with an order for [REDACTED]. Record Review on 5/21/19 Nursing progress note dated 5-3-19 at 17:00 Resident 26 returned from the hospital via facility transport. Record Review on 5/23/19 unable to locate written notice to family/representative and ombudsman that Resident 26 had been discharged to the hospital on 5-1-19. Staff interview on 5/23/19 at 12:03 p.m. to 12:12 p.m. Social Services Coordinator confirmed the inability to locate any letter notifying Resident 26's family/representative of the discharge to the hospital. Staff interview on 5/23/19 at 2:45 p.m. to 2:50 p.m. Social Services Coordinator and Director of Nursing verified that no letter had gone out to Resident 26's family/representative notifying them of the resident's discharge to the hospital on [DATE]. It was also verified by the Social Services Director and Director of Nursing that the ombudsman had also not been informed in writing of Resident 26's discharge to the hospital on [DATE]. F. Record review of Progress Notes from 4/22/19 at 8:29 PM, revealed that the facility notified a physician that Resident 83 had an elevated blood sugar and abdominal pain. After receiving an order to send the resident to the ER (emergency room ), the resident was transferred by the facility van. A follow-up note on 4/23/19 at 9:39 AM revealed that Resident 83 had been admitted to the ICU/PCU (Intensive Care Unit/Progressive Care Unit). On 5/28/19 at 9:32 AM, an interview with the facility's ADON (Assistant Director of Nursing) revealed that no written notice was provided to Resident 83's POA (Power of Attorney) as the facility routinely only notified by phone of facility initiated transfers. The ADON was uncertain whether the state ombudsman was notified of the transfer. On 5/28/19 at 11:15 AM, an interview with the facility's Social Service Assistant verified that no written notice of a facility initiated transfer was provide to Resident 83's PO[NAME] The Social Service Assistant revealed that the ombudsman was not notified of the transfer as the Social Service department had not been aware of this requirement.",2020-09-01
840,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,625,E,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to follow their bed hold policy to ensure residents were informed of bed hold policies at the time of hospitalization for 6 sampled residents (Residents 44, 49, 73, 89, 26. and 83). Facility census was 89. 7 residents with hospital stays were sampled. Findings are: [NAME] Record review of Resident 44's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and for admission/discharge tracking information) revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 3/6/19. Interview with Resident 44 on on 5/20/19 at 11:25 a.m. revealed the resident describing having fallen and sustaining a fracture in (MONTH) of 2019. The resident did not recall the facility providing the resident with a notification of bed hold policy at the time of transfer. Record review of Resident 44's medical record revealed no evidence a written notice of the bed hold policy was provided to the resident at the time of hospitalization on [DATE]. B. Record review of Resident 49's MDS records revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 1/28/19 and again on 3/6/19. Record review of Resident 49's medical record revealed no evidence a written notice of the bed hold policy was provided to the resident at the time of hospitalization s on 1/28/19 and 3/6/19. C. Record review of Resident 73's MDS records revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 4/23/19. Record review of Resident 73's medical record revealed no evidence a written notice of the bed hold policy was provided to the resident at the time of hospitalization on [DATE]. D. Record review of Resident 98's MDS records revealed the resident was admitted to the facility on [DATE] and transferred to an acute hospital for care on 1/29/19. Record review of Resident 98's medical record revealed no evidence a written notice of the bed hold policy was provided to the resident at the time of hospitalization on [DATE]. Record review of the facility's Bed Hold and Return to Facility Policy and Procedure created in may of (YEAR) revealed: It is the policy of this facility that residents who are transferred to the hospital . are provided with written information about the State's bed hold duration and payment amount before the transfer . The facility will provide the resident and resident representative a written notice which specified the duration of the bed-hold policy at the time of transfer for hospitalization . Interviews with the DON (Director of Nursing) and ADON (Assistant Director of Nursing on 5/28/19 at 10:39 a.m. verified residents 44, 49, 73, and 98 had not been provided written notices of the facility bed hold policy at the time of transfer to the hospital. E. Record review on 5/21/19 Progress note dated 5/1/19 at 22:13 identified Resident 26 having been discharged to Regional West Medical Center. Record review on 5-21-19 no documentation of Resident 26's family/representative having been given the bed hold policy within 24 hours. Staff interview on 5-23-19 at 12:03 p.m. to 12:12 p.m. Social Services Coordinator confirmed that no bed hold policy had been given to the family/representative within 24 hours of discharge to the hospital. Staff interview on 5-23-19 at 2:45 p.m. to 2:50 p.m. Social Services Coordinator and Director of Nursing both confirmed that no bed hold policy had been provided to the family/representative of Resident 26 within 24 hours. F. Record review of Progress Notes from 4/22/19 at 8:29 PM, revealed that the facility notified a physician that Resident 83 had an elevated blood sugar and abdominal pain. After receiving an order to send the resident to the ER (emergency room ), the resident was transferred by the facility van. A follow-up note on 4/23/19 at 9:39 AM revealed that Resident 83 had been admitted to the ICU/PCU (Intensive Care Unit/Progressive Care Unit). On 5/28/19 at 9:32 AM, an interview with the facility's ADON (Assistant Director of Nursing) revealed that no bed hold notice was provided to Resident 83's POA (Power of Attorney) as the facility routinely only notified by phone of facility initiated transfers. On 5/28/19 at 11:15 AM, an interview with the facility's Social Service Assistant verified that no bed hold notice was provide to Resident 83's POA related to this hospitalization .",2020-09-01
841,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,626,G,1,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05 (5b) Based on record reviews and interviews, the facility failed to allow one sampled resident (Resident 89) to return to the facility following hospitalization to stabilize the resident's condition. The failure resulted in an extended hospital stay for the resident who no longer required hospital level of care. Facility census was 85. Sample size included 7 residents discharged from the facility to an acute care hospital setting. Findings are: Record review of an Admission Record for Resident 89 printed on 5/8/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Discharge- return anticipated MDS (Minimum Data Set, a federally mandated assessment and tracking tool) completed on 1/29/19 revealed Resident 89 had been discharged to an Acute hospital on [DATE] and the facility expected the resident to return when stabilized. Record review of Resident 89's electronic Progress Notes revealed on 1/29/19 the resident's physician was notified at 10:11 a.m. regarding the resident's aggression and anxiety and informed the the resident was either going to be put under an EPC (Emergency Protective Custody) or admitted to an available behavioral facility. At 1:39 p.m. the facility phoned the local police department, resident's physician, and resident's psychiatrist to inform them the resident was being sent EPC from the facility. At 1:53 p.m. the resident was escorted off the unit by the police department. At 1:56 p.m. an attempt was made to notify the resident's Sibling-[NAME] At 2:51 p.m. the facility received a call from the resident's psychiatrist who stated will let the psychiatrist know the resident was being EPC'd from the facility. An entry on 2/1/19 at 2:17 recorded by the facility SSD (Social Services Director) recorded an emergency contact, Sibling-B, was called and a message left that the resident was being admitted to a behavioral unit. There were no other progress notes regarding the resident after the admission to the behavioral health unit. Record review of Resident 89's closed record documents revealed: There was no discharge summary completed by the facility regarding Resident 89's discharge, nor was there any evidence the resident was notified in writing by the facility indicating the facility initiated discharge. Record review of a document dated 2/14/19 received by Certified Mail at the facility on 2/21/19 revealed a General Counsel attorney for the local hospital sent correspondence to the facility. The corresponding letter recorded Resident 89 was admitted to the hospital's Behavioral Health Unit at the request of the facility and law enforcement for short term care. The patient is now stabilized and ready for discharge back (to the facility). However when (the hospital) contacted (the facility) to make arrangements for discharge, we (the hospital) were advised by (the facility) that it would not accept the patient back from (the hospital) citing behavioral issues with the patient. The correspondence goes on stating: You (the facility) have advised on the telephone that you will not accept the patient back because of behavior issues. We hereby request copies of the medical records that document or substantiate these behavior issues . As you know, we (the hospital) are a short term Behavioral Health Unit. We are not a long-term behavioral health facility. We are not equipped to house nursing home residents on a long-term basis. Request is made for (the facility) to accept the patient back as a resident. Interviews with the hospital General Counsel attorney were conducted in person on 5/21/19 at 1:05 p.m. and by phone on 5/22/19 at 11:00 a.m. The General Counsel attorney verified that Resident 89 was admitted for acute care following an EPC request from the facility on 1/29/19. The resident's condition was stabilized and the facility informed the facility the resident was ready for re-admission. The facility denied the re-admission stating issues with the resident's behavior. The attorney stated the facility had not come to the hospital to evaluate the resident's stable condition at the time of the request. The denial of re-entry by the facility prompted the attorney's formal correspondence to the facility sent and verified as received on 2/21/19 by certified mail. The hospital never received any documentation as requested regarding the behavioral issues or medical records supporting the facility's decision not to re-admit the resident. Further interview by phone revealed the resident remained in the hospital's Behavioral Health acute care unit until 4/9/19 when the hospital found suitable placement for Resident 89 in a facility in Colorado. Record review of a facility policy entitled Transfer and Discharge from the Facility Policy, created in (MONTH) of (YEAR), included the following policy statements: - It is the policy of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident. The policy identifies exceptions to this which included: . resident's needs cannot be met in the facility . - Should a resident's need (s) not be met by the services provided by the facility, the facility staff will reevaluate the resident's care plan to determine if changes to the care plan will help meet the resident's needs. If the facility cannot provide for the resident's needs, the resident may have to be transferred to another healthcare facility that can provide the services needed . - The resident and representative will receive timely notification, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. The notice contain information about the transfer and information about resident's appeal rights . The resident will not be discharged during the appeal process. If the transfer is due to an emergency, the notice will be issued as soon as practicable . - The objective of the transfer/discharge policy is to ensure that the resident is informed of an impending discharge and their right to appeal the discharge . - Overview Of Regulatory Requirement Components for This Policy recorded Facility requirements The facility must permit each resident to remain in the facility and not transfer or discharge the resident unless-- (A) The transfer or discharge is necessary for the resident's welfare and the residents needs cannot be met in the facility . Record review of the facility's Facility Assessment Tool updated on 5/9/19 revealed the facility offered and was licensed for care in both an Advanced Alzheimer's unit of 22 beds and an Alzheimer's unit of 20 beds. The assessment identified Services and Care We offer Based on our Residents' Needs which included: Mental health and behavior- Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[MEDICAL CONDITIONS], other psychiatric diagnoses, intellectual or developmental disabilities . Interview with the facility Administrator on 5/21/19 at 11:30 a.m. confirmed Resident 89 was admitted to the facility in (MONTH) of (YEAR) and resided in one of the locked Alzheimer's care units at the facility during the resident's stay. The Administrator verified the resident's behavioral episodes escalated and experienced nine episodes of aggression toward other residents in a short period of time. The facility attempted various interventions and involved both the resident's physician and psychiatrist in attempting to treat the resident. Due to failure in stabilizing the resident, the resident was EPC'd to an acute Behavioral Health facility on 1/29/19. The Administrator verified the facility determined it was not safe to allow the resident to return and the facility denied re-admission after the hospital had notified the facility the resident's condition stabilized and the resident was ready for discharge back to the facility. The Administrator verified the facility had no documentation supporting why they chose not to allow the resident to return. The resident was not given a notice of discharge or allowed an appeal to the decision. The resident's psychiatrist and medical practitioner had not been involved in the decision or provided any supportive documentation why the resident's needs could not be met by the facility. The Administrator verified that the facility does admit and care for both Alzheimer's residents and those with psychiatric [DIAGNOSES REDACTED]. The Administrator verified the decision to not re-admit the resident to the facility was based on the resident's condition at the time of transfer and not based on any evaluations of the resident at the time the hospital described the resident's condition was stable and appropriate for return to long-term care management.",2020-09-01
842,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,641,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B3 Based on record reviews and interviews, the facility failed to ensure that the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) was accurately coded for 1) activities of daily living for one current sampled resident (Resident 48) and 2) a fall and fracture for one current sampled resident (Resident 44). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of Resident 48's MDS, dated [DATE], revealed that the resident required extensive assistance with two plus persons assist with transfers (how the resident moves from one surface to another such as wheelchair to the bed). Review of the MDS, dated [DATE], revealed that the resident was totally dependent with two plus persons physical assist with transfers. Interview with LPN (Licensed Practical Nurse) - H, MDS Coordinator, on 4/22/19 at 2:10 PM revealed that the MDS was not coded accurately on 1/21/19. LPN - H stated that the resident was dependent on staff for transfers at that time. B. Record review of Resident 44's MDS assessments revealed the following: - An OBRA (Omnibus Reconciliation Act, type of MDS either Admission, Quarterly, or Significant Change type of MDS). Admission MDS assessment was completed on 2/20/19. The assessment recorded the resident was admitted to the facility on [DATE]. The assessment recorded the resident had a fall in the last month prior to admission with no fracture related to the fall. - A Discharge MDS was completed on 3/6/19 which recorded the resident was discharged to an acute hospital. - A re-entry MDS was completed on 3/15/19 which recorded the resident was readmitted from an acute hospital. - An OBRA Significant Change in Status MDS was completed on 3/22/19. This MDS recorded the resident had not had any falls since admission or the prior assessment (OBRA or PPS (Prospective Payment System type of assessment used for Medicare reimbursement)) and did not record a major injury. Record review of an investigation report completed by the facility on 3/6/19 revealed during a bath transfer Resident 44 leaned forward and fell out of the tub chair. The staff responded and notified the ambulance for transport to the hospital for complaints of left leg pain by the resident. The report identified the resident had surgery at the hospital for a Left intertrochanter fracture. Source: The facility's Long-Term Care Facility Resident Assessment Instrument (an instructional manual with directions on how to accurately assess and code MDS items) 3.0 User's Manual Version 1.16. Revised (MONTH) (YEAR). Instructions in the manual in section J1800 (section for recording resident falls) reveal that when recording falls in a Significant change of status assessment the review period is from the day after the ARD (Assessment Reference Date) of the last MDS assessment to the ARD of the current assessment. The Coding instructions direct the staff to code yes if the resident has fallen since the last assessment. Interviews with the facility's MDS Coordinator, LPN-H on 5/23/19 at 11:20 a.m. confirmed Resident 44 had an Admission MDS completed on 2/20/19 and that the resident had fallen on 3/6/19 resulting in the [DIAGNOSES REDACTED].",2020-09-01
843,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,644,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to evaluate a Level II PASRR (Pre-Admission Screening and Resident Review) as required for one current sampled resident (Resident 48). The facility census was 85 with 24 current sampled residents. Findings are: Review of Resident 48's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 4/8/19, revealed a [DIAGNOSES REDACTED]. Further review revealed no Level II PASRR was done to determine the need for mental illness care. Interview with the Social Services Director on 4/22/19 at 12:00 PM confirmed that a Level II PASRR was indicated with the mental illness [DIAGNOSES REDACTED].",2020-09-01
844,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,656,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number: 12-0006.09C Based on observations, record reviews and interviews, the facility failed to develop a care plan to address mood for one current sampled Resident (Resident 88). The facility census was 85 with 24 current sampled residents. Findings are: Resident observation on 5/20/19 at 3:16 p.m. Resident 88's mood seemed to be depressed and anxious at the same time as Resident 88 kept asking the same question over and over. Record review of Resident 88's Admission Record printed on (MONTH) 23, 2019 revealed an admitted to the facility on [DATE]. Resident observation on 5/22/19 at 7:31 a.m. Resident 88 was laying down in the bed observing television. Resident 88 stated I will be having breakfast with my wife this morning, then Resident 88's mood changed and Resident 88 became very quiet and anxious. Staff interview on 5/22/19 at 9:03 a.m. LPN (Licensed Practical Nurse)-Q Confirmed Resident 88's mood will change when the wife does not show up for meal times. LPN-Q reported that Resident 88 will become depressed and anxious during these times when the wife does not present to the facility for meal times. Staff interview on 5/22/19 at 1:22 p.m. NA (Nursing Assistant)-R confirmed that Resident 88's mood will change when the wife is present, as Resident 88 will get down or depressed if the wife is not present for meal times. Record review on 5/22/19 MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized for tracking purposes) dated on 5/6/19 for Resident 88 revealed the mood of the resident as having little interest or pleasure in doing things, trouble concentrating on things, such as reading the news paper or watching television, and poor appetite or over eating. Resident's total severity score on the MDS dated on 5/6/19 was a 4. The MDS previously completed on 2/18/19 only had a severity score of 2, as it identified Resident 88 with a poor appetite or overeating. This identified Resident 88's score in mood/behavior as being worse over the last quarter. Record review on 5/22/19 of Resident 88's care plan with goals through 8/16/19 revealed there was nothing developed on the Care Plan related to Resident 88's mood/behavior. Staff interview on 5/22/19 at 4:00 p.m. to 4:05 p.m. Administrator Verified there had been no care planning addressing the identified need in the care area of mood/behavior for Resident 88. Administrator reported this would be addressed immediately.",2020-09-01
845,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,657,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C1c Based on record reviews, and interviews the facility failed to invite on sampled Resident's (Resident 26) family to meetings to develop and update personal care plans. Sample size was 24 current residents. Facility census was 85. Findings are: Family interview on 5/20/19 at 4:52 p.m. Resident 26's daughter identified that she had not been invited to Resident 26's care plan meetings and had not received any kind of written or verbal notification. Record review of Resident 26's Admission Record printed on 5-23-19 revealed the resident was admitted to the facility on [DATE] Record review on 5/22/19 identified there were no progress notes identifying that Resident 26's daughter had been invited to Resident 26's quarterly care plan meeting held on 3/4/19. Record review on 5/22/19 identified there were no copies of any kind of formal letters in Resident 26's paper chart or Electronic Medical Chart, identifying Resident 26's daughter/Power of Attorney had been invited or informed of the quarterly review care plan meeting dated 3-4-19. Staff interview on 5/22/19 at 2:30 to 2:35 p.m. with Social Services Coordinator and Social Services Assistant verified, there was no way to track if a letter or a call had been made to Resident 26's family/Power of Attorney identifying they had been invited to Resident 26's care plan meeting. Staff interview on 5/22/19 at 4:00 p.m. Administrator verified that no invitation had been extended to Resident 26's family/Power of Attorney to attend the resident's care plan meetings.",2020-09-01
846,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,676,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1b Based on record reviews and interview, the facility failed to assess potential causal factors and develop a plan to restore an identified decline in bed mobility for one current sampled resident (Resident 41). The facility census was 85 with 24 current sampled residents. Findings are: Review of Resident 41's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/11/19, revealed that the resident required extensive assistance of with one person physical assist with bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed). Review of the MDS, dated [DATE], revealed that the resident required extensive assistance of two plus persons physical assistance with bed mobility. Interview with LPN (Licensed Practical Nurse) - H, MDS Coordinator, on 5/22/19 at 1:45 PM revealed that further assessment of the resident's decline in bed mobility was not done to determine potential causal factors and a plan to restore bed mobility to one person physical assist.",2020-09-01
847,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,684,G,1,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) abnormal bleeding was assessed and follow up was completed to ensure care was provided promptly for one current sampled resident (Resident 41) on blood thinning medication, 2) low blood sugar readings were assessed and follow up care provided to ensure needs were met for one current sampled resident (Resident 42, 3) [MEDICAL CONDITION] were assessed and follow up completed to ensure healing without complications for one current sampled resident (Resident 48) and 4) a PICC (Peripherally Inserted Central Venous Catheter) line was monitored every shift and a heart monitor present on re-admission was monitored as indicated for one current sampled resident (Resident 73). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/3/19, revealed that the resident was at risk for bruising and bleeding related to the use of blood thinning medication. Interventions included that the staff were to inspect the resident's skin for bruising or unusual bleeding daily during care and report to the charge nurse and provider for further interventions. Further review revealed that the resident had both short term and long term cognitive deficits and had difficulty making self understood and understanding others. Review of the Progress Notes revealed the following including: - 2/25/19 at 4:30 AM This nurse noted a large bruise to the left side of the hip, bruise area was hardened, the resident grimaced when the area was touched, no reports of injury from the previous nurse, resident was unable to state the source of the injury due to cognitive impairment, will pass report to coming nurse to notify the primary care physician for evaluation; - 2/25/19 at 1:29 PM Nursing Late Entry Note: Was told in morning report that the resident had a bruise. Later in the day, during the skin assessment in the bath house, the bruise was assessed and appeared dark purple and spanned approximately 29 cm. (centimeters) across and 9 cm. wide. The resident was assessed by a Nurse Practitioner and orders were received to send the resident to the Emergency Department; - 2/25/19 at 9:23 PM Update from the hospital showed that the the resident's INR (International Normalized Ratio), a blood laboratory test for bleeding time, showed a critically high level at 6.16 ( a range of 2.0 - 3.0 generally considered a therapeutic range for people taking blood thinning medication such as [MEDICATION NAME]). Further review revealed that the resident was to be admitted to the Intensive Care Unit at least overnight. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the night shift nurse should have identified the resident's high risk for abnormal bleeding due to the use of blood thinning medication and completed a skin assessment including the size and characteristics of the bruising. Further interview confirmed that the nurse should have notified the provider right away to determine the need for further evaluation and treatment. The DON confirmed that the day shift nurse should also have identified the resident's high risk for abnormal bleeding, should have assessed and documented the bruise and followed up with the resident's provider for further evaluation and treatment to ensure that the resident's needs were met. B. Interview with Resident 42 on 5/20/19 at 9:40 AM revealed had a low blood sugar this morning and had to drink orange juice. Further interview revealed no follow up blood sugar was done. Review of the Care Plan, goal date 6/18/19, revealed that the resident had a [DIAGNOSES REDACTED]. Interventions included that the nursing staff would observe the resident for low blood sugar symptoms including flushed face, sweating, change in usual mental status, lethargy, irritability, fruity breath odor, nervousness, trembling and light headedness. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident's blood sugar was 64 on 5/16/19 at 6:59 AM and at 11:30 AM and the blood sugar on 5/1/19 at 7:30 AM was 61. Review of the Progress Notes, dated 5/20/19 and and 5/1/19 revealed no assessment of the resident, including symptoms of hypogylcemia (low blood sugar), treatment provided or a follow up assessment of symptoms or blood sugar obtained. Further review revealed that on 5/16/19 at 6:59 AM, the resident was given glucose for low sugar with no assessment of the resident's symptoms or follow up blood sugar. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the blood sugar levels listed above were abnormally low for the resident. Further interview confirmed that the nurses were to assess and document the resident's symptoms of low blood sugar, interventions provided and the resident's response to the interventions, including a follow up blood sugar in about an hour, to ensure that the resident was stable and needs were met. C. Observations of Resident 48 on 5/20/19 at 3:50 PM revealed dried [MEDICAL CONDITION] and redness on face and arms and a bandage on the right outer neck area. Further observations at 1:30 PM revealed MA (Medication Aide) - C and MA - D provided skin care and applied [MEDICATION NAME] to excoriated areas on the coccyx and gluteal folds. Review of the Care Plan, goal date 7/2/19, revealed that the resident had altered skin integrity related to incontinent [MEDICAL CONDITION] and excoriation. Interventions included weekly skin inspection, thorough skin care and apply barrier cream after incontinent episodes. Review of the Weekly Skin Review, dated 5/16/19, revealed no assessment of the multiple [MEDICAL CONDITION], area covered with a bandage on the neck or the excoriation on the coccyx and gluteal folds. Interview with the DON on 5/23/19 at 10:10 AM confirmed that there was no documentation on weekly summaries or progress notes of the resident's current skin injuries including the [MEDICAL CONDITION] on the face and arms, area on the neck or excoriation. Further interview confirmed that these areas needed to be routinely assessed and documented to ensure healing without complications. D. Record review of Resident 73's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and tracking for admissions and discharges) records revealed the resident was initially admitted to the facility on [DATE]. The tracking MDS records indicated the resident was admitted to an acute care hospital on [DATE] and re-admitted to the facility on [DATE]. A Significant change in status MDS was completed on 4/29/19. The assessment revealed the was receiving IV (intravenous) therapy both during the hospital stay and during the reference period of the MDS (4/23/-4/29/19). Interview on 5/20/19 at 10:30 a.m. with MA (Medication Aide)-E revealed the unit where Resident 73 now resided was a unit designed for residents with minimal care needs. MA-E stated there was no charge nurse routinely staffed on the unit. Observation of Resident 73's PICC line dressing change on 5/20/19 at 2:40 p.m. revealed RN (Registered Nurse)-F and the facility DON assisting the resident during the dressing change. RN-F and the DON discovered the resident's surrounding area to the PICC line was bright red measuring 7 x 12 cm with some blistering areas alongside the insertion site. Both RN-F and the DON stated this was not present at the last changes. Also, during the observation, a heart monitor was observed in place. Interview with the DON following the observation 5/20/19 at 3:00 p.m. revealed Resident 73's PICC line was scheduled for weekly dressing changes and as needed. The DON also verified there was no licensed nurse assigned as a charge nurse on the 300 unit, but that licensed nurses from other halls come over and do the dressing changes when scheduled and LPN (Licensed Practical Nurse)-I (A restorative nurse) is on the unit some days. The DON was unaware of any orders or monitoring that should be done regarding the resident's heart monitor. Interview with LPN-I on 5/20/19 at 3:30 p.m. revealed LPN-I is not involved in the PICC line care and treatment for [REDACTED]. Interviews and observations of the night shift staff on 5/22/19 between 4:45 a.m. and 5:30 a.m. revealed MA-X was assigned to the unit where Resident 73 resided. MA-X described being the only staff member on the unit during from 6 p.m. to 6 a.m. and if needing a licensed nurse, the Alzheimer's unit charge nurse would come down to the unit. RN-T described working on the locked Alzheimer's units from 6 p.m. to 6 a.m. and confirmed there was no licensed charge nurse on the 300 unit where Resident 73 resided. RN-T described assisting with PICC line dressing changes for Resident 73 on the days scheduled for change, but does not make routine rounds or check the dressing on other days. Record review of Resident 73's current physician orders [REDACTED]. An order dated 4/22/19 for Change central Line dressing weekly and PRN (as needed) as needed for dislodgement or soiled. There were no instructions or orders related to the resident's heart monitor. Record review of Resident 73's Treatment Administration Record for (MONTH) 2019 revealed the facility was documenting weekly central line dressing changes every Monday. There was no documentation the line was changed on 5/13/19. There was no documentation on the resident's treatment records for (MONTH) 2019 that licensed nurses were monitoring the PICC line site other than on dressing change days. Record review of Resident 73's electronic progress notes revealed no documentation by licensed nurses that the PICC line site and heart monitor sites were being monitored except on days when the PICC line dressing was changed. Interviews with the DON and ADON (Assistant Director of Nursing) on 5/28/19 at 10:30 a.m. verified there was no supportive documentation that Resident 73's PICC line dressing was being monitored on every shift and there was no documentation or orders pertaining to the resident's heart monitor placed during the hospitalization in April. Source: University of Michigan Serious risks from common IV (intravenous) devices (MONTH) (YEAR). These (PICC lines) are not innocuous devices. The time has come to stop thinking of them as a device of convenience, and rather one with clear risks and benefits. Many studies and patient safety efforts have worked to reduce another clear risk associated with PICCs: infections often called CLABSIs, for central line associated bloodstream infections. But the risks of [MEDICAL CONDITION]'s ([MEDICAL CONDITION] clotting_ and the potentially lethal risk of a [MEDICAL CONDITION] embolism if the PICC clot breaks away, haven't gotten the kind of attention that a common device would warrant.",2020-09-01
848,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,686,G,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12- D2 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to provide care to prevent pressure ulcers and to promote healing, including repositioning at least every two hours, pressure relieving seat cushions, dressing changes as ordered, aseptic technique for dressing changes and follow up with ongoing resident non compliance with interventions for two current sampled residents (Residents 42 and 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/18/19, revealed that the resident required assistance with activities of daily living including repositioning in bed, transfers and personal hygiene and cares. Further review revealed that the resident was at risk for pressure ulcers due to assistance required with bed mobility, diabetes, history of pressure ulcers and placed a pillow in the wheelchair. On 9/12/18, the resident had a pressure area to the coccyx and right buttock, on 1/17/19 the area to the coccyx was closed, on 2/22/19 the area was opened, and 5/17/19 the area was stable with 100% granulation tissue. Interventions included treatments as ordered, weekly skin assessments, pressure reducing wheelchair cushion and air mattress, the resident frequently sits on a pillow on top of the pressure reducing wheelchair cushion and staff will continue to educate the resident on the importance of not using a pillow on top of the pressure reducing device and to comply with treatment. Review of the Wound Evaluation Flow Sheet Multiple Weeks - V 4, dated 4/28/19, revealed the following including: - 2/22/19 Stage 4 pressure ulcer ( full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) at the coccyx which measured 0.5 cm. (centimeters) wide, 1 cm. long and 0.5 cm. depth; - pressure ulcer acquired in the facility; - tunneling/undermining at 0.5 cm.; - moderate amount of drainage present; - peri wound with macerated (moist)/soft skin; - treatment order 3/28/19 honey fiber and foam dressing and skin prep peri- wound; - current preventative interventions are pressure redistribution mattress and wheelchair cushion; - current wound status/additional comments included maceration peri-wound (around the wound) is worse, resident is non-compliant with utilizing pressure reducing wheelchair cushion appropriately and puts a pillow on top of the cushion, education provided on the risks associated with non-compliance. Further review revealed the Wound Evaluation Week 3 on 5/17/19 including: - wound measured 0.7 cm. long, 1 cm. wide (larger) and 0.5 cm. depth; - no drainage; - 100% granulation tissue; - 4/18/19 treatment order of honey fiber and foam dressing, change daily; - education provided on putting pillow on top of the pressure reducing wheelchair cushion; - maceration around the wound is resolved at this time. Observations on 5/20/19 at 9:44 AM revealed the resident seated in the wheelchair with a pillow placed on the top of the wheelchair cushion and the Microair mattress set at 8 which is for 315 pounds. Further observations at 2:50 PM revealed the resident resting on the bed, air mattress set at 8 and a pillow placed at the resident's lower back. LPN (Licensed Practical Nurse) - L, Charge Nurse, applied disposable gloves, assisted the resident to turn onto side, removed the dressing at the coccyx area, noted brown and red colored drainage on the dressing, noted open area approximately 2 cm. and 1 cm. in depth and surrounding skin reddened and macerated. LPN - L, wearing the same disposable gloves, cleansed the ulcer with saline, wiped the area with gauze, applied skin prep to the surrounding skin, changed gloves with no hand washing, applied the honey fiber dressing to the inside of the wound, resident stated that hurts and the cover foam dressing was applied. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed an order, dated 3/21/19, for LiquaCal two times a day for wound healing. Further review revealed no documentation that the medication was administered on 5/2/19 at 5:00 PM or on 5/8/19 at 9:00 AM and 5:00 PM. Review of the TAR (Treatment Administration Record) for (MONTH) 2019 revealed an order to cleanse the wounds to the coccyx, pat dry, apply honey fiber to the wound bed, cover with foam dressing, change daily until resolved, apply skin prep around the wound to macerated skin, for Stage 4 pressure area. Further review revealed that the resident refused the treatment on 5/2/19 and no documentation that it was done on 5/7/19 and 5/10/19. Interview with the DON (Director of Nursing) on 5/21/19 at 3:50 PM confirmed that the air mattress was not set at a therapeutic level for the resident. The DON set the air mattress at 5 based on the resident's weight of approximately 200 pounds. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the resident continued to sit in the wheelchair with a pillow over the pressure reducing cushion which decreased the therapeutic benefits of the cushion. Further interview confirmed that the resident should not place a pillow over the air mattress as that also reduced the effectiveness of the pressure relieving mattress. The DON confirmed that wound care needed to be done as ordered and the protein supplement needed to be administered as ordered to promote healing of the pressure ulcer. Further interview confirmed that dressing changes, including the proper use of disposable gloves and hand washing, should be done to promote healing of the pressure ulcer. The DON confirmed that the disposable gloves were to be removed after the soiled dressing was removed and hand washing done before new gloves were donned to treat and apply the clean dressing to reduce the risk of cross contamination. B. Review of Resident 48's Care Plan, goal date 7/2/19, revealed that the resident required assistance of two staff for bed mobility and transfers, had impaired cognition due to confusion and [DIAGNOSES REDACTED]. Interventions included weekly skin inspection, pressure reducing wheelchair cushion and mattress, reposition side to side during the night, educate the resident on the importance of off loading pressure and repositioning side to side to reduce the risk for pressure and to improve current skin issues, respect the resident's right to refuse, encourage the resident to lay down and reposition to sides between meal times and treatments as ordered. Review of the Weekly Skin Review - V 3, dated 5/16/19, revealed that the resident had an open area at the left buttock which measured 0.5 cm. by 0.5 cm. and an open area (not measured) at the right gluteal fold. Observations on 5/20/19 at 9:15 AM, 10:00 AM, 11:00 AM, 12:15 PM and 1:30 PM revealed the resident seated in the wheelchair with a pillow over the wheelchair seat cushion and the canvas mechanical lift transfer sling. Further observations at 1:30 PM revealed MA (Medication Aide - C and MA - D transferred the resident to the bed with a full mechanical lift. MA - C and MA - D removed the resident's soiled disposable brief and provided skin care. Dressings were noted on the resident's right and left inner buttocks areas. The resident was positioned on back after cares were completed and remained positioned on back at 2:30 PM. Interview with MA - D on 5/20/19 at 1:45 PM revealed that the resident usually sat in the wheelchair all morning, usually got up around 5:00 AM, and would sometimes agree to lay down in bed for awhile in the afternoon. so that the disposable brief could be changed. Further interview revealed that the resident could not reposition self in the wheelchair. Observations on 5/21/19 at 7:00 AM, 11:45 AM and 1:20 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Observations on 5/22/19 at 5:00 AM, 7:50 AM, 9:00 AM, 12:00 PM, 1:30 PM and 3:10 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Further observations at 3:10 PM revealed MA - N and MA - S transferred the resident from the wheelchair to the bed with the full mechanical lift for skin care. MA - N and MA - S removed the soiled disposable brief, noted smeary bowel movement and urinary incontinence and provided skin care. The resident's anal, coccyx and scrotum were noted to be excoriated with some open areas. Interviews with MA - N and MA - S on 5/22/19 at 3:10 PM confirmed that the resident had been in the wheelchair all day until now and was not able to reposition self in the wheelchair due to bilateral [MEDICAL CONDITION]. Further interview revealed that the resident often refused to lay down during the day to check and change the disposable brief, wanted the pillow and the lift sling kept in the wheelchair and didn't want to be repositioned in the wheelchair. Observations on 5/22/19 at 3:15 PM revealed RN (Registered Nurse) - M, applied disposable gloves, removed the dressing at the left inner buttock area and with the same gloves, cleaned the open area (which measured approximately 4 cm. x 1.5 cm.) with saline, applied skin prep around the wound and a collogen dressing and a cover dressing. RN - M removed gloves and applied new gloves without hand washing in between, repositioned the resident to the other side, removed the dressing at the right inner buttock, noted brown colored drainage on the dressing, cleaned the open area with saline (area measured approximately 4cm. x 1.5 cm.), applied skin prep to the surrounding skin and applied a collogen and cover dressings. RN - M applied [MEDICATION NAME] to open and excoriated areas at the anal, coccyx area and scrotum and assisted MA - N to apply a disposable brief. RN - N removed the disposable gloves and gathered trash and supplies. Further observations revealed that the resident requested to get up into the wheelchair and MA - N and MA - S transferred the resident back into the wheelchair with a pillow and the mechanical lift sling on top of the wheelchair seat cushion. Review of the Treatment Administration Record, dated (MONTH) 2019, revealed an order dated 5/10/19 for Collagen and foam to left buttock three times a day until healed. Further review revealed no documentation that the treatment was done at 10:00 PM on 5/13/19, 6:00 AM on 5/14/19 and at 2:00 PM on 5/17/19. Further review revealed a treatment order, dated 5/18/19, for the right ischeal tuberosity daily until resolved. There was no documentation that the treatment was done on 5/19/19 at 8:00 PM as scheduled. Interview with the DON on 5/23/19 at 10:10 AM confirmed that the the pressure ulcers were facility acquired and interventions were not in place to promote healing, including repositioning at least every two hours and off loading at least every two hours while in the wheelchair. The DON confirmed that sitting in the wheelchair with a pillow and mechanical lift sling over the wheelchair pressure reducing cushion reduced the effectiveness of the seat cushion. Further interview confirmed that the treatments were to be done as ordered to promote healing as scheduled and skin assessments completed weekly to include all open areas to ensure healing without complications. The DON confirmed that disposable gloves were to be removed after soiled dressings were removed and hand washing done before clean gloves were donned to reduce the risk of cross contamination. Further interview revealed that the residents continued with non compliance with interventions to prevent and promote healing of pressure ulcers and further assessments needed to completed to determine the reasons and possible interventions to obtain compliance. Review of the facility policy Prevention and Management of Wounds, dated 5/21/19, revealed the Policy Statement An interdisciplinary approach to pressure ulcer treatment encourages nurses and therapists to work closely together to assess risk and intervene with preventative measures such as pressure relieving devices and proper positioning. The Wound Care Coordinator and/or licensed nurse shall be designated as being responsible for prevention and treatment of [REDACTED].",2020-09-01
849,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,688,D,1,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D4 Based on record reviews and interviews, the facility failed to provide a restorative nursing care program to 1) prevent further declines in range of motion for two current sampled residents (Residents 41 and 42) and 2) reduce the risk for the development of contractures (shortening of muscle tissue that prevents normal mobility of a joint) for one current resident identified at risk for contractures (Resident 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of Resident 41's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 4/1/19, revealed that the resident had limitations in range of motion involving the upper extremity on one side. Review of the Care Plan, goal date 6/3/19, revealed that the resident was to have passive range of motion exercises to all joints for fifteen minute sessions three times a week or as tolerated to improve contractures and to prevent further declines. Interview with LPN (Licensed Practical Nurse) - I, Restorative Care Nurse, on 5/22/19 at 1:00 PM revealed that the resident was not on a Restorative Nursing Care Program. B. Review of Resident 42's MDS, dated [DATE], revealed that the resident had limitations of range of motion at both lower extremities. Review of the Care Plan, goal date 6/18/19, revealed that the resident was at risk for decline in range of motion and activities of daily living. Interventions included restorative active range of motion program to upper and lower extremities and restorative bed mobility to practice safe skills getting in and out of bed. Interview with LPN - I on 5/22/19 at 1:10 PM revealed that the resident was not on a Restorative Nursing Care Program. C. Review of Resident 48's MDS, dated [DATE], revealed that the resident had limitations in range of motion at both lower extremities. Review of the Care Plan, goal date 7/2/19, revealed that the resident had limitations in range of motion due to bilateral [MEDICAL CONDITION] and was at risk for worsening contractures. Interview with the Director on Nursing on 5/23/19 at 10:30 AM confirmed that the resident was a high risk for the development on contractures. Further interview revealed that the resident was not on a Restorative Nursing Care Program.",2020-09-01
850,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,689,G,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews and interviews; the facility failed to ensure that 1) safety measures were in place to prevent one sampled resident (Resident 44) from falling during bathing. The failure resulted in the resident sustaining a fracture; 2) care plan interventions were in place to reduce the risk for recurrent falls for one current sampled resident (Resident 41); and 3) a loose grab bar was secured to the bed frame to reduce the risk for injuries for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Interview with Resident 44 on 5/22/19 at 1:45 p.m. revealed the resident describing having sustained a fall and fracture requiring surgery and hospitalization about a month after being admitted . The resident described the incident by stating the fall occurred in the tub room after the bath was completed. The resident stated being in a bath chair and that Usually the staff strapped the resident in the chair and had a second person present during transfers. On this occasion, the staff did not apply the strap or have a second person present. The resident described tumbling out of the chair and fracturing a leg resulting in the need for surgery after being diagnosed with [REDACTED]. Record review of Resident 44's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed an Admission assessment was completed on 2/20/19. The assessment recorded the following items regarding the resident's condition: - The assessment recorded the resident was admitted from another nursing home on 2/14/19. - The assessment recorded a resident BIMS (Brief Interview for Mental Status) test score was 15 (cognitively intact memory). - The assessment recorded the resident's ability to transfer between surfaces (to and from bed, chair, wheelchair) required the assistance of Two (or more) and that the resident required Total dependence- full staff performance to complete transfer tasks. -The assessment recorded the resident required Two (or more) persons and Physical assist support for Bathing. - The assessment recorded the resident's weight at the time of the assessment was 355 pounds. - Under the fall history portion of the assessment the facility recorded the resident had a history of [REDACTED]. Record review of Resident 44's electronic Progress Notes revealed the following entry: - 3/6/19 at 5:50 p.m. the note recorded a Situation while the resident was transferring during bath and fell to floor. The note recorded the resident was being transferred during a bath and was in bath chair. Is a bariatric (obese) patient. The note recorded the resident was assessed and assisted to a comfortable position and that the resident complained of Left hip pain. The medical provider was called and an order received to transfer the resident to the emergency room for evaluation. Record review of a hospital History and Physical Reports form dated 3/6/19 revealed the resident's CC (chief complaint) at the time of admission was I fell getting out of the bathroom. The physical recorded the resident was sent from the facility today after falling getting out of the bathroom, landed on left side, and ER (emergency room found to have left displaced femur fracture. The physical assessment diagnosed : Left femur fracture. Record review of a facility undated New ownership investigation of Resident 44's fall on 3/6/19 revealed a nurse was called to the 100 wing tub room and observed resident on floor between tub and north wall. The resident was sitting up with head against the tub, left leg straight out and right leg was bent. The resident expressed pain to the left leg. An ambulance was called and the resident transferred to the emergency room . The BA (Bath Aide)-W was interviewed during the investigation and re-enacted the incident. The investigation recorded the resident bath was completed and BA-W took off the resident's strap to clean under the abdominal folds and then elevated the tub chair to get the resident's feet out of the tub and pulled the chair out of the whirlpool When getting the resident out of the tub chair to put the belt back on the resident leaned forward and fell out of the tub chair. The investigation report indicated the resident was interviewed and stated remembering the bath aide having to jerk the tub chair and I flew out of the chair. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 5/28/19 at 10:39 a.m. verified Resident 44 sustained a fall and fracture during the bathing process on 3/6/19. The DON and ADON verified there was only one staff member assisting the resident during the bath and the transfer out of the tub. The causal factor for the fall was verified as the removal of the seat belt strap by BA-W while assisting the resident out of the tub. The failure to apply the strap resulted in the resident falling forward and sustaining the injury. The DON and ADON stated that safety straps should not be removed during the bathing procedures. B. Review of Resident 41's Care Plan, goal date 6/3/19, revealed that the resident was at risk for falls due to history of falls and the resident was found on the floor by the bed on 4/16/19. Further review revealed interventions including staff will ensure that the resident's bed was left in the low position while the resident was in bed and the call light was within reach at all times when in the room. Observations on 5/22/19 at 5:00 AM revealed Resident 41 resting in bed with eyes closed. Further observations revealed that the bed was positioned approximately waist high and the call light was fastened to the connection on the wall and not within the resident's reach. Interview on 5/22/19 at 5:10 AM with LPN (Licensed Practical Nurse) - G, Charge Nurse, confirmed that the resident's bed was to be left in the low position and that the resident was to have the call light within reach to reduce the risk for falls. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the staff were to follow the care plan interventions to reduce the risk for falls. C. Review of Resident 42's Care Plan, goal date 6/18/19, revealed that the resident required staff assistance with bed mobility and that the resident utilized assist rails on the bed for repositioning. Observations on 5/20/19 at 9:10 AM revealed the assist rail on the open side of the bed was loose and presented a three to four inch gap between the assist rail and the airflow mattress. Interview with the DON on 5/21/19 at 3:50 PM confirmed that the assist rail needed to be tightened to the bed frame to reduce the risk for injuries.",2020-09-01
851,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,690,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3(2) Based on record reviews and interview, the facility failed to ensure that an assessment was completed to determine causal factors and a plan to restore bowel continence was developed for one current sampled resident (Resident 48) who had a decline in bowel continence. The facility census was 85 with 24 current sampled residents. Findings are: Review of Resident 48's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 1/21/19, revealed that the resident was frequently incontinent of bowel (two or more episodes of bowel incontinence with at least one continent bowel movement). Review of the MDS, dated [DATE], revealed that the resident was always incontinent of bowel with no episodes of continent bowel movements. Interview with LPN (Licensed Practical Nurse) - H, MDS Coordinator, on 5/22/19 at 2:10 PM, confirmed that the resident had a decline in bowel continence. Further interview revealed that further assessment to determine potential causal factors and a plan to restore bowel continence to the previous level was not done.",2020-09-01
852,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,695,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observations, record reviews and interview; the facility failed to document the actual dose of oxygen administered to assess the amount needed to maintain oxygen saturation levels within the ordered range for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: Observations on 5/20/19 at 9:30 AM revealed Resident 42 seated in the wheelchair with oxygen on per concentrator at two liters per minute. Further observations at 3:00 PM revealed the resident in bed with oxygen on per concentrator at two liters per minute. Review of the Treatment Administration Record, dated (MONTH) 2019, revealed an order for [REDACTED]. Interview with the Director of Nursing on 5/23/19 at 9:20 AM confirmed that the actual dose of oxygen administered needed to be documented to determine the amount needed to keep the oxygen saturation levels at at least 88%.",2020-09-01
853,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,697,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to complete a pain assessment when pain symptoms occurred and failed to administer pain medications every four hours as requested for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: Review of the Admission Record, printed 5/21/19, revealed that Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/18/19, revealed that the resident needed pain management and monitoring related to [MEDICAL CONDITION] and Peripheral [MEDICAL CONDITION]. Further review revealed that an acceptable level of pain was 4 on the pain scale 1-10 with 10 being the highest level of pain. Interview with the resident on 5/20/19 at 9:40 AM revealed had ongoing headaches, neck pain and feet pain. Further interview revealed that they don't wake me up for pain medications like I asked and the doctor said that I could have the pain medication every four hours to keep pain controlled. The resident stated that when the [MEDICATION NAME] wasn't given every four hours, it took a long time for the next dose to work. Review of the Progress Notes revealed that on 4/29/19 the resident returned from an appointment with pain management with no new orders. The resident did have an injection in the neck and will consider a cervical block if indicated. Review of the Order Summary Report, dated 5/21/19, revealed that the resident had orders for pain monitoring every shift per numerical scale, [MEDICATION NAME] every day and every bedtime for [MEDICAL CONDITION], [MEDICATION NAME] every 72 hours for pain, [MEDICATION NAME] two times a day for [MEDICAL CONDITION], and 5/17/19 [MEDICATION NAME] every four hours for pain, severe while awake. Review of the Medication Administration Record, [REDACTED]. Further review revealed pain level was recorded 49 times higher than 4. Review of the Pain Evaluation, dated 4/18/19, revealed that the resident had no pain. Further review no pain assessment was completed with increased complaints of pain and medication changes on 5/17/19. Interview with the Director of Nursing on 5/23/19 at 9:10 AM confirmed that a pain assessment should have been completed when the resident had increased pain to ensure that pain was managed effectively with medications and non pharmacological interventions. Further interview confirmed that the nurses could give the pain medication every four hours as the resident requested to manage the pain at 4 or less.",2020-09-01
854,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,725,E,1,1,3V0011,"> Licensure Reference Number: 175 NAC 12-006.04C7 Based on observations, record reviews, and interviews, the facility failed to ensure staffing for resident care for: 1) PICC line monitoring for one sampled (Resident 73) and one non-sampled resident (Resident 35); 2) the provision of a Restorative Care Program for 3 sampled residents (41, 42, and 48) and ensure the Restorative Care Program was staffed to meet resident needs as specified in the Facility Assessment Tool. Facility census was 85. Sample size was 24 current residents. Findings are: [NAME] Interview with MA (Medication Aide)-E on 5/20/18 at 10:30 a.m. revealed MA-E was routinely scheduled from 6 a.m. to 6 p.m. on the 300 unit of the facility. MA-E described being the only staff member scheduled for the unit, but that an LPN (Licensed Practical Nurse) from restorative does help out on some days. MA-E described being the only staff person on the unit on weekends. MA-E stated being responsible for bathing residents, providing personal cares, and medications. MA-E verified two current residents on the unit had PICC (Peripherally Inserted Central Venous Catheter) lines. MA-E stated facility RN (Registered Nurse) staff provide the cares for the PICCs. Observation of Resident 73's PICC line cares on 5/20/19 at 2:40 p.m. revealed RN-F and the facility DON (Director of Nursing) assisted the resident with a dressing change. RN-F described being assigned to the special care units (400 and 500 wings) but does assist Resident 73 when the PICC line dressing is scheduled for changes. Interview with the DON on 5/20/19 at 2:40 p.m. confirmed there is no licensed charge nurse or RN assigned to the 300 wing. Interviews with staff working the night shift on 5/22/19 between 4:45 a.m. and 5:30 a.m. revealed MA-X assigned to the 300 unit. MA-X described working 6 p.m. to 6 a.m. routinely on the unit and stated there is no charge nurse or other staff assigned to the unit during hours of working. MA-X stated both Residents 73 and 35 had PICC lines and that an RN from the special care unit would assist with the dressing changes when scheduled. RN-T described working 6 p.m. to 6 a.m. routinely on the Alzheimer units (400 and 500) and verified no rounds were made by the RN to check the PICC lines on 300 unless the dressings were due for changes. Record review of a Day of Survey Staffing form requested by surveyors for the scheduled staff on 5/20/19 at the time of survey entrance revealed MA-E was the only staff scheduled on the 300 wing for the day shift, MA-E and MA-X split the evening shift, and MA-X was the only staff scheduled for the night shift. Interview with the DON and ADON (Assistant Director of Nursing) on 5/28/19 at 10:30 a.m. confirmed there were no licensed nurses scheduled on the 300 unit and that Medication Aides were assigned. The DON and ADON verified there was no evidence that licensed nurses did daily checks or rounds to check PICC lines for Residents 73 or 35 except during the ordered weekly dressing changes. B. Record review of Staff Posting information from 4/28/19 through 5/20/19 revealed there were no hours recorded for the Restorative LPN or Restorative Aides. Record review of an MDS Indicator Factuality Rate Report (A document based on the Minimum Data Set, a federally mandated comprehensive assessment tool identifying resident problem areas). revealed the facility had a total of 27 residents with Range of Motion limitations that were not receiving services. Record reviews for two sampled residents (41, 42, and 48) revealed both residents had limited range of motion without any restorative program. Interviews with LPN-I, the Restorative licensed nurse on 5/22/19 at 1 P.M. and 1:10 P.M. confirmed Residents 41 and 42 had range of motion limitations with no program to improve or maintain function. Interview with the DON on 5/23/19 at 10:30 a.m. confirmed Resident 48 had a limitation of range of motion and a potential for development of contracture (fixed movement in a joint) and was not on a program to improve or maintain function. Record review of the Facility Assessment Tool revised on 5/9/19 revealed the facility had an average census of 91. The assessment described the Staffing plan based on resident population and care needs with descriptions of their approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time. The plan identifies the need for: One full time Restorative Nurse to oversee the fall program, elopement risk program, manage wheelchairs, mattresses, and other support devices in use for residents. The plan identifies the need for three Restorative/Rehab aides each working 7.5 hour shifts. Interview with LPN-I on 5/21/19 at 2:45 p.m. revealed LPN-I's position at the facility was as a Restorative Nurse. LPN-I stated there was one restorative aide assigned to the department and verified the restorative aide was on vacation and no one was assigned to cover. LPN-I also stated not working exclusively in restorative but being utilized in other positions and covering as a charge nurse. LPN-I also stated there are various times when the restorative aide is pulled from assignment to help cover direct care staffing areas.",2020-09-01
855,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,726,E,0,1,3V0011,"Licensure Reference Number 175 NAC 12-006.04B Based on observations, record review and interviews; the facility failed to ensure competencies were done related to 1) whirlpool tub cleaning which on the East 200 wing whirlpool and 2) dressing changes for two current sampled residents (Residents 42 and 48). The facility census was 85 with nine residents on the 200 wing who routinely use the East whirlpool tub for bathing (Residents 70, 51, 50, 69, 66, 38, 54, 68 and 84). Findings are: [NAME] Observations on 5/20/19 at 2:30 PM revealed MA (Medication Aide) - N cleaned the whirlpool tub. MA - N turned the water on as hot as it would go until the hot water shut off, filled the tub about half full, poured about a cup of full strength disinfectant (Classic Whirlpool Disinfectant Cleaner) into the tub and cleaned the inside of the tub with a brush. MA - N stated would turn the whirlpool jets on and let it run for about 15 minutes and then come back and rinse the tub. Review of the Classic Whirlpool Disinfectant Cleaner directions for use revealed the following including: For Cleaning Bath and Therapy Equipment: After using the whirlpool unit, drain the water and refill with fresh water to just cover the intake valve. Add 2 ounces of Classic Whirlpool Disinfectant Cleaner to one gallon of water into the unit at this point. Briefly start the pump to circulate the solutions. Turn off the pump. Wash down the unit sides, seat of the chair/lift and any/all related equipment with a clean swab or sponge. After the unit has been thoroughly cleaned, drain solutions from the unit and rinse any/all cleaned surfaces with fresh water. The unit is ready for re-use. Interview with LPN (Licensed Practical Nurse) - L, 200 Wing Unit Coordinator, on 5/22/19 at 1:30 PM revealed that Residents 70, 51, 50, 69, 66, 38, 54, 68, and 84 routinely bathed in the 200 East whirlpool. B. Observations of the dressing change for Resident 42 on 5/20/19 at 2:50 PM revealed LPN - L donned disposable gloves, removed the soiled dressing from the resident's coccyx area, removed the disposable gloves, donned new gloves (with no hand washing), cleansed the wound with saline, wiped the area with gauze and applied skin prep to the surrounding skin. Further observations revealed LPN - N removed disposable gloves and donned clean gloves (with no hand washing) and applied a honey fiber dressing to the wound bed, covered the wound with a dressing and removed the gloves. C. Observations of the dressing changes for Resident 48 on 5/22/19 at 3:15 PM revealed RN (Registered Nurse) - M, Charge Nurse, applied disposable gloves, removed the dressing from the left hip area (did not change gloves or perform hand washing), cleansed the wound with saline, applied skin prep to the surrounding skin, applied a Collogen dressing to the wound and covered the wound with a foam dressing, removed the disposable gloves and donned new gloves (with no hand washing). Further observations revealed RN - M assisted the resident to reposition on the other side, removed the dressing from the right hip area ( did not change gloves or perform hand washing), cleaned the wound with saline, applied skin prep to the surrounding skin, applied Collogen to the wound bed, applied the cover dressing (did not remove gloves or perform hand washing), opened dresser drawers and closet to get a clean disposable brief, removed the disposable gloves and left the room to get some cream to finish the treatment. Interview with the Director of Nursing on 5/23/19 at 8:30 AM revealed that there was no documentation of competencies related to whirlpool cleaning for MA - N or for dressing changes for LPN - L and RN - M. Further interview confirmed that the nursing staff did not follow acceptable practice for cleaning the whirlpool tub or dressing changes to reduce the risk for cross contamination.",2020-09-01
856,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,732,C,1,1,3V0011,"> Based on observation and interview, the facility failed to ensure the required direct care staffing hours were posted daily. The failure could potentially prevent all residents, families, and visitors from reviewing facility direct care staffing hours worked. Facility census was 85. Findings are: Observation on Monday 5/20/19 at 8:00 a.m. revealed the Direct Care Staffing Hours form was posted on the 100 wing bulletin board. Further examination of the document revealed the staffing hours posted were for Friday 5/17/19. Interview with the facility Administrator and Director of Nursing on 5/20/19 at 8:20 a.m. verified the bulliten board at the front entry was the area the facility posts its daily staffing hours. The Administrator and Director of Nursing verified the form posted on the bulliten board was dated 5/17/19 and the hours worked by direct care staff had not been posted since Friday 5/17/19.",2020-09-01
857,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,745,D,1,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04E3 Based on record reviews and interviews, the facility failed to provide social services support in assisting one sampled resident (Resident 89) with cognitive impairments to ensure the resident had a valid established POA (Power of Attorney) or guardianship during the resident's stay at the facility. Facility census was 85. Sample size was 24 current residents and 3 closed records. Findings are: [NAME] Record review of an Admission Record for Resident 89 printed on 5/8/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review Resident 89's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and track resident admissions/discharges) records revealed an Admitting MDS was completed on 4/19/18 and quarterly (every 90 day assessments) were completed with the last assessment completed on 1/14/19. On 1/29/19 a discharge to an acute care hospital MDS was completed. Review of the records showed the resident was unable to complete a BIMS (Brief Interview of Mental Status) exam testing memory recall throughout the resident's stay due to the severity of the resident's cognition. The assessments also recorded the resident was diagnosed with [REDACTED]. An admitting History and Physical form signed by the physician on 4/13/18 diagnosed Resident 89 with Dementia and recorded the resident's rehabilitation potential listed as poor. The physician documentated the patient was not informed of the medical condition due to Dementia. Record review of Resident 89's closed medical record revealed decision making forms (including Resuscitation Orders) and legal admission documents were signed by the resident's sibling (Sibling-A). Review of the closed record revealed no documents indicating the resident had a valid Power of Attorney or Guardianship in place at the time of admission and during the resident's stay at the facility from 4/13/18 until the resident discharged on [DATE]. Record review of electronic Progress Notes revealed the following entries: 4/13/19 at 1:44 p.m. an Admission Summary Note text documented the resident arrived at the facility with (Sibling-A) via private vehicle at approximately 11:30 a.m. The note recorded (Sibling-A) spoke with admissions and social services regarding acquiring PO[NAME] - 4/13/18- The SSD (Social Services Director) recorded: Resident 89's family member, Sibling-A, was in the office discussing the resident's financial accounts. The note documented the resident had no guardian or POA to look over the resident's affairs. 4/13/18 at 11:46 p.m. the nursing note text recorded the resident was alert with confusion. Resident wandering through halls, confused, looking for parents . -8/10/18 entry recorded the SSD contacted the state Ombudsman in regards to the resident's advanced directive (signed by Sibling-A). Ombudsman voiced that if the resident was trying to leave the facility, the facility could have a guardian or conservator and be court appointed if resident putting self in danger, however it would cost a fee for the lawyer to draw up the petition. Other options would be to seek out a business that would help with guardianship/conservatorship (names of businesses provided). - 9/17/18- entry recorded the SSD met with a lawyer to help resident and family file a petition for guardianship. - 10/1/18- entry recorded the SSD met with lawyer and cost of guardianship would be $1000-1500. Notified Sibling-A of cost and Sibling-A indicated will talk to private lawyer. Sibling-A indicated the family did not have funds to pay for a guardianship and will be in touch after talking to their lawyer. - 10/24/18 the SSD recorded that Resident 89's Sibling-B stopped by the office to discuss the resident's financial accounts. Sibling-B voiced being worried the resident has no guardian/POA to look over the resident's accounts and financial well-being. There was no further documentation in Resident 89's closed record indicating anything else had been done regarding guardianship or POA being pursued for the resident. Record review of a certified mail correspondence from the General Counsel attorney for a local Behavioral Health acute care unit to the facility dated 2/14/19 revealed Resident 89 had been admitted to the acute unit for short-term care. Further review of the document revealed the facility had denied re-entry following hospital stabilization of the resident's condition. The document also recorded In the course of admission to the Behavioral Health Unit, it was also determined that the patient was a resident at (the facility) without a Power of Attorney or Guardian. Interviews with the hospital's General Counsel attorney were conducted in person on 5/21/19 at 1:05 p.m. and by phone on 5/22/19 at 11:00 a.m. The attorney verified Resident 89 was sent to the hospital for acute care treatment in the hospital's Behavioral Health Unit. The attorney verified upon arrival there was no valid Power of Attorney or Guardianship in place for the resident who had significant cognitive memory impairments and a [DIAGNOSES REDACTED]. The hospital also had to file petitions for a temporary guardianship for the resident and this led to a permanent guardian being established by the court. The resident remained in acute care after stabilization in (MONTH) until 4/22/19 when placement could be found at a facility in Colorado. Interviews with the SSD on 5/21/19 at 4:50 p.m. and again on 5/22/19 at 10:45 a.m. revealed Resident 89 was living at home with a spouse prior to admission at the faciliy. Both had memory issues with Resident 89's cognitive state highly impaired along with a [DIAGNOSES REDACTED]. The SSD verified the resident had no valid POA or guardian appointed at the time of admission or throughout the resident's stay. The SSD verified Sibling-A signed all the admitting paperwork. Sibling-A pursued POA or guardianship and was told it would cost $1000-$1500 dollars to obtain and Sibling-A stated the family didn't have the funds. The SSD verified the resident was receiving social security checks but they were going to a step-child and attempts to contact the step-child were not received. The SSD contacted the state Ombudsman who recommended the facility look into private business to obtain guardianship and gave some examples of places. The SSD verified the facility had not pursued the options suggested by the Ombudsman. The SSD verified the resident remained in the facility from 4/18/18 until 1/29/19 with no valid guardian or POA to attend care plan meetings, sign legal documents pertaining to the resident's stay, or make informed decisions for the incapacitated resident regarding care and treatment or medical decisions during the resident's stay at the facility. Interview with the facility Administrator on 5/21/19 at 11:30 a.m. confirmed Resident 89 was a resident at the facility residing in a special care unit for Alzheimer's care from 4/13/18 until 1/29/19. The Administrator produced a form entitled General Durable Power of Attorney signed on 4/17/18 (not included in the resident's closed medical record). The form authorized Resident 89's step-child as the POA but was not signed by the resident or authorized by a court of law. There was also no witness of the signatures on the form. The Administrator agreed the form was not a legal authorization and that the severely cognitive impaired resident had no POA or guardian while residing at the facility, nor did the facility provide services to assist the family in utilizing resident funds from social security payments or explore other avenues suggested by the state Ombudsman to ensure a POA or guardian was obtained. The Administrator confiremd there was no POA or guardian to oversee the interests and care and treatment of [REDACTED].",2020-09-01
858,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,757,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) medications were reviewed to determine potential adverse side effects related to symptoms of increased lethargy or sleepiness, blood pressure was monitored with routine use of medication administered for high blood pressure and symptoms of depression were monitored with the use of an antidepressant medication for one current sampled resident (Resident 41) and 2) blood sugars were monitored as directed with the administration of insulin agents for one current sampled resident (Resident 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Observations of Resident 41 on 05/20/19 at 9:45 AM revealed the resident seated in wheelchair in hallway by the nurses station with eyes closed and leaning heavily to the left in chair. Further observations revealed at 11:40 AM the resident was seated in recliner in room with eyes closed and at 1:45 PM was resting on the bed with eyes closed. Observations on 5/21/19 at 7:00 AM and 9:15 AM revealed the resident seated in wheelchair in the hallway with eyes closed. At 10:15 AM the resident was on the bed with eyes closed. At 11:45 AM the resident was seated in the wheelchair in the dining room with eyes closed until wakened for the meal. Observations at 1:20 PM revealed the resident in bed with eyes closed. Observations on 5/22/19 at 8:00 AM revealed the resident seated in the dining room in the wheelchair leaning heavily to the left side with eyes closed until wakened for breakfast at 8:30 AM. Review of the MAR (Medication Administration Record), for (MONTH) 2019, revealed orders,dated 2/8/19, for [MEDICATION NAME] (Antidepressant) every day for Mood Disorder and [MEDICATION NAME] (Antihypertensive) every day for High Blood Pressure. Further review revealed no documentation that targeted symptoms of depression were identified or routinely monitored or blood pressures were routinely monitored. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the resident seemed to be more sleepy and medications were not reviewed for the potential cause and possible need for adjustments. Further interview confirmed that symptoms of depression were not identified or routinely monitored related to the routine use of an antidepressant medication. The DON confirmed that there were no blood pressure readings documented this month related to the routine use of high blood pressure medication. Further interview confirmed that targeted symptoms of depression should be monitored routinely and blood pressure readings should be obtained at least weekly to ensure the therapeutic benefits of the medications. B. Review of Resident 48's MAR, dated (MONTH) 2019, revealed that the resident received routine [MEDICATION NAME] and sliding scale doses of Humalog insulin. Further review revealed no blood sugar checks as scheduled on on 5/1/19 and 5/2/19 at 11:30 AM and 5:30 PM. Interview with the DON on 5/23/19 at 10:20 AM confirmed that the blood sugars were to be obtained and documented as scheduled to ensure that the resident's diabetes was managed to meet the resident's needs.",2020-09-01
859,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,761,D,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12E1 Based on observation, interviews, and record review, the facility failed to securely store medication for one sampled resident (Resident 83). Facility census was 85. Sample size was 24. Findings are: On 5/20/19 at 10:01 AM during an initial inspection of the bathroom in room [ROOM NUMBER], TUMS (medication containing calcium which can be used to treat heart burn, upset stomach, or low calcium levels) and rubbing alcohol (a topical antiseptic) were observed on the bottom shelf of an open bathroom cabinet next to the sink. Resident 83 who resided in room [ROOM NUMBER] verified ownership and use of all the containers stored in the bathroom. On 5/23/19 at 7:40 AM while Resident 83 was at breakfast, observation of the bathroom in room [ROOM NUMBER] revealed TUMS and rubbing alcohol remained in the open cabinet as seen previously. On 5/28/19 at 7:55 AM, TUMS and rubbing alcohol remained on the bottom shelf in the bathroom cabinet in room [ROOM NUMBER]. Review of Resident 83's Order Summary Report did not reveal an order from a physician that would permit the resident to keep medications in the bathroom or to use medications without direct supervision. No record of an assessment for safe self-administration of medications could be found for Resident 83. On 5/28/19 at 9:43 AM, the facility's ADON (Assistant Director of Nursing) observed and verified that TUMS and rubbing alcohol were being stored in Resident 83's bathroom. The ADON also verified that Resident 83 did not have a physician's orders [REDACTED]. In addition, the ADON verified that room [ROOM NUMBER] was located in a locked unit which housed residents with dementia including at least one resident (Resident 29) who was known to wander into other residents' rooms.",2020-09-01
860,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,812,F,0,1,3V0011,"License Reference Number: 175 NAC 12- E Based on observations and interviews the facility failed to ensure dishes consisting of plates, bowls and cups were stored serving side down in order to prevent cross contamination. This had the potential to affect all residents. facility census was 85. Findings Are: Kitchen observation on 5/20/19 at 8:15 a.m. Identified dishes consisting of bowls plates and cups stored right side up instead of upside down on the kitchen shelves located above the counter top on the right side of the window in the main kitchen. Kitchen observation on 5/21/19 at 11:36 a.m. Identified dishes consisting of bowls plates and cups stored right side up instead of upside down on the kitchen shelves located above the counter top on the right side of the window in the main kitchen. Kitchen Observation on 5/22/19 at 7:15 a.m. Identified dishes consisting of bowls plates and cups stored right side up instead of upside down on the kitchen shelves located above the counter top on the right side of the window in the main kitchen. Staff interview on 5/22/19 at 4:29 p.m. Dietary Manager confirmed the dishes located on the shelf above the counter top on the right side of the window in the main kitchen were turned right side up instead of upside down in order to prevent cross contamination. Dietary Manager reported this would be addressed immediately. Staff interview on 5/22/19 at 4:30 p.m. Administrator and Director of Nursing Verified the dishes on the shelves were not turned upside down and were exposed to dirt and debris, which could cause cross contamination. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service santitation practices, revealed the following: 4-9-4.13 Present Tableware (A) Exept as specified in (B) of this sectin, TABLEWARE that is present shall be protected from contamination by being wrapped, covered or inverted.",2020-09-01
861,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,867,G,0,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].07 Based on observations, record reviews, and interviews, the facility Quality Assurance Program failed to identify, correct, and maintain regulatory required compliance resulting in multiple citations and repeat areas of non-compliance from prior surveys. Facility census was 89. Sample size included 24 current residents and three closed records. Findings are: Record review of the facility QAPI (Quality Assurance Program) plan developed on [DATE] revealed the purpose of the committee was to educate, support and encourage staff to increase their skills to provide quality care to all residents. To provide residents with a comfortable environment where they are involved in, and have a voice in, the daily activities of their home. The committee's plan is to review all data sources and other available data to identify, prioritize, and correct issues with performance. The QAPI committee will evaluate the effectiveness of actions taken for further recommendation. Observations, record reviews, and interviews during the survey processes from surveys conducted on [DATE] and the current survey from [DATE] through [DATE] revealed the following areas of repeated non-compliance: F578- ensuring facility staff had valid CPR (Cardiopulmonary Resuscitation) certifications. F583- providing privacy with resident personal cares. F622- documentation regarding discharges from the facility. F684- providing assessments and care for residents with skin abnormalities. F689- ensuring staff were performing safe transfer techniques preventing accidents with injury. F726- competency of staff. F732- posting staffing information daily. F757- ensuring medications were being monitored to rule out unnecessary medications. F880- infection control The current survey also identified patterns in five additional areas of non-compliance: F576- mail delivery on Saturdays. F584- environmental issues. F623- notice provision in writing for facility-initiated transfers and discharge. F625- written notice of bedhold policies when residents are transferred to the hospital. F725- provision of staffing to meet the needs of the residents. Failures at the following tasks resulted in negative outcomes: F626- facility denial of re-admission to Resident 89 following hospitalization . The failure resulted in a prolonged stay in an acute setting after the resident's condition was stabilized. F684- facility failed to assess and monitor Resident 41's bruising condition resulting in hospitalization for an adverse effect of medication. F686- facility failed to provide care and treatment to prevent the development and/or healing of pressure sores for Residents 42 and 48 F689- facility failed to ensure safety measures in place during bathing resulting in hospitalization and surgery for [REDACTED]. Interview with the Administrator on [DATE] at 10:39 a.m. discussed and confirmed the repeated areas of deficiency and current survey findings.",2020-09-01
862,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,880,E,0,1,3V0011,"Licensure Reference Number 175 NAC 12-006.17 B 175 NAC 12-006.17D Based on observations, record reviews and interviews; the facility failed to ensure that 1) the East 200 wing whirlpool bath was cleaned as directed after use to reduce the risk of cross contamination for nine residents who routinely use that whirlpool for bathing (Residents 70, 51, 50, 69, 66, 38, 54, 68 and 84) and 2) disposable gloves were changed and hand washing was performed when disposable gloves were removed during dressing changes for two current sampled residents (Residents 42 and 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Observations on 5/20/19 at 2:30 PM revealed MA (Medication Aide) - N cleaned the whirlpool tub. MA - N turned the water on as hot as it would go until the hot water shut off, filled the tub about half full, poured about a cup of full strength disinfectant (Classic Whirlpool Disinfectant Cleaner) into the tub and cleaned the inside of the tub with a brush. MA - N stated would turn the whirlpool jets on and let it run for about 15 minutes and then come back and rinse the tub. Review of the Classic Whirlpool Disinfectant Cleaner directions for use revealed the following including: For Cleaning Bath and Therapy Equipment: After using the whirlpool unit, drain the water and refill with fresh water to just cover the intake valve. Add 2 ounces of Classic Whirlpool Disinfectant Cleaner to one gallon of water into the unit at this point. Briefly start the pump to circulate the solutions. Turn off the pump. Wash down the unit sides, seat of the chair/lift and any/all related equipment with a clean swab or sponge. After the unit has been thoroughly cleaned, drain solutions from the unit and rinse any/all cleaned surfaces with fresh water. The unit is ready for re-use. Interview with LPN (Licensed Practical Nurse) - L, 200 Wing Unit Coordinator, on 5/22/19 at 1:30 PM revealed that Residents 70, 51, 50, 69, 66, 38, 54, 68, and 84 routinely bathed in the 200 East whirlpool. Review of the facility procedure Cleaning and Disinfecting Tubs, Whirlpools, dated 5/1/10, revealed the following including: Procedure: 1. Specialty Bathing Systems: - Ensure that a current copy of the manufacturer's procedures for cleaning and disinfecting each special bathing system is posted in the room where the system is located. - Follow the manufacturer's procedures for cleaning special bathing systems. - Pay particular attention to the following items/areas: a. Tub edges where the sidewall meets the floor. b. The drain, turbine assembly tubes, and the thermometer. - If the whirlpool tank has a stretcher or chair lift that is place in the whirlpool, be sure to spray and scrub the stretcher/chair lift at the same time as the whirlpool. - Rinse the entire whirlpool tank to drain and air dry. - Ensure that spray hoses or inlet hoses are drained completely after use to avoid pooling and bacteria growth. Interview with LPN - V, Infection Control Nurse, on 5/23/19 at 8:15 AM confirmed that the staff were to follow the whirlpool bath cleaning procedures to reduce the risk of cross contamination. B. Observations of the dressing change for Resident 42 on 5/20/19 at 2:50 PM revealed LPN - L donned disposable gloves, removed the soiled dressing from the resident's coccyx area, removed the disposable gloves, donned new gloves (with no hand washing), cleansed the wound with saline, wiped the area with gauze and applied skin prep to the surrounding skin. Further observations revealed LPN - N removed disposable gloves and donned clean gloves (with no hand washing) and applied a honey fiber dressing to the wound bed, covered the wound with a dressing and removed the gloves. C. Observations of the dressing changes for Resident 48 on 5/22/19 at 3:15 PM revealed RN (Registered Nurse) - M, Charge Nurse, applied disposable gloves, removed the dressing from the left hip area (did not change gloves or perform hand washing), cleansed the wound with saline, applied skin prep to the surrounding skin, applied a Collogen dressing to the wound and covered the wound with a foam dressing, removed the disposable gloves and donned new gloves (with no hand washing). Further observations revealed RN - M assisted the resident to reposition on the other side, removed the dressing from the right hip area ( did not change gloves or perform hand washing), cleaned the wound with saline, applied skin prep to the surrounding skin, applied Collogen to the wound bed, applied the cover dressing (did not remove gloves or perform hand washing), opened dresser drawers and closet to get a clean disposable brief, removed the disposable gloves and left the room to get some cream to finish the treatment. Review of the facility procedure Pressure Ulcers, dated 5/1/10, revealed the following including: Procedure 1. Wear gloves for anticipated contact with blood, secretions, mucous membranes, non intact skin, and moist body substances for all residents. 2. Change gloves and wash hands before treating another resident. 9. Wash hands before contact with clean dressings or dressing supplies. 11. Once hands are soiled with wound secretions, remove gloves and discard properly; wash hands before touching the remaining clean dressings or other supplies. Interview with the Director of Nursing on 5/23/19 at 8:30 AM revealed that the staff were to follow procedures for dressing changes, including removing gloves after soiled dressings were removed and hand washing between glove use to reduce the risk of cross contamination.",2020-09-01
863,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-05-28,919,E,1,1,3V0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-007.04G Based on observation and interview, the facility failed to ensure the call monitoring system was functioning and answered to the resident satisfaction. Findings are: [NAME] On 5/23/2019 at 9:01 AM a review of the grievance/complaint log dated (MONTH) 2019 revealed a complaint call light not working in bathroom on 200 hall. In room [ROOM NUMBER] the resident was taken to the bathroom and left there for 2 hours in the bathroom. On 5/23/2019 at 9:01 AM a review of the grievance/complaint log dated (MONTH) 2019 revealed the resident in 108 complaint the staff did not empty the commode for over 30 minutes. The call light would be answered and the staff would not return for over 30 minutes. During the Resident Council Meeting on 5/21/2019, held by a surveyor, revealed residents complained call lights were turned off and the issue not addressed. Eight Residents attended the resident council meeting. Interview with MA-E (Medication Aide), MA-O and NA-P (Nurse Aide) on 5/23/2019 at various times revealed the expectation was to answer the call light as soon as possible like in a minute. Meet the residents needs. If a nurse does not answer the call light the individual was to do what they can and if they can not meet the residents needs leave the light on for a nursing person to answer the call light. Interview with the Administrator on 5/23/2019 at 10:12 AM revealed the expectation was for the call lights to be answered in less that 5 minutes. If the census goes up then the employee ration goes up. The facility had no call light monitoring system.",2020-09-01
864,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,561,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (4) Based on interviews and record review, the facility failed to ensure one sampled resident (Resident 20) received bathing assistance as requested. Sample size was 26 current residents. Facility census was 93. Findings are: Record review of Resident 20's Admission Record revealed the resident was admitted to the facility on [DATE]. Interview with Resident 20 on 7/3/18 at 9:07 a.m. revealed the resident expressed a concern about not receiving her baths as requested. The resident explained a preference of receiving evening baths on Tuesday evenings and stated this was not always occurring. Record review of Resident 20's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed the resident required Total Dependence on staff for bathing. Record review of Resident 20's bathing record forms for (MONTH) and (MONTH) revealed the resident had received bed baths on 6/5/18 and 6/19/18 and no recorded baths in July. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 7/10/18 at 2:13 PM confirmed Resident 20 had no recorded baths for the month of (MONTH) (YEAR) and only two baths recorded in June.",2020-09-01
865,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,578,E,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to: 1) ensure one sampled resident (Resident 5) Advanced Directive was not contradictory in the resident's medical record: and 2) ensure CPR (Cardiopulmonary Resuscitation) certifications were current for 3 licensed nurses providing direct care to residents. This failure could potentially affect 17 residents (Residents 9, 12, 15, 37, 40, 46, 50, 52, 58, 59, 60, 67, 76, 85, 87, 89, and 196). requesting CPR in the event of [MEDICAL CONDITION]. Facility census was 93. Findings are: [NAME] Record review of Resident 5's Admission Record printed on [DATE] revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed under the section entitled Advance Directive revealed the resident was a Full Code (requesting CPR in the event of a cardiac stoppage). Record review of Resident 5's Resuscitation Orders form on the resident's chart revealed the resident had signed the document on [DATE] requesting in the event of cardiac and/or respiratory arrest, NO cardiopulmonary resuscitation (NO CPR) will be initiated . The resident's physician signed the form agreeing with the No CPR request by the resident per pt (patient) wishes on [DATE]. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on [DATE] at 9:32 a.m. confirmed Resident 5's Admission Record and electronic record indicated the resident was a full code while the Resuscitation Orders document signed by the resident and resident's physician ordered that no CPR be initiated in the event of cardiac stoppage. B. Record review of employee files for three sampled licensed nurses providing direct care for residents revealed the following: - Employee file for LPN (Licensed Practical Nurse)-G revealed the staff member's Basic Life Support (CPR skills) expired on (MONTH) of (YEAR). - Employee file for RN (Registered Nurse)-H revealed the staff member's Basic Life Support skills expired on (MONTH) of (YEAR). - Employee file for LPN-I revealed there was no evidence the employee had received and completed a Basic Life Support course. Record review of an Order Listing Report printed on [DATE] listed 17 current facility residents requesting Full Code Status. Included in the document were Residents 9, 12, 15, 37, 40, 46, 50, 52, 58, 59, 60, 67, 76, 85, 87, 89, and 196. Interview with the DON and ADON on [DATE] at 2:13 p.m. confirmed 17 current residents (Residents 9, 12, 15, 37, 40, 46, 50, 52, 58, 59, 60, 67, 76, 85, 87, 89, and 196) requested full code status with regard to CPR initiation in the event of [MEDICAL CONDITION]. The DON and ADON confirmed LPN-G, RN-H, and LPN-I all worked in direct care areas providing care to residents and that LPN-G and RN-H CPR verification courses had expired. The ADON verified LPN-I's CPR verification was not found.",2020-09-01
866,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,583,D,0,1,PRIL11,"Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations and interview, the facility failed to ensure privacy during a medical procedure for one current sampled resident (Resident 88.) The facility census was 93 with 26 current sampled residents. Findings are: Observations on 7/10/18 at 7:50 AM revealed Resident 88 seated in a wheelchair in the hallway across from the dining room. Further observations revealed Laboratory Technician - A obtained a blood sample from the resident's arm while in the hallway. Interview on 7/10/18 at 7:55 AM with LPN (Licensed Practical Nurse) - B, Unit Coordinator, confirmed that medical procedures were to be done in a private area to ensure the resident's privacy.",2020-09-01
867,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,584,E,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18B Based on observations and interviews, the facility failed to ensure that 1) stained bathroom flooring was cleaned or replaced for room [ROOM NUMBER] (Residents 83 and 32) and room [ROOM NUMBER] (Residents 71 and 24), 2) a sink drain [MEDICATION NAME] was in place for the bathroom sink in room [ROOM NUMBER], 3) the caulking in the bathroom sink for room [ROOM NUMBER] (Resident 87) was repaired, 4) a worn toilet seat was replaced in room [ROOM NUMBER] (Resident 20), 6) marred flooring and stained carpets on the 100 wing were repaired and cleaned, 5) a window was not repaired in room [ROOM NUMBER] (Resident 11), 6) the bathroom wall was not repaired in room [ROOM NUMBER] (Resident 93), 7) marked, marred tile flooring in room [ROOM NUMBER] A (Resident 5); 8) stained carpets and marred wood flooring were not repaired or cleaned on the 100, 300 and 400 hallways wings and 9) damaged ceilings were not repaired on the 200 and 300 wing hallways. The facility census was 93 with 19 residents residing on the 100 wing and 47 residents on the 200 and 300 wings. Findings are: [NAME] Observations of the bathroom flooring in room [ROOM NUMBER] (Residents 83 and 32) and room [ROOM NUMBER] (Residents 22 and 23) on 7/2/18 at 2:30 PM and on 7/10/18 at 8:45 AM revealed stained and damaged flooring. B. Observations of the bathroom sink in room [ROOM NUMBER] (Residents 71 and 24) on 7/2/18 at 2:30 PM and on 7/10/18 at 8:45 AM revealed no sink [MEDICATION NAME] at the drain. C. Observations of the bathroom sink in room [ROOM NUMBER] (Resident 87) on 7/2/18 at 2:30 PM and on 7/10/18 at 8:45 AM revealed cracked and stained caulking on the edge by the wall. Interview with the Maintenance Supervisor on 7/10/18 at 8:45 AM confirmed that the bathroom flooring in room [ROOM NUMBER] and 507 needed cleaned, repaired or replaced. Further interview confirmed that the bathroom sink in room [ROOM NUMBER] needed a drain [MEDICATION NAME], the bathroom sink in room [ROOM NUMBER] needed to be replaced. D. Observations of room [ROOM NUMBER]'s (Resident 20's) bathroom on 7/3; 7/5; and 7/9/18 revealed the resident's toilet seat was damaged and the finish worn off the edge of the seat and underneath the seat exposing the underlying surfaces. E. Observations of hallways on the 100 unit on 7/3; 7/5; 7/9/18 revealed the laminate wood flooring on the west side of the unit was marred leaving tracks of wheels from resident wheelchairs and facility equipment marring the finish. Further observations of the 100 unit carpet outside the Director of Nursing office revealed a circular discolored stain in the carpet. F. Observations in room [ROOM NUMBER]-A on 7/3; 7/5; 7/9; and 7/10/18 on the side occupied by Resident 5 revealed the tile flooring was marred with linear brown discolorations and dark marks from the resident's wheelchair and facility equipment. Interview with the facility Administrator on 7/9/18 at 6:20 p.m. reviewed the findings of the 100 unit's marred laminate hallway flooring and dark discolored circular stain in the carpet; the bathroom toilet seat damage in bathroom in room [ROOM NUMBER] (Resident 20's); and tile floor mars in room [ROOM NUMBER]-A (Resident 5's). The Administrator acknowledged that prior to the facility going into receivership, the facility was having difficulties getting equipment for proper cleaning of the facility and had been working on environmental issues since. The Administrator acknowledged environmental issues had not been completely resolved since that time. [NAME] Observation on 07/02/18 at 11:20 a.m. Resident 11 room [ROOM NUMBER]-A window was broken and was covered with a fiber board and duct tape. Resident 11's room [ROOM NUMBER]-A bed was covered with food items, video discs, clothing, papers, books and there were 4 boxes of items on the floor stacked between the resident bed and cabinet where the TV was sitting. Observation on 07/10/18 9:40 a.m. Resident 11 room [ROOM NUMBER]-A window was broken and was covered with card board fiber board and duct tape. Resident 11's room [ROOM NUMBER]-A bed was covered with food items, video discs, clothing, papers, books and there were 4 boxes of items on the floor stacked between the resident bed and cabinet where the TV was sitting. H. Observation on 07/02/18 3:03 p.m. Resident 93 room [ROOM NUMBER]-A wall in the bathroom was damaged and sheet rock was exposed and damaged. Observation on 07/10/18 at 9:45 a.m. Resident 93 room [ROOM NUMBER]-A wall in the bathroom was damaged and sheet rock was exposed and damaged. Observation on 07/09/18 at 9:19 a.m. 200 hall and 300 hall flooring was stained throughout the hall ways and tile had deep grooves in it and carpets were stained. Observation on 07/09/18 at 9:19 a.m. 200 hall and 300 hall flooring was stained throughout the hall ways and tile had deep grooves in it and carpets were stained. Observation on 07/10/18 at 7:55 a.m. 200 hall and 300 hall flooring was stained throughout the hall ways and tile had deep grooves in it and carpets were stained. Observation on 07/09/18 at 9:19 a.m. 200 hall and 300 hall flooring was stained throughout the hall ways and tile had deep grooves in it and carpets were stained. Staff interview on 07/10/18 at 9:35 a.m. with the Administrator verified the floors on 200 hall and 300 hall were stained and required cleaning. The Administrator also verified the damage to the ceilings on the 200 hall and 300 hall as stucco that was chipping and falling off and how the sheet rock was damaged and cracked around vents and on the seams. Staff interview on 07/10/18 at 9:47 a.m. with the Administrator verified the window in room [ROOM NUMBER]-A was broken and covered with duct tape and some form of cardboard. The Administrator also verified the damage to the wall in the bathroom located in room [ROOM NUMBER]-[NAME] [NAME] Observation on 07/02/18 at 11:43 a.m. of the East dining room lights above the serving window and lights above the door entering the kitchen had dead insects and debris in them. Observation on 07/03/18 at 7:05 a.m. of the East dining room lights above the serving window and lights above the door entering the kitchen had dead insects and debris in them. Observation on 07/05/18 at 6:08 a.m. of the East dining room lights above the serving window and lights above the door entering the kitchen had dead insects and debris in them. Staff interview on 07/10/18 at 8:35 a.m. with the Administrator and Dietary Manager verified there were dead insects and debris in the lights above the serving window and the door way entrance to the kitchen. K. Observation on 07/03/18 at 7:05 a.m. of the East dining room floors were un-swept, un-mopped and covered with food particles that were left over from the evening meal and floors were dirty during resident breakfast time. Floors in the east dining room were also stained and tile was marked up. Observation on 07/05/18 at 6:08 a.m. of the East dining room floors were un-swept, un-mopped and covered with food particles that were left over from the evening meal and floors were dirty during resident breakfast time. Floors in the east dining room were also stained and tile was marked up. Staff interview on 07/10/18 at 8:35 a.m. with the Administrator and Dietary Manager verified the East Dining room floors had not been cleaned the night before and floors were dirty the next morning for Resident breakfast time. L. Observation on 07/05/18 at 6:08 a.m. there were flies and millers/moths flying in the East Dining Room. Observation on 07/09/18 at 12:15 p.m. revealed that Resident 29 who had been sitting at table 1 was swatting at the flies with their hands while trying to eat the evening meal in the east dining room. Staff Interview on 07/10/18 at 9:07 a.m. with the Administrator and Dietary Manager verified there were flies and millers/moths flying in the east dining room.",2020-09-01
868,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,622,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.16B Based on record review and interviews, the facility failed to provide documentation of the reason for the discharge for Resident 94. Sample size was 26 current residents. Facility census was 93. Findings are: Record Review on 07/09/18 at 10:19 a.m. of Resident 94's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-26-18 showed an admission date of [DATE]. Record Review on 07/09/18 at 10:19 a.m. Identified there was no documentation in the progress notes identifying why Resident 94 was discharged or where Resident 94 was discharged too. Record Review on 07/09/18 at 10:19 a.m. identified there was no documentation in the Care Plan of Resident 94 discharge. Record Review on 07/09/18 at 10:19 a.m. identified there were no physician orders identifying Resident 94's discharge. Staff Interview on 07/10/18 with the Administrator and DON (Director of Nursing) verified the clinical record for Resident 94 was not complete and there had been a lack of documentation on the discharge for Resident 94.",2020-09-01
869,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,636,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09B Based on observations, record reviews, and interviews, the facility failed to: 1) identify a PASRR (Pre-Admission Screening and Resident Review, an assessment to determine if Mental Disorders are candidates for placement) 2 evaluation on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment for one sampled resident (86); and 2) ensure residents identified as receiving Restorative Nursing programs met the required components for inclusion in the MDS for 2 sampled residents (Residents 20 and 64). Sample size include 26 current residents. Facility census was 93. Findings are: [NAME] Record review of Resident 86's Admission Record printed on 7/4/18 revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed the resident had a medical [DIAGNOSES REDACTED]. Record review of Resident 86's MDS assessments revealed the resident had an Admission MDS completed on 4/17/18. Review of this assessment revealed in the Identification Information section of the assessment for coding PASRR information revealed in the question for whether or not the resident had received a PASRR 2 evaluation, the facility recorded No. Record review of Resident 86's chart revealed the resident's PASRR screening forms were received by fax at the facility on 4/9/18 revealed the resident from the level 1 screening on 4/4/18 the resident was referred for a level 2 evaluation for mental illness due to a [DIAGNOSES REDACTED]. Interview with the MDS Coordinator, LPN (Licensed Practical Nurse)-C on 7/5/18 at 11:14 a.m. confirmed Resident 86 had an admission assessment MDS completed on 4/17/18 and the PASRR 2 evaluation completed on 4/6/18 was not identified on the admission MDS. Source: Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (an instructional manual on how to code MDS assessment items) Version 1/14 (MONTH) (YEAR). For Preadmission Screening and Resident Review items the manual instructs to Review the PASRR report provided by the state if Level 2 screening was required and Code 1, yes if PASRR Level 2 screening determined that the resident has a serious mental illness . B. Record review of Resident 20's Admission Record printed on 7/4/18 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 20's MDS assessments revealed a Quarterly review assessment was completed on 4/20/18. Review of the assessment revealed under the Special Treatments and Programs section that the resident received a restorative nursing program on 6 days for Range of Motion (ability to move joints) and Eating and/or swallowing. Observations of Resident 20 at meal services in the dining room on 7/3/18 at noon, 7/5/18 at breakfast and noon, 7/9/18 at noon and supper meals revealed the resident was seated at a dining room table in the resident's motorized wheelchair. Trays were delivered to the resident and staff cut up bread items at the resident's request. Resident fed self during the meals without assistance or any activity to improve self performance. Observations of Resident 20's Restorative program on 7/9/18 beginning at 9:55 a.m. and continuing until 10:25 a.m. revealed RA (Restorative Aide)-J performed passive range of motion to the resident's toes, ankles, knees, hips, hands, elbows, and shoulders. There was no activity performed related to the resident's dining skills. Interview with RA-J on 7/10/18 at 11:02 a.m. confirmed Resident 20 receives passive range of motion to the toes, ankles, knees, hips, hands, elbows, and shoulders for the resident's restorative range of motion program. When questioned on the resident's eating swallowing program, RA-J stated the restorative staff monitor the resident's ability to feed self but do not perform any activities or tasks related to this. Record review of Resident 20's Care Plan with the Last Care Plan Review Completed date recorded as 5/4/18. The care plan identified a Restorative Program Focus problem identifying the resident at risk for decline in ROM (Range of Motion) and ADL's (Activities of Daily Living, ability to perform daily tasks) . Further review of the care plan revealed goals for the problem listed as To maintain the ability to feed self after set up assist and To Have no further decline in Range of Motion. Interventions to meet the goals documented: Encourage and Praise all efforts, Restorative Eating/swallowing program, and Restorative Passive Range of Motion. The care plan had not identified what activities or tasks were included in the eating/swallowing program nor the passive range of motion program. Record review of Resident 20's medical record restorative nursing documents revealed the following documents: - (MONTH) (YEAR) Documentation Survey Report v2 form (Documenting resident restorative program) dated 7/9/18 revealed the resident received an Eating/Swallowing program 9 of 9 days for 15 minutes each day; and Passive Range of Motion to upper and lower extremities 8 of 9 days for 15 minutes each day. The form did not specify exact activities performed for these programs. - Request for periodic licensed nurse assessments or documentation of Resident 20's Restorative program revealed no assessments by a licensed nurse were completed. After request of the documentation a Restorative Monthly Review or Discharge Summary form was completed by LPN-K, the Restorative Coordinator. The form dated 7/9/18 recorded (MONTH) Note: (the resident) Participated 25 times in PROM program and refused 1 time. Participated 26 times in Eating/swallowing Program. Visited with resident about moving to the Assistance table for more assistance. Resident doesn't want to move at this time. Will Re-Evaluate for needing assistance table and continue program. Interview with LPN-K on 7/10/18 at 11:30 a.m. included discussion in Resident 20's restorative program with review of required MDS instructions for coding. LPN-K verified there was no periodic documentation by a licensed nurse regarding the resident's restorative program until requested on 7/9/18. LPN-K verified no measurements of Resident 20's limitations in Range of Motion were done and could not explain how the facility could identify changes in Range of Motion to determine if the resident maintained Range of Motion as per the care plan goal. LPN-K described Resident 20's eating/swallowing program consisted of monitoring the resident to determine if the resident continued to feed self independently. LPN-K could not explain any activities provided by the restorative staff related to maintaining this ability. LPN-K verified the resident Range of Motion program was not specific in identifying what joints were to be worked with or how many repetitions the resident required or accepted during treatment. After review of the MDS manual requirements, LPN-K verified the requirements to code the Restorative section of the MDS had not been met in order to include the restorative program in the MDS. Source: Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (an instructional manual on how to code MDS assessment items) Version 1/14 (MONTH) (YEAR). With regard to Restorative Nursing Programs the manual instructs staff that The following criteria for restorative nursing programs must be met in order to code (a restorative program in the MDS) These criteria included: Measurable objective and interventions must be documented in the care plan and in the medical record . Evidence of periodic evaluation by the licensed nurse must be present in the medical record . In addition when coding Range of Motion (Passive) Activities the manual instructs These exercises must be individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. For coding of Eating and or Swallowing the instructions were to Code activities provided to improve or maintain the resident's self performance in feeding oneself food and fluids, or activities used to improve or maintain the resident's ability to ingest nutrition and hydration by mouth. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. C. Record review of Resident 64's Admission Record printed on 7-4-18 revealed the resident was admitted to the facility on [DATE]. Further review of the document revealed the resident had a medical [DIAGNOSES REDACTED]. Record review of Resident 64's MDS assessments revealed a Quarterly Assessment completed on 5-23-18. Review of the assessment revealed under the Special Treatments and Programs section that the resident received a restorative nursing program on 7 days for Range of Motion (Active) and Training and skill practice in Bed Mobility for 6 days. Record Review on 07/10/18 at 10:28 a.m. Restorative Program Care Plan initiated on 10-11-17 Goal: To maintain the ability to put arms in or out of shirt. Second Goal: Maintain the ability to get in and out of bed. Observation on 07/02/18 at 2:57 p.m. Resident 64 was lying in bed with the lights out and watching television and no Restorative exercise at this time. Observation on 07/10/18 Resident 64 coming out of west dining room going back to the room without staff assistance. Resident interview on 07/02/18 at 2:57 p.m. revealed that Resident 64 received minimal therapy and did not do much with restorative. Resident 64 reported doing some range of motion with legs but not with upper body. Resident interview on 07/10/18 at 8:30 a.m. revealed that Resident 64 verified having some restorative service but then stated they were minimal as exercises did not involve walking. Resident 64 displayed the range of motion performed with lower extremities using legs in bed. Resident 64 reported no exercise on upper body. Staff Interview on 07/10/18 at 1:40 p.m. with LPN ( Licensed Practical Nurse)-K verified Resident 64 being in the Restorative Program and how they assist and provide training with Range of Motion. LPN-K verified that Resident 64 chooses to attend Restorative Programming when up to it and will refuse to attend at times. LPN-K could not identify specific activities related to Resident 64 training for Range of Motion and what it consisted of. Staff Interview on 07/10/18 at 2:05 p.m. with RA (Restorative Aid)-J Reported that there were times when they helped the resident with bed mobility by using the trapeze to position self or RA-J stated that they just observed Resident 64 propel the wheelchair to the dining area with no staff interaction and only observation. RA-J unaware of Goal: To maintain ability to put arms in or out of shirt. Staff Interview on 07/10/18 at 2:24 p.m. with LPN-K verified there was no prior documentation or assessments completed by a licensed nurse. LPN-K stated they had just completed one Restorative Monthly Review or Discharge Summary as it had been requested by another surveyor on 07/09/18. LPN-K presented a Restorative Monthly Review or Discharge Summary form dated on 07/09/18 and signed by LPN-K. No prior documentation. The form dated 07/09/18 recorded (MONTH) Note: (the resident) Participated 28 times in a AROM Program and 28 times in Bed Mobility without difficulties, will continue program. LPN-K was unclear on MDS coding. LPN-K Verified the resident Range of Motion program was not specific as to what joints were to be worked with how many repetitions the resident required or accepted during treatment and they had not met the MDS requirements to code Restorative Section of MDS. Staff interview on 07/10/18 at 3:26 p.m. with the Administrator, Director of Nursing, and Assistant Director of Nursing verified the Restorative Program had not met the requirements due to lack of care planning, assessing and documentation. Source: Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (an instructional manual on how to code MDS assessment Items) Version 1/14 (MONTH) (YEAR). With regard to Restorative Nursing Programs the manual instructs staff that the following criteria for restorative nursing programs must be met in order to code (a restorative program in the MDS) These criteria included: Measurable objective and interventions must be documented in the care plan and in the medical record . In addition when coding Range of Motion (Passive) Activities the manual instructs These exercises must be individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record.",2020-09-01
870,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,656,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C Based on observations, record reviews and interviews; the facility failed to develop and implement a comprehensive care plan to address specific behaviors and interventions for one sampled resident, (Resident 11). Sample size included 26 current residents. Facility census was 93. Findings are: Observation on 07/02/18 at 11:28 a.m. Resident 11's room [ROOM NUMBER]-A was visibly cluttered with Resident 11's bed completely covered with random items consisting of unopened bags of chips, CD Movie discs, books magazines, empty plastic bags, can of peanuts and multiple books. There were boxes stacked next to the bed, bottom drawer was opened on Resident 11's ward robe as it was evident it could not close as it was over flowing with a variety of items too numerous to identify. Resident sink in the room was cluttered with a box of electrical items consisting of blow dryer, electric razor, hair clippers and many other cords that were hanging out of the box. Observation on 07/09/18 at 2:50 p.m. Resident 11's room [ROOM NUMBER]-A electrical devices and cords that were located next to the sink and in the sink were plugged in. A box of electrical items sat next to the sink and in the box appeared to be a blow dryer, hair clippers, electric razor and multiple electric cords. Room remains cluttered and disorganized with the resident bed being covered with books, CD movie discs, magazines, bags of unopened chips, a shopping bag full of items, boxes stacked next to the bed and the bottom drawer of the wardrobe was open and full of a variety of items too numerous to identify. Resident interview on 07/09/18 at 2:50 p.m. revealed Resident 11 was sitting in recliner in room [ROOM NUMBER]-[NAME] Resident 11 was alert and Resident 11 was able to report the location of facility but could not report the day of the week or year. Resident 11 verified that Resident 11's room was messy and stated there just wasn't enough time in the day to keep it clean. Staff Interview on 07/09/18 at 3:09 p.m. with LPN (Licensed Practical Nurse)-G Verified that Resident 11's room [ROOM NUMBER]-A was needing organized and cleaned up as there were items scattered throughout the room. LPN-G verified there was a box of electrical items consisting of a hair blow dryer, hair clipper and electric razor and multiple electric cords on the counter of the sink. LPN-G also verified there were electric cords plugged into the wall next to the sink and cords were laying in the sink and along the sink. LPN-G reported this was dangerous and these items would be removed immediately. Review of Resident 11's Admission Record revealed that Resident 11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 04/13/18, revealed a BIMS (Brief Interview Mental Status) score of 8. Identifying inattention and disorganized thinking behaviors at all times. Review of Resident 11's care plan identified there was no care plan identifying Resident 11's inability to keep the room clean and clear of clutter in order not to endanger self. Review of Resident 11's progress notes identified there were no progress notes identifying any hoarding or non-compliant behavior in trying to keep the room clear of clutter and debris. Review of Resident 11's physician orders [REDACTED]. Observation on 07/09/18 at 6:40 p.m. revealed electrical cords that had been plugged into the wall next to the sink had been removed and so had the box of electrical items. Resident 11's bed had been cleaned up and items on the bed organized on the bed. Plug in next to the sink had a default reset button. Resident interview on 07/09/18 at 6:40 p.m. revealed that Resident 11 was sitting in recliner located in the center of the room. Resident 11 was smiling and reported the nurse came in and assisted in organizing the room since it was a mess. Resident 11 reported that staff plan to help in keeping the room organized and neat. Staff interview on 07/10/18 at 3:29 p.m. with the Administrator, Director of Nursing an Assistant Director of Nursing verified the resident had electronics stored next to sink, cords plugged in and draped in and out of the sink, and verified there were no care plans in place to address Resident 11's room which had items all over the bed and boxes stacked on the floor. The Administrator verified the behavior of Resident 11 being unable to keep the room clean and free of clutter could be a potential danger to self and care planning should have been completed.",2020-09-01
871,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,657,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c Based on record reviews and interview, the facility failed to ensure that care plan interventions were updated related to nutrition for one current sampled resident (Resident 83). The facility census was 93 with 26 current sampled residents. Findings are: Review of Resident 83's Progress Notes. dated 6/14/18, written by the Registered Dietician, revealed that the resident had a recent significant weight loss, a nutritional supplement was started on 6/8/18, meal intake varied from 25-50% and rarely accepted snacks. Review of the care plan, goal date 9/13/18, revealed that the resident was at risk for nutritional problems due to [DIAGNOSES REDACTED]. Further review revealed no changes in interventions since 6/16/17. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/9/18 at 1:10 PM, revealed that the resident usually slept late in the mornings and did not eat breakfast. Further interview revealed that the resident would only accept snacks from staff members that the resident liked. These staff members were to offer and encourage the resident to eat preferred snacks in the afternoon and evening, while the resident was watching television in the lobby area, to increase calories and reduce the risk for further weight loss. Further interview confirmed that this should be included in the care plan interventions with a list of snacks that the resident liked and will accept.",2020-09-01
872,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,676,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1b Based on record review and interview, the facility failed to ensure that identified declines in activities of daily living were further assessed to determine potential causal factors and develop a plan to restore function for one current sampled resident (Resident 83). The facility census was 93 with 26 current sampled residents. Findings are: Review of Resident 83's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/16/18, revealed that the resident required one person physical assist and supervision for transfers (how the resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Further review revealed that the resident required one person physical assist with limited assistance for personal hygiene (including combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands). Review of the MDS, dated [DATE], revealed that the resident required one person physical assist and limited assistance with transfers and extensive assistance with personal hygiene. Interview with LPN (Licensed Practical Nurse) - C, MDS Coordinator, on 7/9/18 at 4:00 PM confirmed that the resident had declines in activities of daily living including transfers and personal hygiene. Further interview confirmed that there was no documentation of further assessment to determine potential causal factors, determine the need for a referral or a plan to restore the resident's function if possible.",2020-09-01
873,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,677,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, record reviews and interview; the facility failed to ensure that nail care was provided for one current sampled resident (Resident 70) and routine bathing was provided for one current sampled residents (Resident 24) who was dependent on staff for care. The facility census was 93 with 26 current sampled residents. Findings are: [NAME] Observations of Resident 70 on 7/2/18 at 7:30 AM, 7/3/18 at 7:30 AM and on 7/5/18 at 7:10 AM and 2:30 PM revealed black and brown colored debris under the resident's fingernails. Review of the care plan, goal date 9/5/18, revealed that the resident required extensive assistance with personal hygiene due to [DIAGNOSES REDACTED]. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/9/18 at 2:50 PM confirmed that the resident was dependent on staff for nail care and needed more frequent nail care to ensure cleanliness. LPN - B stated that the resident often used fingers to eat and needed nail care after meals which was not done. B. Review of Resident 24's care plan, goal date 8/1/18, revealed that the resident required extensive assistance with activities of daily living due to confusion and impaired balance. Review of the Weight and Bath Sheets for (MONTH) (YEAR) revealed that the resident received a bath on 6/11, 6/13, 6/18 and 6/28. Interview with LPN - B on 7/9/18 at 2:00 PM confirmed that the resident was dependent on staff for bathing and should have a bath at least weekly which was not done.",2020-09-01
874,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,679,E,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D5b Based on observations, record reviews and interviews; the facility failed to provide an individualized activity program to meet the resident's needs for seven current sampled residents (Residents 83, 24, 23, 74, 70, 87 and 20). The facility census was 93 with 26 current sampled residents. Findings are: [NAME] Observations of Resident 83 on 7/2/18 at 9:00 AM, 11:10 AM and 3:00 PM revealed the resident sleeping in a chair in the lobby area. Observations on 7/3/18 at 1:00 PM revealed the resident resting on the bed with eyes closed. Observations on 7/5/18 at 2:00 PM revealed the resident seated in a chair in the lobby area with eyes closed. Review of the care plan, goal date 9/13/18, revealed that the resident had [DIAGNOSES REDACTED]. Further review revealed that the resident had a short attention span and wandered in and out of activities. Intervention included encourage resident to attend short activities and provide 1:1 activities and invite to sit in during activity programs if would rather not actively participate in the activity. Review of the facility Alzheimer's Care Programming Calendar for (MONTH) (YEAR), where the staff document the resident's attendance in activities, revealed nothing marked to indicate that the resident attended. B. Observations of Resident 24 on 7/2/18 at 4:00 PM revealed the resident seated in a wheelchair in the dining room with other residents. Further observations revealed a movie playing but the resident was not looking at it. Observations on 7/3/18 at 9:30 AM and 1:00 PM revealed the resident on the bed with eyes closed. Observations on 7/5/18 at 10:00 AM and 3:00 PM revealed the resident resting on bed with eyes closed. Interview with the resident's family member on 7/3/18 at 10:00 AM revealed not sure if the resident participated in any activity programs. Review of the care plan, goal date 8/1/18, revealed that the resident had [DIAGNOSES REDACTED]. Further review revealed that the resident liked to socialize with staff, residents and family and liked to get hair done and watch movies. The resident required assistance and escort to activities and needed a variety of activity types and locations to maintain interest. Review of the facility Alzheimer's Care Unit Programming Calendar for (MONTH) (YEAR) revealed that the resident attended TV time and snack on 6/7/18 and 6/26/18; lunch together, sensory and games, TV, snacks on 6/21/18 and sensory stimulation, TV time, lotion, talking and music on 6/26/18. C. Observations of Resident 23 on 7/2/18 at 9:30 AM revealed the resident seated in a chair in the hallway and at 4:00 PM seated in the recliner in room with eyes closed. Observations on 7/3/18 at 7:15 AM revealed the resident seated in the dining room with no interaction observed with the other residents. Further observations at 1:00 PM revealed the resident on the bed with eyes closed. Observations on 7/5/18 at 9:30 AM revealed the resident seated in the dining room in a coloring activity. Further observations revealed the resident with eyes closed and not coloring. Observations at 2:15 PM revealed the resident seated in the recliner in room with eyes closed. Review of the care plan, goal date 10/3/18, revealed that the resident had impaired cognition and hearing, English is second language and may take time to understand what is being said, enjoyed spending time in the living room area interacting with others and needed reminded of group activities and liked Bingo, energize, socials and watching Spanish channel television programs. Review of the facility Alzheimer's Care Programming Calendar for (MONTH) (YEAR) revealed that the only activity marked was walk and chips on 6/8/18. D. Observations of Resident 74 on 7/2/18 at 9:30 AM and at 4:00 PM resting on bed with eyes closed. Observations on 7/3/18 at 7:15 AM revealed the resident seated in the dining room with no interaction with the other residents. Further observations at 1:00 PM revealed the resident resting on the bed with eyes closed. Observations on 7/5/18 at 10:00 AM and 2:15 PM revealed the resident resting on the bed with eyes closed. Review of the care plan, goal date 9/11/18, revealed that the resident had [DIAGNOSES REDACTED]. Review of the facility Alzheimer's Care Programming Calendar for (MONTH) (YEAR) revealed that the resident attended a movie and lotion activity on 6/8/18. E. Observations of Resident 70 on 7/2/18 at 2:00 PM, 7/3/18 at 10:00 AM and 1:00 PM and on 7/5/18 at 10:30 AM and 2:15 PM revealed the resident resting on the bed with eyes closed. Interview with a family member on 7/2/18 at 12:30 PM revealed had not observed the resident in activities and was not sure if the resident attended any of the activity programs. Review of the care plan, goal date 9/5/18, revealed that the resident had [DIAGNOSES REDACTED]. Interventions included needed encouragement to participate in activities and used the sensory room for stimulation or relaxation. Review of the facility Alzheimer's Care Unit Programming Calendar for (MONTH) (YEAR) revealed that the resident had a family visit on 6/7/18, recipe on 6/14/18, lotion therapy on 6/2218 and 6/29/18 and music, watching birds and talking on 6/26/18. F. Observations of Resident 87 on 7/2/18 at 9:30 AM revealed the resident seated in the wheelchair in the hallway by the door looking at the corn plants and at 2:00 PM resting on the bed with eyes closed. Observations on 7/3/18 at 9:15 AM revealed the resident resting on the bed with eyes closed and at 1:00 PM seated in the wheelchair in the hallway. Observations on 7/5/18 at 11:15 AM and 2:30 PM revealed the resident resting on the bed with eyes closed. Review of the care plan, goal date 8/23/18, revealed that the resident had [DIAGNOSES REDACTED]. Interventions included invite to activities and allow to join in at the resident's comfort level and offer activities and supplies in room. Review of the facility Advanced Alzheimer's Care Unit Programming Calendar for (MONTH) (YEAR) revealed that the resident participated in walk and ice cream on 6/7/18, ice cream on 6/14/18, lotion on 6/21/18 and sensory stimulation on 6/25/18. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/9/18 at 2:20 PM confirmed that there was no individualized activity program in place based on the residents' individual needs, preferences or goals. Further interview confirmed that there was no documentation to include the resident's response to activities to ensure that the activities were beneficial and therapeutic to meet their needs. [NAME] Record review of Resident 20's Admission Record printed on 7/4/18 revealed the resident was admitted to the facility on [DATE]. Interview with Resident 20 on 7/3/18 at 9:07 a.m. revealed the resident had developed contractures and limitations to the resident's extremities due to [MEDICAL CONDITION] Arthritis and Polio. During the interview the resident described attending few activities due to vision and medical debilities. Record review of the resident's care plan with the Last Care Plan Review Completed on 5/4/2018. Among the focus problems identified on the care plan was a problem entitled: I (Res 20) would like to continue participating in the recreational activities I currently enjoy. I prefer to spend time in my room sitting in the quietness and/or watching the news. I will come out to the hallway at times to socialize. My family call me almost daily from out of town and we visit for a while. The goal for this problem was for the resident to continue to express my enjoyment and satisfaction with the independent and/or social activities I currently participate in. The target date for the goal was recorded as 7/21/18. Record review of Resident 20's electronic medical record and chart revealed one Progress Notes entry recorded on 1/29/18 at 10:32 a.m. The entry read the resident was encouraged to participate in independent activities, spent most of time in room watching television and coming out into hallway to interact with others. Does participate in spiritual activities and special events. No concerns. There were no other Activity assessments, progress notes, or summaries documented for the resident between 1/29/18 and 7/8/18. On 7/9/18 after requesting activity documentation/assessments for Resident 20 a Recreation Services Assessment was completed by the Activity Director. Interview with the Activity Director on 7/10/18 at 12:55 p.m. verified no activity assessments, summaries, or notes were recorded describing Resident 20's activity program and progress toward the resident's activity goals between 1/29/18 and 7/8/18 until a request was made for documentation on 7/9/18.",2020-09-01
875,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,684,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2c Based on observations, record reviews and interviews; the facility failed to assess and provide care to 1) promote healing of impaired skin excoriation and redness due to episodes of diarrhea and to address low blood sugar and blood pressure readings for one current sampled resident (Resident 74), 2) an abrasion and bruising for one current sampled resident (Resident 19) and 3) an abrasion for one current sampled resident (Resident 29). The facility census was 93 with 26 current sampled residents. Findings are: [NAME] Review of Resident 74's care plan, goal date 9/11/18, revealed that the resident was at risk for skin breakdown related to decreased mobility and incontinence, was frequently incontinent (unable to control bowel movements) due to a current colon infection and required extensive assistance with toileting and personal hygiene. Interventions included apply skin barrier after morning and afternoon care and on going assessment of skin condition during routine care. Observations on 7/3/18 at 11:00 AM revealed the resident seated on the toilet and was incontinent of a diarrhea stool. Further observations revealed that NA (Nursing Assistant) - L assisted the resident to stand and provided skin care with disposable wipes. The resident called out ow, that is sore as NA - L provided skin care. The resident's skin at the perianal area and buttocks was reddened. NA - L stated that there was no Calmo cream in the room to apply to the reddened skin. NA - L notified MA (Medication Aide) - M that needed some Calmo for the resident. Further observations at 11:05 AM revealed that MA - M brought in some cream and applied it to the resident's reddened skin areas. Observations on 7/5/18 at 9:10 AM revealed that the resident was seated in the dining room and had an episode of incontinent diarrhea. Further observations revealed NA - N and MA - M assisted the resident to the bathroom and assisted to stand. NA - N provided skin care with disposable wipes. Further observations revealed the resident's skin at perianal and buttocks area was bright red and the resident stated ow while skin care was provided. No moisture barrier was applied to protect the resident's skin or cream applied to promote comfort and healing. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 5/31/18 for Calmozine cream, apply to the resident's buttocks daily due to redness and chaffing. Further review revealed that the treatment was scheduled for 7:30 AM. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/9/18 at 1:50 PM revealed was not notified of the resident's skin condition and no skin assessment was completed. Further interview confirmed that routine skin care, including the use of a moisture barrier, should be done after each diarrhea stool to protect the resident's skin from further irritation and to promote comfort and healing. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident's blood sugar was 54 at 7:00 AM. Review of the Progress Notes, dated (MONTH) (YEAR), revealed no documentation of an assessment or follow up of the low blood pressure and blood sugar. Interview with LPN - B, Unit Coordinator, on 7/9/18 at 1:50 PM confirmed that there was no documentation of an assessment or follow up with the resident's low blood pressure and low blood sugar readings on 7/4/18. B. Observation on 07/02/18 at 10:56 a.m. revealed that Resident 19 was sitting in room [ROOM NUMBER]-A in the wheelchair watching television. Resident 19 had been wearing a short sleeved shirt and Resident 19 had an abrasion on the left upper for arm with some redness around it. The abrasion had a dark brown scab on it. Observation on 07/05/18 at 7:30 a.m. revealed that Resident 19 was sitting outside the room in the wheelchair and Resident 19 was wearing a short sleeve shirt with no covering or bandage located on it. Resident 19 had an abrasion on the left upper part of the fore arm with a scab that had already formed however the color around the scab was red in color. Observation on 07/09/18 at 1:56 p.m. as Resident 19 was sitting in the recliner watching television revealed Resident 19 had a band aid covering the abrasion on the left upper fore arm. When asked who placed the band aid on the abrasion on the left upper fore arm, Resident 19 replied the nurse had placed the band aid on arm. Resident interview on 07/03/18 at 9:39 a.m. revealed Resident 19 was sitting in the recliner watching television. When Resident 19 was asked how the abrasion on the left upper fore arm came about Resident 19 replied Not sure how I got that. When Resident 19 was asked if it hurt the answer was no. Record Review on 07/09/18 at 1:42 p.m. Weekly skin assessments that had been completed for Resident 19 did not identify any skin abrasions to Resident 19's upper left fore arm. All weekly skin assessments completed on 04/02/18 through 07/03/18 report Skin intact no red areas noted. Record Review on 07/09/18 at 1:42 p.m. Nursing progress notes provided for the month of (MONTH) 1, (YEAR) through (MONTH) 3, (YEAR) did not identify any skin abrasions to Resident 19's left upper fore arm. Record Review on 07/09/18 at 1:42 p.m. of Resident 19's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 04/20/18, revealed a BIMS (Brief Interview Mental Status) score of 14. Record Review on 07/09/18 at 1:42 p.m. Care plan dated 04/24/18 Skin will remain intact, will have no skin tears or bruising in 90 days, did not identify the abrasion on Resident 19's upper fore arm. Staff Interview on 07/09/18 at 1:50 p.m. with LPN-G revealed all weekly skin assessments were completed by the nurse in charge of the specific floor and with input from the Nurses Aids. Staff Interview on 07/09/18 at 2:24 p.m. with LPN-G confirmed that Resident 19 had an abrasion on the left upper fore arm and no one had identified, documented or confirmed how Resident 19 had obtained this abrasion or sore. LPN-G was unaware who placed a band aid on the abrasion on the left upper fore arm where the abrasion was located. Staff Interview on 07/10/18 at 3:23 p.m. with the Administrator, Director of Nursing and Assistant Director of Nursing verified Resident 19 had an abrasion on left upper fore arm and confirmed there was no identification or documentation of Resident 19's injury. C. Observation on 07/02/18 at 1:38 p.m. revealed Resident 29 had been sitting on the recliner in the resident's room and was dressed in a short sleeve shirt and slacks. Resident 29 had an abrasion located on the right elbow. Observation on 07/05/18 at 7:20 a.m. revealed Resident 29 had been sitting in the room in the wheelchair listening to the radio. Resident 29 had a visible abrasion on right elbow with a dark brown scab on it and it was bright red around the scab. Resident interview on 07/05/18 at 7:20 a.m. revealed Resident 29 was in own room sitting in wheelchair listening to the radio. When asked what happened to the right elbow, Resident 29 looked at it and then reported it was not clear how this abrasion on the right elbow occurred. Resident 29 stated it could have occurred by running into the door as there are times when Resident 29 comes to close to the door jams and hits with the wheelchair and arms. Resident 29 also reported maybe had scraped it on the wheelchair. Record Review on 07/05/18 at 8:18 a.m. of Resident 29's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated on 04/05/18, revealed a BIMS (Brief Interview Mental Status) Score of 15. Record Review on 07/05/18 at 8:44 a.m. of Resident 29's Care plan for Potential for alteration in skin integrity tears and bruising, Skin will remain intact, with decrease bruising. Skin tear to left inner elbow C 10 cm X 8 cm hematoma et abrasion from wrist to above the elbow- resolved. There was no identified focus on Resident 29's right elbow abrasion. Record Review on 07/05/18 at 8:54 a.m. of Resident 29's Weekly Skin checks dated 5-9-18, 5-16-18, 5-23-28, 5-30-18, 6-6-18, 6-13-18, 6-15-18, 6-22-18, and 6-29-18 all reported Skin intact no red or open areas. Record Review on 07/05/18 at 9:14 a.m. revealed there were no Nursing Progress Notes having identified the abrasion, to Resident 29's right elbow. Staff interview on 07/05/18 at 9:18 a.m. with LPN-G reported the LPN was not aware of Resident 29's abrasion to the right elbow. Staff interview on 07/05/18 at 9:30 a.m. with LPN-G verified there had been no charting on Resident 29's abrasion to the right elbow. LPN-G verified all weekly skin checks just reported that skin was intact and no red or open areas. Staff interview on 07/10/18 at 3:15 p.m. with the Administrator, Director of Nursing and Assistant Director of Nursing verified Resident 29 had an abrasion to the right elbow that had not been identified or documented on.",2020-09-01
876,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,689,G,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews, and interviews, the facility failed to: 1) safely transfer residents between surfaces for 2 sampled residents (Residents 5 and 89) resulting in fractures for Resident 5 and skin tearing for Resident 89; 2) ensure oxygen concentrators were turned off when unattended for one sampled resident (Resident 80) increasing the risk for room oxygenation which increases the risk for fire; and 3) transport wheelchair residents using footrests for four sampled residents (Residents 81, 88, 65, and 74) increasing the risk of injury for these residents. Sample size was 26 current residents. Facility census was 93. Findings are: [NAME] Record review of Resident 5's Admission Record printed on 7/4/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Physical Therapy Discharge Summary for Resident 5 signed by the therapist on 8/14/2017 revealed the PT provided resident and caregiver training and instruction and education to nursing staff on how to properly set-up the sit to stand lift and the pt (patient or Resident 5) in order to ensure safety was enhanced and pt knew how to perform transfer properly.: The summary identified outcomes at the time of discharge recorded Mobility for Chair or bed to chair transfer and Toilet Transfer required Substantial/Maximal Assistance from staff to perform the task. Record review of Resident 5's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on 4/6/2018 revealed the resident required Extensive assistance (resident involved in activity, staff provide weight bearing support) with Transfer- how the resident moves between surfaces including to or from bed, chair, wheelchair, standing position. The MDS recorded two or more staff persons provided physical assistance for the task. Regarding Balance during transitions the MDS recorded the resident was Not steady, only able to stabilize with human assistance. The assessment recorded the resident's weight at 253 pounds. Record review of a Fall document dated 6/9/18 at 1:15 p.m. revealed an incident occurred involving Resident 5 on 6/9/18. The description of the incident read: Nurse called to room, noted resident laying on floor in between sit to stand lift and motorized wheelchair. Staff states resident was unresponsive prior to alerting this nurse. Resident noted to be responsive and answering questions appropriately, resident states doesn't know what happened, passed out and woke up on floor. The form listed a witnesses statement which described the resident was standing up in the sit to stand lift while they were holder (holding) the bucket from the bedside commode under (the resident) . Resident then became weak, let go of the lift, fell through the sling and fell to the floor . Record review of a fax communication to Resident 5's physician on 6/9/18 recorded Resident became weak and let go of sit to stand lift while in use, slipped through harness et (and) fell to floor. Did hit back of head on leg rest of wheelchair . Record review of an Occupational Therapy updated plan of treatment for [REDACTED]. Record review of a Fall document involving Resident 5, dated 6/27/18 at 8:40 p.m., revealed a description of the incident documented a nurse aide was assisting resident with lift transfer when resident became weak and lost grip and legs gave out. Resident noted by this nurse hanging with just left hand and wrist in the sit to stand lift sling. Resident described I think I passed out. The nurse assisted the Nurse Aide in lowering the resident to the floor and noted a skin tear on the left wrist along with the resident complaining of a sore wrist. The resident was assisted onto the bed and the on-call medical practitioner was notified with orders to notify primary care doctor if wrist pain continues. A witness statement from the Nurse Aide involved during the incident documented on the form on 6/28/18 I was getting (the resident) transferred from the bath chair to (the resident's) bed in the sit to stand and (the resident) went limp. I think (the resident) passed out. The notes section of the form recorded Resident uses sit to stand for transfers . New interventions: Staff to utilize 2 staff with lift transfers. Record review of Resident 5's Progress Notes on 6/28/18 revealed at 10:32 a.m. a call was placed to the resident's physician reporting the left wrist was swollen and painful due to the fall the previous night. At 11:50 a.m. the physician returned call and ordered x-rays for the resident. At 4:28 p.m. the physician reported the x-ray indicated the resident sustained [REDACTED]. On 6/29/18 the resident went to orthopedics and returned with orders to keep cast clean and dry to left wrist with the cast to remain at least 6 weeks. Correspondence to the State Agency on 7/10/18, verified by phone interview with Resident 5's POA (Power of Attorney) on 7/17/18 at 8:00 a.m. revealed the POA contacted Res 5 by phone on 6/10/18 after the facility reported an incident/fall on 6/9/18. The resident described passing out from hanging out in the sit to stand lift too long. The POA stated the facility contacted the POA again on 6/28/18 and told about the resident having another incident in the lift. The POA contacted the facility DON (Director of Nursing) who returned a call at 4:19 p.m. The DON stated the resident passed out in the sit to stand lift and the Nurse Aide could not keep the resident from falling. The POA asked the DON if two persons performed the lift as the resident was supposed to be a two person lift transfer. The DON responded, confirming only one staff member attempted the resident's transfer. The POA reported coming to the facility on [DATE] and speaking with the DON around 11:30 a.m. about the concerns of Resident 5 being transferred with only one person and reported the resident had said this wasn't the first time one person did the transfers alone (prior to 6/27/18). The DON assured the POA the resident would be a two-person assist. Observation of Resident 5 on 7/2/18 at 3:50 p.m. revealed the resident had a cast on the left arm below the elbow extending across the forearm and hand. Interview with Resident 5 on 7/2/18 at 3:51 p.m. revealed the resident experienced two recent falls while being transferred with a mechanical lift. Resident 5 stated on the first occasion, the resident passed out while being assisted on a sit to stand lift with two staff members helping. The second occasion resulted in the resident's arm being fractured. The resident described being transferred with the sit to stand lift but only one staff member was assisting with the lift transfer. The resident stated having passed out and does not recall much until being assessed by the nurse. The resident described continued pain from the fall and was x-rayed and diagnosed with [REDACTED]. The resident stated the staff were supposed to have two persons assisting with mechanical lifts, but at the time of the second fall, the staff member attempted the lift by self. The resident also stated that other occasions prior to 6/27/18 staff members were transferring the resident with only one staff member instead of two. Interview with the facility PT (Physical Therapist) on 7/5/18 at 2:18 p.m. revealed the PT was familiar with Resident 5 and the resident's therapy plans and treatment. The PT confirmed OT (Occupational Therapy) began seeing the resident on 6/22/18 for alignment and functional skills and reviewed the use of the sit to stand lift. The PT verified the staff were transferring the resident at the time of falls on 6/9/18 and 6/27/18 with the use of a sit to stand lift due to previous recommendations by therapy. The resident was now using a sling lift due to the fractured wrist and cast and difficulty for the resident to hang on. The PT stated staff should be utilizing two persons for transfers with sit to stand and sling lifts especially with this resident due to the resident's size and inability to bear weight without staff assistance. Interview with LPN (Licensed Practical Nurse)- K, the Restorative Nurse Coordinator, on 7/9/18 at 4:00 p.m. confirmed Res 5 had passed out in the sit to stand lift on 6/9/18 during a transfer while being assisted with two staff. LPN-K confirmed a second incident occurred on 6/27/18 while a single staff member, NA (Nurse Aide)-T, was transferring the resident from a bath chair using the sit to stand lift without another staff member. LPN-K agreed that due to a similar incident and the size of the resident, the staff should have been aware of the resident's potential to pass out in the lift and should have had additional staff assisting with the transfer on 6/27/18. Interview with NA-T on 7/9/18 at 5:27 p.m. confirmed NA-T was present during the 6/27/18 incident involving Resident 5. NA-T stated having assisted the resident with a bath and returned the resident to the room to transfer the resident in the wheelchair. NA-T stated looking for additional help to transfer the resident but could not find anyone. NA-T confirmed transferring Resident 5 by self in the sit to stand lift and the resident blacked out and slumped during the transfer. NA-T then screamed for help and the charge nurse responded. NA-T stated Resident 5's left hand got caught in the lift and the resident sustained [REDACTED]. Record review of NA-T's employee files revealed NA-T was hired at the facility on 2/28/18. Further review of the file revealed there was no evidence of training or competency testing for NA-T regarding the use of mechanical lifts during resident transfers. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed NA-T's employee file had not included any training or competency testing regarding the use of mechanical lifts during resident transfers. B. Record review of Resident 89's Admission Record revealed the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident 89's MDS assessments revealed an Admission assessment was completed on 6/20/2018. Review of the assessment revealed the resident's functional status for Transfer recorded the resident received Extensive Assistance from two or more staff members to complete transfer tasks from bed to chair. The assessment recorded the resident received Extensive Assistance from two or more staff members when transferring onto the toilet. The MDS assessment recorded Balance during transitions and walking was Not steady, only able to stabilize with human assistance for surface to surface transfer. Record review of Resident 89's care plan printed on 7/4/18 revealed a focus problem initiated on 6/20/18 which described the resident Requires assistance with ADL functions and recorded in the interventions Two person assist with transfers. Record review of a Fall document dated 6/28/18 at 10:21 a.m. for Resident 89 revealed an incident description involving the resident which recorded: Resident lowered to floor by cna (Nurse Aide) after knees buckled in restroom. The resident described knees just gave out while holding the transfer bar in restroom. The form recorded skin tear injuries to the right and left elbow. In the Witnesses section of the form, NA-X described being present and transferring resident from the wheelchair to the toilet with a gait belt and transfer bar, when resident's knees began to buckle. NA-X lowered the resident to the floor and called for help. Further review of attached Progress Notes revealed a late entry recorded on 6/28/18 at 10:36 which read Recommendation: Resident is to be 2 person transfer with all transfers and gait belt . Interview with Resident 89 on 7/2/18 at 2:42 p.m. revealed the resident had fallen recently. The resident described being assisted in the bathroom by a nurse aide and lost balance and fell resulting in an injury to the elbow. The resident stated there were supposed to be two staff assisting with transfers, but on this occasion, only one staff member assisted the resident. Interview with the DON and ADON (Assistant Director of Nursing) on 7/10/18 at 2:13 p.m. confirmed Resident 89's care plan identified the resident was to be transferred with two person assistance. The ADON confirmed the resident had an incident of being lowered to the floor on 6/28/18 while only one staff member was assisting the resident with a toilet transfer and that the resident sustained [REDACTED]. Record review of NA-X's employee file revealed the staff member was hired by the facility on 5/9/18. Record review of NA-X's education file revealed there was no documentation the employee was trained or competency tested in safe resident transfer techniques. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed NA-X's employee file had not included any training or competency testing regarding transfer techniques for safe resident transfers. C. Observations of Resident 80's room on 7/3/18 at 7:40 AM and at 11:40 AM revealed the oxygen concentrator on while the resident was out of the room for meals. Further observations on 7/9/18 at 3:20 PM revealed the oxygen concentrator on while the resident was out of the room. Interview with LPN - B, Unit Coordinator, on 7/10/18 at 7:30 AM confirmed that the oxygen concentrator should be turned off while the resident was out of the room to reduce the risk of fire and injuries. D. Observations on 7/5/18 at 7:40 AM revealed NA - P propelled Resident 81, seated in a wheelchair, though the hallway to the dining room without utilizing footrests. Observations on 7/5/18 at 11:10 AM revealed LPN - B propelled the resident, seated in a wheelchair, in the hallway without utilizing footrests. E. Observations on 7/5/18 at 7:40 AM revealed Resident 83 pushing Resident 88, seated in a wheelchair, in the dining room without utilizing footrests. F. Observations on 7/5/18 at 11:15 AM revealed a family member pushing Resident 65, seated in a wheelchair, in the hallway without utilizing footrests. [NAME] Observations on 7/5/18 at 11:30 AM revealed LPN - B transported Resident 74, seated in a wheelchair, in the hallway from the dining room to room without utilizing footrests. Interview with LPN - U, Assistant Director of Nursing, on 7/10/18 at 7:30 AM confirmed that resident were to be transported in wheelchairs and utilize footrests to support the residents' feet, reduce the risk of injuries and to promote comfort. H. Observation on 02/02/18 at 11:28 a.m. room [ROOM NUMBER]-A which belonged to Resident 11 had electrical cords plugged into the electrical sockets located next to the sink and cords were just dangling down. There was a box with a hair blow dryer, and electric razor, hair clippers and multiple electrical cords hanging out of the box located next to the sink. Observation on 07/09/18 at 2:50 p.m. revealed Resident 11 was sitting in the recliner in room [ROOM NUMBER]-A watching television. There were electrical cords that might have belonged to Resident 11's electric razor and or possibly a cell phone and they were plugged into the electric plug ins located next to the sink. One of the cords was dangling off to the side of the sink and the other cord was in the sink but were not attached to the electric razor or cell phone. Plug in by the sink did have a default reset located on it. Staff interview on 07/09/18 at 3:09 p.m. with LPN-G verified the resident had electrical cords that had been plugged into the electrical outlets along with a box full of electronics being stored on the sink counter top in Resident 11's room [ROOM NUMBER]-[NAME] LPN-G reported this was not safe having these electric cords plugged in and hanging in and round the sink. LPN-G reported she would move these items immediately. Observation on 07-09-18 at 6:40 pm room [ROOM NUMBER]-A where Resident 11 resides, all electrical cords and box of electronics that had been on counter top next to the sink had all been removed. Staff interview on 07/10/18 at 3:29 p.m. with the Administrator, Director of Nursing and Assistant Director of Nursing verified Resident 11 had electronics stored next to the sink and had electrical cords plugged in to the electrical outlets which were hanging in and along the sink. Administrator identified that electrical cords should not be left plugged into the electrical outlets next to sinks in resident rooms as this could increase the risk of injury to residents.",2020-09-01
877,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,690,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews; the facility failed to ensure that 1) an identified decline in bowel continence (ability to control bowels) was further assessed to determine potential causal factors and develop a plan to restore function for one current sampled resident (Resident 87) and 2) offer toileting and provide personal cares in a manner to reduce the risk of urinary tract infections for one current sampled resident (Resident 90). The facility census was 93 with 26 current sampled residents. Findings are: Licensure Reference Number 175 NAC 12-006.09D3 (2) [NAME] Review of Resident 87's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 3/21/18, revealed that the resident was continent of bowel. Review of the MDS, dated [DATE], revealed that the resident was frequently incontinent of bowel with two or more episodes of bowel incontinence and at least one continent bowel movement during the assessment period. Interview with LPN (Licensed Practical Nurse) - C, MDS Coordinator, on 7/9/18 at 4:00 PM confirmed that the resident had a decline in bowel continence. Further interview confirmed that there was no documentation of further assessment to determine potential causal factors or to develop a plan to restore the resident's bowel continence if possible. Licensure Reference Number 175 NAC 12-006.09D3 (1) B. Record review of Resident 90's MDS Quarterly review assessment on 6/20/18 revealed the resident was admitted to the facility on [DATE]. Further review of the assessment revealed the resident was Frequently (7 or more episodes of incontinence in one week) incontinent of urine. Observation on 07/02/18 at 09:30 AM revealed NA (Nurse Aide)-D and MA (Medication Aide)-V answered the call light for Resident #90. NA-D and MA-V knocked on the resident's door, announced themselves. Resident #90 asked to be assisted to bed. A sit-to-stand lift was utilized for the transfer. NA-D and MA-V transferred the resident to bed and no offer to use the toilet was made. When Resident#90 was lifted in the sit-to-stand, the resident was observed to have been incontinent of urine. The urine soaked through the brief, through the pants, and onto the resident's wheelchair cushion. The resident was placed onto the bed with clean bedding while still wearing the saturated pants and brief soiling the clean bedspread. Peri-care (cleansing of the groin and bottom) was provided by NA-D as follows: NA-D utilized one wipe to cleanse abdominal skin fold and then used for the left side groin/peri-area. NA-D wiped front to back and then back to front on the left side of groin/peri-area with the same wipe and same area of the wipe. NA-D then used a clean wipe to wipe front to back and then back to front on the right side of groin/peri-area, with the same area of the wipe. Resident #90 was turned on the side to complete cares including finalizing peri-care to bilateral buttocks On 07/05/18 at 03:35 PM, interview with the Administrator, DON (Director of Nursing) and ADON (Assistant Director of Nursing) confirmed peri-care was not performed appropriately by staff and no offer to toilet was made when transferring Resident 90.",2020-09-01
878,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,692,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D8 Based on record reviews and interviews, the facility failed to: 1) ensure accuracy of resident weights for one sampled resident (Resident 20) at risk for nutritional deficiencies; and 2) follow Registered Dietitian recommended interventions for one sampled resident (Resident 70) at risk for nutritional weight loss. Sample size was 26 current residents. Facility census was 93. Findings are: [NAME] Record review of Resident 20's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident 20's Care Plan with the Last Care Plan Review Completed dated 5/4/18 revealed the resident was identified at Nutritional risk AEB (as evidenced by) mech (mechanically) alt (altered diet, poor meal intake) . The goal, with a target date of 7/21/18, for the problem recorded: Resident will have no significant weight changes through next review. Resident desires wt (weight) gain. Among the interventions to monitor the problem and progress was an intervention to weigh per facility protocol or as needed. Record review of a facility Monthly Weight Report dated 7/2/18 revealed the following monthly weight recordings for Resident 20: - (MONTH) (YEAR) was 82.5 pounds. - (MONTH) (YEAR) was 88 pounds. - (MONTH) (YEAR) was 107 pounds. - (MONTH) (YEAR) was 107 pounds. -February (YEAR) was 106 pounds. - (MONTH) (YEAR) was 104 pounds. Record review of MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments for Resident 20 revealed the following: - 4/20/18 quarterly assessment recorded the resident's weight at 90 pounds. -1/18/18 quarterly assessment recorded the resident's weight at 104 pounds. - 10/18/17 a significant change assessment recorded the resident's weight at 86 pounds. - 9/1/17 an annual assessment recorded the resident's weight at 107 pounds. Record review of Dietary RD (Registered Dietitian) notes for Resident 20 revealed the following entries: - 5/2/17 recorded the Resident has poor intake and had no significant weight changes in 180 days. - 10/6/17 the resident was assessed for weight change recorded at 108 pounds and noted the resident gained weight over the course of 6 months. - 10/17/17 the resident weight was recorded at 86.2 pounds. - 11/14/17 the resident's weight was recorded at 88.4 pounds. - 12/20/17 weight recorded at 101 with weight gain planned. - 1/7/18 weight recorded at 104 pounds within desired weight range. - 1/29/18 weight recorded at 103 pounds. - 4/25/18 weight recorded at 84 pounds. - 5/15/18 weight recorded at 88 pounds. - 5/29/18 weight recorded at 84 pounds. - 6/11/18 weight recorded at 82.5 pounds- maintaining weight of 80-90 since 4/11/18. - 6/26/18 weight recorded at 82.5 pounds. Record review of a Nutrition Assessment completed by the RD on 4/25/18 recorded the resident's weight at 89.6 pounds and reported a month ago at 107, 90 days ago 103; and 180 days ago 101. The RD identified weight loss. In the Additional Comments section of the document, the RD recorded 4/25/18 Residents weights are showing a significant weight loss. Spoke with nursing and we suspect weighing errors. Resident's intakes have not decreased and (the resident) is likely meeting (the resident's) needs. (Resident 20) is very small framed and a 17 # (sign for pound) wt loss would be apparent and (the resident) does not look to have lost any weight. Nursing will plan to get daily weights. Interview with the facility RD on 7/10/18 at 11:41 a.m. revealed the RD had concerns with how Resident 20 was being weighed by staff regarding accuracy. Weights over time showed in some weeks the resident would gain upwards of 20 pounds in a two week period and then lose it again at the next review a few weeks later. The RD had concerns that Resident 20 was being weighed by different staff members, different times of day, and possibly on different scales causing discrepancies. The RD stated conversations with the resident, the resident did not feel having lost any significant weight during the time frame and intake records had not changed. The resident's appearance did not show dramatic weight loss between these times. The RD reported having taken the weight concerns to standup meetings but uncertain if any changes had been made. The RD would like the same person doing weights and this was not done. The RD stated without accuracy of weights for Resident 20 it is near impossible to develop a dietary plan for the resident. Interview with DA (Domestic Aide)-O on 7/10/18 at 1:00 P.M. confirmed Resident 20 is weighed in the wheelchair on the wheelchair scale located in a room between the 200 and 300 halls. Observation of Resident 20's wheelchair throughout the survey on 7/3; 7/5; 7/9; and 7/10 revealed the resident has a motorized wheelchair and keeps multiple personal items on the wheelchair along with an oxygen tank. Interview with the facility MM (Maintenance Man)-Q on 7/10/18 at 1:13 p.m. revealed the maintenance department calibrates the wheelchair scale in the room between the 200 and 300 halls on a weekly basis and if problems arise. Staff procedures were described as weight a resident in their wheelchair and then another weight of just the wheelchair and subtracting the difference to obtain resident weight. MM-Q described if the ramp leading into the scale is touching the scale during weighing procedures, a false reading occurs. Observation of the calibration of the wheelchair on 7/10/18 at 1:13 p.m. with MM-Q revealed a 10 pound weight was placed on the scale. The digital reading recorded 10 pounds. MM-Q then demonstrated weight when the ramp leading to the scale is touching the scale and the digital recording was 9.4 pounds. Record review of six sampled Nurse Aide staff employee files (NA (Nurse Aides) E, R, S, M, L, and T) for current employees providing direct care to residents revealed none of these staff had competency testing to verify their ability to use facility wheelchair scales. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed the employee files for Nurse Aides E, R, S, M, L, and T had not contained any performance evaluations or competency testing to verify ability to use facility wheelchair scales. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing on 7/10/18 confirmed Nurse Aides performance evaluations and competency testing to verify abilities to use facility wheelchair scales had not been done. B. Review of Resident 70's care plan, goal date 9/5/17, revealed that the resident was a nutritional risk due to mechanically altered diet, honey thickened liquids and [DIAGNOSES REDACTED]. Review of the Registered Dietician Progress Notes, dated 6/12/18, revealed that the resident weighed 94 pounds which was a significant change over 180 days. Further review revealed recommendations to discontinue Ensure (supplement) and add 2.0 cal 120 cc. (cubic centimeters) three times a day. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident consumed 25% at 8:00 AM on 7/2, 7/3 and 7/4 and at 5:00 PM on 7/1, 7/2 and 7/3. Interview with LPN (Licensed Practical Nurse) - B, Unit Manager, on 7/9/18 at 2:50 PM confirmed that the resident's supplement orders had not been changed as recommended by the Registered Dietician.",2020-09-01
879,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,726,F,1,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04B2 Based on observations, record reviews and interviews; the facility failed to 1) ensure that two staff members, NA's (Nurse Aides) T and X) had received competency testing regarding procedures for safe resident transfers. The failure resulted in improper mechanical lift transfer for 1 sampled resident (Resident 5) resulting in a wrist fracture; and an improper pivot transfer for 1 sampled resident (Resident 89) resulting in elbow skin tears; 2) ensure competency testing was completed regarding skills in resident care provision and policies for five staff members, MA (Medication Aide)-Y, and NA's T, X, E, and Z): 3) ensure competency testing and education was completed for three sampled NAs (Nursing Assistants) L, R and S and one sampled MA (Medication Aide) M specific to care of residents in the SCUs (Special Care Units) and 4) general competency testing was not completed for six sampled employees (NAs R, W, L, [NAME] and MAs I and M). The facility census was 93 with 26 current sampled residents and 28 residents currently residing in the SCUs. [NAME] Record reviews of employee files for NA-T and NA-X revealed NA-T was hired by the facility on 2/28/18 and NA-X was hired by the facility on 5/9/18. Record review of these files revealed the facility had no documentation these employees received competency testing regarding safe lift transfers of residents. Record review of Resident 5's medical record and facility falls investigation report revealed on 6/27/18 NA-T transferred Resident 5 with a mechanical sit to stand lift without obtaining assistance from another staff member (Refer to F689 citation). During the transfer, Resident 5 lost consciousness and the resident's left wrist was caught in the lift resulting in a fractured injury to the wrist requiring medical attention from orthopedics. Interview with NA-T on 7/9/18 at 5:27 p.m. confirmed NA-T transferred Resident 5 per sit to stand mechanical lift on 6/27/18 without assistance from another staff member. NA-T stated looking for additional help but could not find anyone precipitating the transfer without assistance. Record review of Resident 89's medical record revealed the resident's care plan interventions included documentation pertaining to resident transfer assistance which recorded Two person assist with transfers. Further review of the record revealed a facility falls investigation report which recorded NA-X assisted the resident without the assistance of another staff member on 6/28/18 resulting in the resident being lowered to the floor and sustaining skin tear injuries to both elbows. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed neither NA-T nor NA-X's employee files contained any evidence that competency testing for safe resident transfer procedures had been completed and documented for these employees. B. Sampled employee files for five staff members, MA (Medication Aide)-Y, and NA's T, X, E, and Z) revealed these employees provided direct care to residents residing outside of the special care dementia units. Reviews of these files revealed no evidence any of these employees received competency testing in the skills required to provide direct care to residents. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed MA-Y, and NA's T, X, E, and Z's employee files contained any evidence that competency testing for the provision of direct care tasks for residents had been completed and documented for these employees. C. Review of employee files for four sampled NAs (L, M, R and S), currently working in the SCUs and employed for more than one year, revealed no documentation of inservice education or competency testing related to the specific care needs of residents with [MEDICAL CONDITION] and Dementia. Further review revealed no inservice education or competency testing related to contact isolation procedures. Review of the Resident List Report: dated 7/2/18, revealed 28 residents currently resided in the SCUs. Observations on 7/2/18 at 8:45 AM, during the initial tour of the SCUs, revealed one resident (Resident 74) in isolation precautions. Interview with the Business Office Manager/Human Resources Manager on 7/10/18 at 11:00 AM confirmed that these employee files did not contain any documentation of specific in-services or competency testing related to the care of residents in the SCUs with [DIAGNOSES REDACTED]. Further interview confirmed that there was no documentation that the employees received in-service education or competency testing for the care of a resident in isolation.",2020-09-01
880,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,730,E,1,1,PRIL11,"> Licensure Reference Number 175 NAC 12-006.04B2a Based on observations, record reviews and interviews; the facility failed to ensure that the required 1) 12 hours of in-service education was provided for three sampled NAs (Nursing Assistants) L, S and R and one sampled MA (Medication Aide) M and 2) performance evaluations were completed for three sampled NAs (L, S and R). The facility census was 93 with 26 current sampled residents. Findings are: [NAME] Review of the employee files for NAs - L, S and R and MA - M revealed no documentation of the required 12 hours of continuing education. Further review revealed no performance evaluations for NAs L, S and R. Interview with the Business Office Manager/Human Resources Manager on 7/10/18 at 11:00 AM confirmed that these employees were hired more than a year ago. Further interview confirmed that there was no documentation that they completed the required 12 hours of in-service education or that annual performance evaluations were completed.",2020-09-01
881,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,732,C,0,1,PRIL11,"Based on observations, record review and interview; the facility failed to ensure that the nurse staffing hours were posted as required. The facility census was 93 with the potential to affect residents, families and visitors with current information including the resident census and nursing staff providing care. Findings are: Observations on 7/2/18 at 8:15 AM, during the initial tour of the facility, revealed the daily Direct Care Staffing Hours posted by the front entrance office was dated 6/29/18. Interview with the Director of Nursing on 7/2/18 at 9:30 AM confirmed that the staff posting was not current as required.",2020-09-01
882,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,744,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interview, the facility failed to ensure follow up documentation after an aggressive behavior episode to ensure that the resident's needs were met for one current sampled resident (Resident 83). The facility census was 93 with 26 current sampled residents. Findings are: Review of Resident 83's care plan, goal date 9/13/18, revealed that the resident had [DIAGNOSES REDACTED]. Interventions included monitor behavior episodes and attempt to determine underlying cause, assess or possible physical needs and redirect to positive interactions. Review of the Progress Notes, dated 6/5/18 at 1:27 AM, revealed that the resident was pacing throughout the halls, agitated and yelling at staff and exit seeking. The resident was offered snacks and drink which were refused, was toileted and brief was changed. The resident refused assistance to bed and threw medications to the nurse. One on one and redirection was provided with no improvement and the nurse will re-approach the resident for bed. Further review revealed no further documentation of the resident's behavior or condition. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/9/18 at 1:10 PM confirmed that there was no further documentation related to the incident. LPN - B confirmed that further assessment and documentation should have been completed to include follow up with the resident's behaviors, interventions provided and the resident's responses until resolved to ensure that the resident's needs were met.",2020-09-01
883,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,755,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12A Based on observations, record reviews, and interviews, the facility failed to obtain an order for [REDACTED]. Facility census was 93. Findings are: Observation on 7/3/18 at 8:27 a.m. revealed MA (Medication Aide)-V providing medications for Resident 55. Prior to providing the resident with [MEDICATION NAME], 325 milligrams two tablets, MA-V removed the two tablets and crushed them, then mixed the tablets in applesauce and administered them to the resident. Record review of Resident 55's chart and electronic records revealed there was no orders obtained from the practitioner to alter the form, by crushing, the resident's medications. Interview with LPN (Licensed Practical Nurse)-K confirmed Resident 55's medical practitioner had not provided any orders to alter the resident's medications by crushing them.",2020-09-01
884,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,757,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interview, the facility failed to ensure that routine blood pressure readings were obtained and evaluated to ensure the therapeutic benefits of high blood pressure medications for one current sampled resident (Resident 83). The facility census was 93 with a current sampled of 26 and five residents selected for medication review. Findings are: Review of Resident 83's Medication Administration Record, [REDACTED]. Further review revealed an order, dated 11/10/17 for [MEDICATION NAME] for hypertension and an order, dated 10/2/16, for [MEDICATION NAME] for benign essential hypertension. Review of the facility Weights and Vitals Summary, Blood Pressure Summary revealed no blood pressures recorded from 5/8/18 - 7/8/18. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/10/18 at 7:20 AM confirmed that blood pressure readings should be obtained and evaluated at least weekly to ensure that the resident received the therapeutic benefits of the multiple high blood pressure medications with no adverse side effects.",2020-09-01
885,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,758,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interview, the facility failed to ensure that there was a supporting [DIAGNOSES REDACTED]. The facility census was 93 with 26 current sampled residents and five residents selected for pharmacy review. Findings are: Review of Resident 83's Medication Administration Record, [REDACTED]. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/10/18 at 7:20 AM confirmed that there was no supporting [DIAGNOSES REDACTED].",2020-09-01
886,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,761,E,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.12E1 Based on observations, record reviews, and interview, the facility failed to ensure open dates were recorded on medication multi-dose vials and bottles kept in storage. This failure could potentially affect the effectiveness of these medications for residents (Resident 34, 46 and 40) receiving medications from these vials and bottles. Facility census was 93. Findings are: Observations on 7/2/18 beginning at 8:50 a.m. revealed the following: - The 200 hall medication room refrigerator contained 2 vials of [MEDICATION NAME] for Resident 34 and one vial of [MEDICATION NAME] for Resident 46. These multi-dose vials were opened and used with no open date recorded. Further observation revealed 3 opened vials of [MEDICATION NAME] (injectable solution used for [MEDICATION NAME] testing) a stock injectable used on resident's requiring the test. These multi dose vials were undated as to when opened. - The 100 hall medication room revealed eye drop bottles of [MEDICATION NAME] and Latanoprost for Resident 40 had been opened and no open dates were recorded on these medications. Further observation revealed one vial of [MEDICATION NAME] injectable was opened and undated as to when opened. Further observation revealed a stock vial of Influenza vaccine, used for residents with ordered vaccination, was opened and undated as to when opened. Interview with the Administrator, Director of Nursing, and Assistant Director of Nursing on 7/5/18 at 3:25 p.m. confirmed the medication refrigerator room observations of vials and bottles opened and undated as to when opened. Sources: American Diabetes Association, Diabetes Care informs vials of [MEDICATION NAME] should be discarded after 28 days. CDC (Centers for Disease Control): informs vials of [MEDICATION NAME] should be discarded due to possible oxidation after 30 days. The CDC also informs that influenza vaccine multi dose vials should be discarded after 28 days. FDA (Food and Drug Administration): informs multi dose bottles of Latanoprost eye drops should be discarded 6 weeks after opening and multi dose bottles of Bromadine eye drops should be discarded 28 days after opening.",2020-09-01
887,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,812,F,0,1,PRIL11,"Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interviews the facility failed to: 1) ensure that the pantry ceiling was free from cracks and holes; and 2) ensure staff preparing meals used hand hygiene to prevent potential cross contamination. These failures had the potential to affect all residents. Sample size was 26 current residents. Facility census was 93. Findings are: Kitchen Observation on 07/09/18 at 9:18 a.m. revealed the pantry ceiling had cracks and holes located around the light fixture located toward the back of the pantry. Kitchen Observation on 07/10/18 at 8:00 a.m. revealed the pantry ceiling had cracks and holes located around the light fixture located toward the back of the pantry. Staff interview on 07-10-18 at 8:10 a.m. with the Administrator and Dietary manager confirmed the ceiling in the pantry was cracked and damaged and was in need of repair. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Code and used as an authoritive reference to the food service sanitation practices, revealed the following: 6-2-01.11 Cleanability, Floors, Walls, and Ceilings. Except as specified under 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and EASILY CLEANABLE. B. Kitchen Observation on 07/09/18 at 11:37 a.m. revealed Cook-F did not wash hands or use hand sanitizer after moving a cart with dirty dishes on it and then returned to preparing and mixing ingredients for goulash. Kitchen Observation on 07/09/18 at 11:37 a.m. revealed Cook-F did not wash hands or use hand sanitizer prior to placing gloves on hands. Kitchen Observation on 07/09/18 at 11:37 a.m. revealed Cook-F did not wash hands after having removed the gloves and Cook-F proceeded to remove cookies from the cookie sheets. Staff interview on 07/10/18 at 8:10 a.m. with the Administrator and Dietary Manager verified that Cook F did not follow proper hand hygiene while working in the kitchen and completing meal preparations in order to prevent cross contamination. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Code and used as an authoritive reference to the food service sanitation practices, revealed the following: 2-301.14 When to Wash (E) After handling soiled Equipment or Utensils; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.",2020-09-01
888,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,867,G,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].07C Based on observations, record reviews, and interviews, the facility's QA (Quality Assurance) committee failed to: 1) identify regulatory deficient practice in systems including: Advanced directives regarding employee CPR (Cardiopulmonary Resuscitation) documentation; environment and maintenance, Activities, prevention of accident/hazards; verifying nursing employee competencies, education, and performance evaluations; Posting of nurse staffing; dating opened multi dose vials and bottles to ensure efficacy of these medications, vaccines, and injectables; Dietary department sanitation; Infection control practices; and Pest control. Failure to identify and correct issues related to improper resident transfers resulted in a fracture for one sampled resident (Resident 5) and elbow skin tears for one sampled resident (Resident 89); and 2) failed to maintain compliance in areas previously cited for deficient practice at the [DATE] annual survey. Facility census was 93. Findings are: Record review of the facility's (YEAR) Quality Assurance & Performance Improvement Plan revealed from Guiding Principle #4 that Our organization focuses on systems and processes. Listed in the document's Plan recorded in the Feedback, Data Systems and Monitoring section that the committee will put in place systems to monitor care and services drawing data from multiple sources . It also includes tracking, investigation, and monitoring adverse events every time they occur. The monitoring section documented the QA committee will decide what data to monitor routinely including Clinical care areas, medications, hospitalization s . care plans . state survey results and deficiencies . Business and administrative processes Regarding QA Evaluation the plan recorded: The team will thoughtfully and thoroughly consider the progress made in the last year toward achieve . goals and current status of measurement in meeting and sustaining the performance indicators . Results of the survey observations, record reviews, and interviews conducted between [DATE] and [DATE] revealed the facility received citations for deficient practice at scopes of patterns (more than 3 residents but not all residents), widespread (affecting all residents), and an actual harm severity related to resident accidents involving Residents 5 and 89; and staff competency regarding transfer techniques used for Residents 5 and 89. Citations with scopes of pattern or widespread were as follows: - E-001 The facility's emergency preparedness plan failed to include 13 required components describing policies and procedures for those components. - F578- the facility failed to maintain CPR certification for three licensed nurses providing direct cares for residents. The failure could potentially have affected 17 current residents requesting CPR in the event of a [MEDICAL CONDITION]. - F584- the facility environment was cited regarding multiple clinical areas of halls and resident rooms requiring repair, cleaning, or replacement of walls and flooring. - F679- the facility was cited for failure to document activity responses and progress for one resident and failure to provide ongoing activities in the special care units. - F689- the facility was cited for accident/hazards. Two sampled residents were identified to have been improperly transferred. Resident 5 was transferred with one assistant in a mechanical standing lift and lost consciousness catching the left wrist in the lift resulting in a wrist fracture. Resident 89 was care planned to have two staff during transfers and was lowered to the floor when only one staff assisted the resident resulting in skin tears to the elbows. In addition, four sampled residents were observed being transported in wheelchairs without the use of footrests increasing the potential for injury during transport. One resident's oxygen concentrator was left on while unattended increasing the risk for room oxygenation and potential fire hazard. Employee files revealed the two staff members involved in transfers for Residents 5 and 89 had no evidence of competency testing in use of mechanical lift or pivot transfers. - F726- Sampled employee files for nurse aides and medication aides revealed no evidence of competency testing related to the provision of direct care skills to residents. - F730- Sampled employee files for staff employed for direct care to dementia residents residing on the Special Care Units revealed no evidence of education hours pertaining to dementia care and no required annual performance reviews for these employees was included in their employee files. - F732- Staff posting for review by residents, families, and visitors was not accurate. - F761- Injectable medications, eye drop containers, and vaccination multi-use vials on two clinical areas were not dated when opened to ensure efficacy of these medications, eye drops, and vaccines. - F812- Dietary sanitation was cited potentially affecting potential cross-contamination of meals served to all residents. - F880- infection control practices regarding isolation and hand hygiene were cited in different clinical areas. - F925- pest control was cited due to the presence of flies and millers/moths found in hallways and in a dining area; and dead bugs discovered in light fixtures in different hallways of the facility. Record review of the facility's survey inspection from an annual survey conducted from [DATE] through [DATE] revealed the following areas of repeat deficient practice during the current survey from [DATE] through [DATE]: - Environmental and maintenance issues were cited at a scope of pattern and the severity was cited with no actual harm with potential for harm. - Accident/hazards were cited at a scope of pattern and severity of actual harm. This citation included accident with fracture and issues of oxygen concentrators left on while unattended. - Infection control was cited at a scope of pattern and severity of no actual harm with potential for harm. - Staff posting was cited as being inaccurate. - Dietary sanitation was cited was cited at a scope of widespread and severity of no actual harm with potential for harm. - Medication labeling was cited at a scope of pattern and severity of no actual harm with potential for harm. - Pest control cited flies in the facility at a scope of widespread and severity of no actual harm with potential for harm. - Staff education was cited related to emergency preparedness at a scope of widespread and severity of no actual harm with potential for harm. Interview with the facility Administrator on [DATE] at 2:47 p.m. revealed the facility had multiple systems issues related to issues with the ownership leading to the facility being transitioned through a receivership. The Administrator confirmed there were multiple systems problems including the loss of records and assessments, employee file documents, and difficulties obtaining necessary supplies and equipment to maintain the facility. The Administrator stated the focus at the facility has been maintaining staff and residents in light of the receivership management taking over. The Administrator verified there are many issues needing resolution and correction.",2020-09-01
889,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,880,E,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews; the facility failed to ensure that 1) isolation precaution procedures were followed for one current sampled resident (Resident 74) on the 500 wing and 2) hand washing was completed after the removal of disposable gloves during personal cares for two current sampled residents (Residents 74 and 18), during wound care for one current sampled resident (Resident 89) and during restorative nursing care for one current sampled resident (Resident 5) to reduce the risk for cross contamination. The facility census was 93 with 26 current sampled residents and 11 current residents on the 500 wing. Findings are: Licensure Reference Number 175 NAC 12-006.17B [NAME] Observations of the 500 wing on 7/2/18 at 8:45 AM, during the initial tour, on 7/3/18 at 11:00 AM, on 7/5/18 at 6:00 AM and on 7/9/18 2:00 PM revealed isolation supplies and a biohazard container in the hallway by room [ROOM NUMBER] (Resident 74). Further observations revealed no sign on the door to direct staff and visitors to the nursing station for instructions before entering the room. Further observations revealed no containers for soiled linens and clothing or trash in the room. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/2/18 at 8:45 AM revealed that Resident 74 was in contact isolation due to an intestinal infection. Observations on 7/3/18 at 11:00 AM revealed the resident in the bathroom, incontinent (unable to control bowel) of diarrhea. Further observations revealed NA (Nursing Assistant)- L donned a disposable gown and applied disposable gloves in the hallway, provided skin care for the resident with disposable wipes. NA - L placed the disposable wipes in a plastic trash bag. Further observations revealed NA -L left the resident's room, wearing the gown and contaminated disposable gloves, opened the bathroom door on the 500 wing with gloved hands, placed the soiled trash in a container, removed gown and gloves and placed them in the container and then washed hands. Observations on 7/3/18 at 11:05 AM revealed MA (Medication Aide) - M donned a disposable gown and gloves and applied cream to the resident's buttocks. Further observations revealed MA - M removed the disposable gown and gloves in the hallway outside of the resident's room and placed them in the biohazard trash container in the hallway. MA - M picked up the plastic bag containing the contaminated gloves and wipes, opened the door to the 400 wing and then the door to the 400 wing utility room, placed the bag into the biohazard container and then washed hands. Observations on 7/5/18 at 9:10 AM revealed NA - N and MA - M donned disposable gowns and gloves, provided incontinence care for the resident, assisted the resident to bed, positioned the resident for comfort and removed gowns and gloves in the hallway outside of the residents room, placed them in the biohazard container and used hand gel from the container in the hallway. Review of the facility procedure Infection Control Initiating Isolation , revised 5/1/10, revealed the following including: Policy To provide guidance for isolation precautions when residents have or are suspected to have an infectious or communicable disease. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. Procedure . 3. Isolation precautions are initiated: - Maintain an adequate supply of isolation supplies (gloves, gowns, masks, etc., as needed) at the entrance of the isolation room so that appropriate personal protective equipment can be easily used. - Post an isolation notice sign on the room entrance door instructing staff and visitors to report to the nursing station before entering the room. - Place a container for laundry and containers for waste in the isolation room. Interview with LPN (Licensed Practical Nurse) - U, Infection Control Nurse, on 7/9/18 at 12:10 PM confirmed that the isolation room should have a sign on the door to direct staff and visitors to the nurse's station for instructions before entering the room. Further interview confirmed that containers for soiled linens and clothing and trash should be placed inside the room for safe handling and to reduce the risk of cross contamination. Licensure Reference Number 175 NAC 12-006.17D B. Review of Resident 74's care plan, goal date 9/11/18, revealed that the resident had [DIAGNOSES REDACTED]. Further review revealed that the on 6/18/18 the resident had [MEDICATION NAME] related to C - diff ([MEDICAL CONDITION]), a contagious infection that damages the intestinal lining and causes diarrhea. Observations on 7/3/18 at 11:05 AM revealed MA (Medication Aide) - M donned a disposable gown and gloves and applied cream to the resident's buttocks. Further observations revealed MA - M removed the disposable gown and gloves in the hallway outside of the resident's room and placed them in the biohazard trash container in the hallway. MA - M did not wash hands or apply hand gel when the disposable gloves were removed. MA - M picked up the plastic bag containing the contaminated gloves and wipes, opened the door to the 400 wing and then the door to the 400 wing utility room, placed the bag into the biohazard container and then washed hands. Observations on 7/5/18 at 9:10 AM revealed NA - N donned a disposable gown and disposable gloves, provided incontinence care for the resident with disposable wipes, removed gloves and without hand washing, applied another pair of gloves, adjusted the resident's clothing, assisted to the wheelchair and then to bed. Review of the facility policy and procedure Infection Prevention and Control Program, created (MONTH) (YEAR), revealed the following including: Policy Explanation and Compliance Guidelines: . 4 Hand Hygiene Protocol: a. All staff shall wash hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE (Personal Protective Equipment) removal . Interview with LPN - U, Infection Control Nurse, on 7/9/18 at 12:10 PM confirmed that the nursing staff were follow the infection control policies including washing their hands after disposable gloves were removed to reduce the risk of cross contamination. C. Observation of incontinence care for Resident 18 on 7/2/10 revealed NA-E and MA (Medication Aide)-V assisting the resident with care. During the observation the resident was repositioned on the bed for a change of incontinence brief and neither NA-E nor MA-V washed hands prior to the procedures. During incontinence cares the staff members applied disposable gloves for the procedure and failed to perform hand hygiene (washing or using hand sanitizer) after removing the gloves. Interview with Administrator, DON, and ADON on 7/5/18 at 3:35 p.m. revealed staff members were expected to perform hand hygiene prior to resident cares and after removal of gloves per facility policies. D. Observation of wound care provided to Resident 89 on 7/02/18 from 10:40 a.m. to 11: 20 a.m. revealed LPN (Licensed Practical Nurse)-AA was changing an abdominal wound vac for the resident. During the procedures LPN-AA was observed washing hands and applying disposable gloves. LPN-AA then proceeded with the procedure by removing the previous wound dressing. LPN-AA then removed the soiled gloves and disposed of them and donned another pair of disposable gloves without performing any hand hygiene after removal. LPN-AA then proceeded to prepare the clean dressings and re-dressing the wound and was observed changing the disposable gloves another three times during the procedure without any hand hygiene after these removals. E. Observation of restorative nursing Range of Motion (movement of bone joints) provided for Resident 20 on 7/10/18 from 9:55 a.m. to 10:25 a.m. revealed RA (Restorative Aide)-J assisting Resident 20 with Passive (staff providing the task) Range of Motion. During the observation, RA-J was observed washing hands before beginning. RA-J then proceeded with the task applying disposable gloves and applying lotion to each of the resident's extremities during the Range of Motion exercises. RA-J removed gloves after each joint area (foot and ankle, elbows and shoulders) on each side involving four changes of the disposable gloves. Following removal of the gloves during the four changes, RA-J failed to perform any hand hygiene before donning a new pair of gloves. Record review of a facility policy for Standard Precautions- Infection Control created in (MONTH) of (YEAR), the Policy explanation and compliance guidelines for hand hygiene directed staff to Perform hand hygiene directed to perform hand hygiene after removing gloves. The policy goes on to provide directions for .Using gloves with instructions to remove gloves after contact with a patient and or surrounding environment (including medical equipment) using proper technique. Interview with DON, and ADON on 7/10/18 at 3:35 p.m. revealed staff members were expected to perform hand hygiene after removal of gloves per facility policies.",2020-09-01
890,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,921,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18B Based on observations and interview, the facility failed to ensure that there were curtains for the outside window for one resident (Resident 65). The facility census was 93 with 26 current sampled residents. Findings are: Observations of Resident 65's room (room [ROOM NUMBER] B) on 7/2/18 at 9:00 AM, during the initial tour, and on 7/10/18 at 7:45 AM revealed no curtains for the outside window with the privacy curtain covering the window. Interview with the Maintenance/Housekeeping Supervisor on 7/10/18 at 7:45 AM confirmed that the resident's window needed curtains. Interview with LPN (Licensed Practical Nurse) - B, Unit Coordinator, on 7/10/18 at 7:45 AM confirmed that there were no curtains on that window for a couple of weeks.",2020-09-01
891,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,923,D,0,1,PRIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04D Based on observations and interview, the facility failed to ensure that the bathroom ventilation system was functioning in room [ROOM NUMBER] (Resident 74) and 507 (Residents 23 and 22) to control bathroom odors. The facility census was 93 with observations of 24 initial pool residents. Findings are: Observations of Rooms 506 (Resident 74) and 507 (Residents 23 and 22) on 7/2/18 at 2:30 PM and on 7/10/18 at 7:45 AM revealed the bathroom ventilation systems not functioning to pull up air at the ceiling vents. Further observations revealed strong bathroom odors. Interview with the Maintenance Supervisor on 7/10/18 at 7:45 AM confirmed that the bathroom ventilation system in these rooms was not functioning to control bathroom odors and needed to be checked and repaired.",2020-09-01
892,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-07-10,925,E,0,1,PRIL11,"Licensure Reference Number: 175 NAC 12-006.18A(4) Based on observation and interviews, the facility failed to prevent the entrance of flies and other flying insects into the facility. All residents could be affected. Sample size was 26 current residents. Facility Census was 93. Findings are: [NAME] Dining observation on 07/03/18 at 11:43 a.m. revealed dead insects in the ceiling lights by the serving window in the East dining room. Dining observation on 07/05/18 at 6:08 a.m. revealed flying Millers/Moths in the East dining room. Dining observation on 07/09/18 at 6:26 p.m. revealed flies in the East dining room and Resident (2) was sitting at the table swatting at the flies that were flying around Resident 2's head. Staff interview on 07/10/18 at 8:35 a.m. with the Administrator and Dietary Manager verified there were flying insects in the dining room. B. Observation on 07/10/18 at 7:55 a.m. of the 200 hall revealed a Miller/Moth flying around and the Miller/Moth landed on the wall. Observation on 07/10/18 at 7:55 a.m. of the 300 hall revealed dead insects in the ceiling light fixtures. Staff interview on 07/10/18 at 9:35 a.m. with the Administrator verified there were Millers/Moths flying in the 200 and 300 hallways and verified there were dead insects in the ceiling light fixtures in the 300 hall way.",2020-09-01
893,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-08-07,657,D,1,0,Q59C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number 175NAC 12-006.09C Based on record review, and interview, the facility failed to develop, review, and revise the comprehensive care plan for 1 sampled resident (Resident #2). Census: 89 residents. Sample size 5 residents. [NAME] On 8/7/18 at 10:00 AM a record review for Resident #2 revealed a history of hypoglycemic (high sugar levels in the blood) incidents. A review of the residents care plan revealed there was a care plan entry regarding [MEDICAL CONDITION] with interventions and goals. The record review also revealed an entry dated 7/22/18 addressing [DIAGNOSES REDACTED] episode with an intervention of Sent to ER to eval and treat with no further interventions and no goals being addressed. Review of the progress notes revealed documentation of a hypoglycemic episode on 7/22/18 at 04:30 AM, documented that Resident #2 was sent to the emergency department for evaluation and treatment. Documentation revealed that after returning to the facility, Resident #2 experienced another hypoglycemic episode documented at 10:20 PM on 7/22/18. Documentation revealed that Resident #2 experienced another hypoglycemic episode on 7/28/18 at 4:28 PM with no interventions or goals added to the care plan. An interview on 8/7/18 at 3:45 PM with the Director of Nursing and Assistant Direcort of Nursing confirmed there was no updated or revised careplan addressing [DIAGNOSES REDACTED] for Resident #2. An interview on 8/7/18 at 4:30 PM with the Administrator confirmed there was no updated or revised care plan addressing [DIAGNOSES REDACTED] for Resident #2.",2020-09-01
894,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,157,G,1,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.04C3a (6) Based on observations, record reviews and interviews; the facility failed to notify 1) the medical practitioner of a change of condition for three current sampled residents (Residents 15, 84 and 169) to ensure that medical care was provided to meet the needs of the residents and 2) the resident's POA (Power of Attorney) of a change in condition for one closed record (Resident 50). The facility census was 107 with 22 current sampled residents and three closed records reviewed. Findings are: [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 8/8/17 at 11:20 AM revealed that the resident had back and neck pain. The resident stated that the resident took pain medications but it still hurts. Observations during the interview on 8/8/17 at 11:20 AM revealed that the resident had pained facial expressions and a clenched jaw. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurt so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Interview on 8/9/17 at 10:00 AM with RN (Registered Nurse) - P, Charge Nurse, revealed that the resident had chronic neck pain and usually requested a pain pill in the morning. RN - P did not mention the resident's back pain. Further interview at 10:10 AM revealed that an order was just received for a urology consult. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complaining of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed the resident had bright red blood in the toilet. Interview on 8/9/17 at 11:30 AM with RN - P revealed that no appointment had been made yet for the resident to be seen by a medical practitioner. Further interview revealed that RN-P would have the Nurse Practitioner check the resident today. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident had a routine [MEDICATION NAME] (narcotic [MEDICATION NAME]). Further review revealed that the resident received [MEDICATION NAME] (Opioid [MEDICATION NAME]), ordered as needed for pain, on 8/7/17 at 8:22 AM, on 8/8/17 at 8:38 AM and 7:12 PM and on 8/9/17 at 8:43 AM for pain rated 9 (severe) on the 1-10 pain scale. Further review revealed documentation that the 8/8/17 at 8:38 AM and the 8/9/17 at 8:43 AM doses were ineffective in relieving the resident's pain. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the LPN (Licensed Practical Nurse) -C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that the medical provider should have been notified of the resident's ongoing unrelieved pain and blood with urination sooner to evaluate the resident and consider further orders to relieve the resident's pain. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/7/17 at 9 AM, during the initial tour of the facility, on 8/8/17 at 11:00 AM and 2:30 PM and on 8/9/17 at 9:30 AM and 1:30 PM revealed a strong, foul odor in the resident's room and into the hallway. Further observations on 8/9/17 at 9:30 AM revealed the resident seated in the wheelchair in room removing the ace wraps and dressings from lower legs to show the bleeding from legs. Noted clear, foul smelling drainage from both lower extremities. Observations of skin care at 1:30 PM revealed that the clear, foul smelling drainage continued from the resident's lower extremities. Review of the Progress Notes, dated 8/1/17 - 8/14/17, revealed no notes related to the ongoing, foul smelling drainage or indication that the medical practitioner was notified. Interview with LPN - C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that there was no documentation that the medical provider was notified of the ongoing, foul smelling drainage at the lower extremities. C. Review of the Admission Record, printed 8/9/17, revealed that Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/9/17 at 1:00 PM with LPN - Q, Charge Nurse, revealed that the resident's dressings at the coccyx area were removed as the resident had diarrhea stools. LPN - Q stated that the diarrhea may be caused from new medications that the resident is taking. Observations on 8/9/17 at 1:00 PM revealed the resident on the bed for wound care. Further observations revealed LPN - Q provided skin care due to diarrhea. Interview on 8/14/17 at 7:45 AM with the resident revealed that diarrhea continued through the weekend. The resident stated had two diarrhea episodes yesterday and one again this morning. Interview on 8/14/17 at 9:00 AM with RN - P, Charge Nurse, revealed that the resident's routine morning dose of Senna (laxative) was not held this morning. RN -P stated would notify the Nurse Practitioner today of the resident's ongoing diarrhea. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that the Nurse Practitioner was not notified of the resident's ongoing diarrhea until 8/14/17. Further interview revealed that a new order was received on 8/14/17 to change the Senna to as needed rather than daily. D. Review of the Admission Record, printed 8/15/17, revealed that Resident 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 7/21/17 at 9:37 AM revealed that the resident's blood pressure was 103/45 and at 3:48 PM the resident's blood pressure was 79/48. Further review revealed no documentation that the resident's POA was notified of the low blood pressure. The POA was notified of the resident's death at 4:49 PM. Interview on 8/15/17 at 2:15 PM with LPN - C, Unit Coordinator, confirmed that there was no documentation that the resident's POA was notified of the resident's low blood pressure reading.",2020-09-01
895,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,164,E,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observations and interviews, the facility failed to ensure that 1) residents were draped during wound care and personal cares to prevent unnecessary exposure of the body for two current sampled residents (Residents 169 and 37), 2) vital signs were not obtained in public areas for five residents (Residents 96, 143, 166, 34, and 111), 3) staff knocked on resident's doors and waited for permission to enter for five residents (Residents 8, 142, 163, 41, 30 and 116), 4) the door was closed or privacy curtain was pulled while a blood sugar was checked and an injection was administered for one resident (Resident 142) and 4) a urinary catheter drainage bag was covered for one resident (Resident 142). The facility census was 107. Findings are: [NAME] Observations on 8/9/17 at 1:00 PM revealed that RN (Registered Nurse) - P and LPN (Licensed Practical Nurse) - Q positioned Resident 169 on left side to provide wound care at the right buttock and coccyx area and to provide personal cares due to incontinent diarrhea. Further observations revealed the resident was exposed from the waist down during the cares with no attempts to drape the resident to prevent unnecessary exposure of the resident's body and to promote comfort. Observations on 8/10/17 at 1:00 PM revealed LPN - R and LPN - C positioned Resident 37 on right side to provide wound care at the resident's coccyx area. Further observations revealed the resident was exposed from the waist down during the cares with no attempts to drape the resident to prevent unnecessary exposure of the resident's body and to promote comfort. B. Observations on 8/10/17 at 7:15 AM revealed MA (Medication Aide) - S obtained an oxygen saturation reading for Resident 90 in the 200 wing hallway with several residents and staff in the hallway at that time. Observations on 8/10/17 at 7:45 AM revealed MA - T obtained a blood pressure from Resident 143 in the dining room with several residents in the dining room eating breakfast. Observations on 8/7/17 at 10:00 AM revealed NA (Nursing Assistant) - O obtained vital signs from Resident 166 in the 100 wing front lobby. C. Observations on 8/10/17 at 9:00 AM revealed MA - M entered Resident 8's room to administer medications without knocking on the door or asking permission to enter the room. Observations on 8/10/17 at 11:45 AM revealed RN - P entered Resident 142's room without knocking on the door or asking permission to enter the room. Observations on 8/10/17 at 2:40 PM revealed NA - U entered Residents 163 and 42's room without knocking on the door or asking permission to enter the room. Observations on 8/10/17 at 2:50 PM revealed NA - K entered Residents 142 and 30's room without knocking on the door or asking permission to enter the room. D. Observations on 8/10/17 at 11:45 AM revealed RN - P obtained Resident 142's blood sugar and administered an insulin injection in the resident's abdomen without closing the door or utilizing the privacy curtain to provide privacy. E. Observations on 8/10/17 at 11:45 AM and 3:15 PM revealed Resident 142's urinary catheter drainage bag attached to the bed frame with no privacy cover. Interview on 8/14/17 at 3:45 PM with the Interim Director of Nursing confirmed that the staff were to make efforts to cover residents during personal cares to prevent unnecessary exposure of the resident's bodies. Further interview confirmed that the staff were not to obtain vital signs in public areas, were to knock on the resident's door and receive permission to enter, were to close the door or utilize the privacy curtain during medical procedures and were to utilize a privacy bag for urinary catheter drainage bags to promote privacy for the residents. F. Observation on 8/8/2017 at 8:00 AM of Resident 166 getting vital signs taken by Licensed Practical Nurse-J in the hallway of the 200 wing in view of other residents, staff and visitors. [NAME] Observation on 8/8/2017 at 11:35 AM of Resident 111 getting blood sugar checked in the hallway of the 300 wing by Licensed Practical Nurse-N in view of other residents, staff, and visitors. H. Observation on 8/8/2017 at 11:45 AM of Resident 34 getting vital signs taken in the hallway of the 100 wing by Medication Aide-M in view of other residents, staff and visitors. I. Observation on 8/8/2017 at 10:00 AM during a resident interview with Resident 116 Licensed Practical Nurse-Q walked in the resident's room without knocking.",2020-09-01
896,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,165,F,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.06A Based on observations and interviews, the facility failed to establish and implement procedures for submitting grievances by failing to display and provide a method of filing grievances for residents and/or family members, employees and others. This failure had the potential to affect all residents. Facility census was 107. Findings are: Observation on 08/07/2017 at 9:00 AM during the initial facility inspection revealed that there were no grievance forms setting out throughout the facility. Observation on 08/14/2017 at 4:29 PM of the facility revealed that there were no grievance forms setting out throughout the facility. Interview on 08/14/2017 at 4:35 PM with Licensed Practical Nurse-C, Unit Coordinator, confirmed that the grievance forms were not accessible to residents and or families in common areas of the facility.",2020-09-01
897,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,223,D,1,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(9) Based on record review and interviews, the facility failed to protect residents from abuse for 4 sampled residents (Residents 10, 60, 132, and 143). The facility census was 113. Findings are: [NAME] Review of the Nursing Progress Note for Resident 60, dated 6/8/2017 at 9:41 PM, stated that Resident voiced concerns early in shift regarding roommate and requesting new room. S/W 300 unit coordinator and they will address it in the am. Will continue to monitor. B. Review of the Nursing Progress Note for Resident 60, dated 6/9/2017 at 12:53 PM, stated Verbal outbursts with roommate continue. C. Record review of Intake Information revealed that Administrator reported an alleged resident to resident abuse to APS (Adult Protective Services) on 6/27/2017 at 5:00 PM by phone. It was reported that Resident 10 and 60 used to be roommates. Resident 10 was intimidating Resident 60. Resident 60 woke up one night and Resident 10 was standing over Resident 60 and scared Resident 60 to death. Resident 60's daughter demanded Resident 60 be moved to a new room. Resident 60 was moved to a new room. The move occurred on 6/13/2017. Administrator stated in the past that Resident 10 also left the television on all night and turned it up and resident stated that resident could because resident can. On 6/27/2017, there was an incident in the hallway between Resident 10 and Resident 60. Resident 60 hollered and either housekeeping or a CNA came out of the room and separated the two women. Resident 10 had grabbed Resident 60 from behind. No injuries were noted. D. Review of the Nursing Progress Note dated 6/27/2017 at 4:11 PM stated that a call was placed to Resident 60's daughter to update on the altercation with Resident 10. A message was left for the daughter to return the call at the daughter's convenience. E. Review of the Nursing Progress Note dated 6/27/2017 at 4:15 PM stated that a call was placed to the Resident 10's daughter to update on the altercation between Residents 10 and 60. A message was left for the daughter to return the call. F. Review of the Nursing Progress Note dated 6/27/2017 at 4:20 PM stated that a fax was sent to Resident 10's physician to update on the altercation with Resident 60 and that the resident had denied any injuries at that time. [NAME] Review of the Nursing Progress Note dated 6/27/2017 at 4:25 PM stated the a fax was sent to Resident 60's physician to update on the altercation with Resident 10 and that resident had denied any injuries at that time. H. Review of the quarterly 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.) for Resident 10 dated 6/30/2017, identified that the resident exhibited physical behaviors directed towards others and that other behavioral symptoms not directed towards others. I. Review of the Comprehensive Care Plan dated 7/06/217, did not identify resident behaviors that were noted on the 6/30/17 quarterly MDS. [NAME] Review of the Social Services Progress Note for Resident 10, dated 6/30/2017 10:04 stated Resident has a behavior of hitting/kicking, using abusive language, and rejection of care. K. Review of the quarterly MDS, dated [DATE] for Resident 60, did not identify any resident behaviors. L. Interview with the Assistant Director of Nursing on 8/10/2017 at 12:00 PM confirmed that the care plan did not address Resident 60's behaviors that were noted on the 6/30/2017 quarterly MDS. M. Review of the Comprehensive Care Plan dated 6/07/2017 for Resident 60 did not identify any resident behaviors. N. Interview with the DON (Director of Nursing) on 8/09/17 at 3:30 PM confirmed that the Administrator called in the event between Residents 10 and 60 on 6/27/2017. DON stated that they did an investigation, but that there was no altercation between the residents. DON stated that the alleged incident occurred in the 200 dining room as the two residents were leaving. O. Interview with the Administrator on 8/09/2017 at 4:25 PM confirmed that the Administrator did not document that Resident 60's daughter requested that Resident 60 be moved to a different room nor that there was documentation that they had moved the resident to a different room. Administrator stated that the daughter caught Administrator in the hallway at the facility, so they just moved the resident right away and Administrator did not document that the moved occurred. P. Interview with the DON on 8/09/2017 at 4:40 PM revealed that the staff moved Resident 10 to another dining room but did not know when it was done and that the Restorative Nurse may know the answer to that question. There was no documentation in the progress notes as to when the change in the dining rooms took place. Q. Interview with the Restorative Nurse on 8/09/2017 at 4:45 PM revealed that Restorative Nurse was aware that Resident 10 was moved from the 200 hall dining room to the 100 hall dining room but did not know when the change occurred. 2. [NAME] Review of the facility policy, titled Abuse Prevention, dated, 2/14/2014, identified the policy as, The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. B. Review of the APS (Adult Protective Services) Intake Worksheet revealed that on 6/30/2017 at 11:51 AM, the Administrator placed a phone call to APS to report an altercation between Residents 132 and 143. The report stated, On 6/30/2017 at 9:30 AM, Resident 132 and 143 were at the dining room table and Resident 132 reached for something and Resident 143 grabbed at Resident 132 on the arm. Staff intervened and were able to separate them. Resident 132 received a small skin tear on the arm that did not need emergency care but staff did clean the area and put a Band-Aid on it. C. Review of the nursing documentation dated 6/30/2017 for Resident 132 identified that Resident 132 got into an altercation with Resident 143 when Resident 132 reached for a bag of creamer/sugar and Resident 143 grabbed Resident 132's arm, causing a skin tear to Resident 132's left arm. The nursing staff intervened and separated the two residents. D. Review of the Comprehensive Care Plan dated 6/30/2017 for Resident 132 identified that an intervention to the resident to resident altercation was staff encouraged to keep residents separated as residents will allow. E. Review of the Comprehensive Care Plan dated 6/30/2017 for Resident 143 identified that an intervention to the resident to resident altercation was to separate resident for safety, moved to different table at meal times. F. Review of the nursing documentation dated on 7/09/2017 at 11:00 AM identified that Resident 132 was upset at another resident about the dining room blinds being open. When the nursing staff was redirecting Resident 132 away from the other resident, Resident 132 pulled a strand of hair from the resident. [NAME] Review of the Comprehensive Care Plan dated 7/09/2017 for Resident 132 identified that an intervention to the resident to resident altercation was to encourage activities, redirect as resident allows. H. Review of the Nursing Progress Note on 7/24/2017 at 2:45 PM identified that Resident 132 was slapped across the left side of the face by Resident 143. Nursing staff intervened and redirected both residents. I. Review of the Comprehensive Care Plan dated 7/24/2017 for Resident 132 identified that an intervention to the resident to resident altercation was to redirect resident to assist staff with other activities. [NAME] Review of the Comprehensive Care Plan dated 7/24/2017 for Resident 143 identified that an intervention to the resident to resident altercation was to encourage staff to do activities with this resident. K. Review of the nursing documentation on 7/26/2017 for Resident 132 identified that the resident was moved off of the 300 wing to the 200 wing. L. Review of the nursing documentation dated on 7/31/2017 at 5:25 PM identified that Resident 132 had grabbed roommates arm. Nursing staff intervened and were separated. No injuries were noted. M. Review of the Comprehensive Care Plan dated on 7/31/2017 for Resident 132 identified that an intervention to the resident to resident altercation was to separate the residents, moved Resident 132 to a private room and requested a medication review. N. Review of the nursing documentation on 7/31/ for Resident 132, identified that resident was moved to a private room on the 100 wing. O. Review of the nursing documentation on 8/01/2017 at 11:15 PM for Resident 132, identified that Resident 132 was pushing another resident from their room, while in their wheelchair, with the oxygen concentrator still on the resident. P. Review of the Comprehensive Care Plan dated on 8/01/2017 for Resident 132, identified that the intervention for the resident to resident altercation was to initiate one to one supervision. Q. Interview with the ACU (Alzheimer's Care Unit) Director on 8/09/2017 at 10:00 AM identified that Resident 132 and Resident 143 had some personality conflicts. Resident 132 was very bossy and busy. Resident 143 had not had any other resident to resident altercations after Resident 132 was moved off of the 300 wing. ACU Director noted that the nursing staff had tried to keep Resident 132 and Resident 143 apart as much as possible but was not always able to. ACU Director confirmed that the nursing staff was not always able to redirect Resident 132 and recommended that the resident be transferred off of the 300 wing.",2020-09-01
898,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,225,D,1,1,2T4P11,"> LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02(8) Based on record review and interviews; the facility failed to conduct and submit an investigation of an alleged resident to resident abuse for 9 sampled residents (Residents 10, 60, 58, 18, 70, 132, 143, 15, and 161). The facility census was 113. Findings are: [NAME] Record review of Intake Information revealed that Administrator reported an alleged resident to resident abuse to APS (Adult Protective Services) on 6/27/2017 at 5:00 PM by phone. It was reported that On 6/27/2017, there was an incident in the hallway between Resident 10 and Resident 60. Resident 60 hollered and either housekeeping or a Nurse Aide came out of the room and separated the two residents. Resident 10 had grabbed Resident 60 from behind. No injuries were noted. Interview with the Administrator on 8/07/2017 at 2:20 PM confirmed that the Administrator reported the alleged resident to resident to abuse to APS (Adult Protective Services) but was not aware that an investigation report needed to be completed and sent to the State Agency. Administrator confirmed that no investigation report was completed on the alleged resident to resident abuse event. B. Review of the APS Intake Worksheet revealed that on 6/30/2017 at 11:51 AM, the Administrator placed a phone call to APS to report an altercation between Residents 132 and 143. The report stated, On 6/30/2017 at 9:30 AM, Resident 132 and 143 were at the dining room table and Resident 132 reached for something and Resident 143 grabbed at Resident 132 on the arm. Staff intervened and were able to separate them. Resident 132 received a small skin tear on the arm that did not need emergency care but staff did clean the area and put a Band-Aid on it. Interview with the Administrator on 8/09/2017 at 2:20 PM confirmed that the Administrator made the initial call on the 6/30/2017 event. However, the Administrator did not turn in an investigation report to the State Agency. Administrator confirmed that an investigation should have been conducted and a completed report should have been sent to the State Agency. C. Review of the Adult Protective Services Intake Worksheet dated 7/06/2017, identified that the Administrator reported an alleged staff to resident abuse on 7/06/2017 at 4:34 PM. The Administrator reported that they received a letter from an anonymous complaint that alleged that a staff member told Resident 58 that they smelled. Review of untitled documents, identified that the facility conducted an investigation by interviewing the residents and the staff but an investigative report was not completed nor was the report sent to the State Agency. Interview with the Administrator on 8/09/2017 at 2:20 PM revealed that the Administrator reported the staff to resident allegation but did not send the investigative report to the State Agency. The Administrator confirmed that the investigative report should have been sent to the State Agency within 5 working days. D. Review of the APS (Adult Protective Services) Intake Worksheet dated 7/13/2017, identified that a resident to resident altercation occurred on 7/13/2017 at 11:08 AM between Residents 15 and 161. The reporter stated that Resident 161 was upset that Resident 15 had the radio on at 8:05 AM and went over to turn it off. Resident 15 pushed Resident 161 to get to the radio to get it turned off. The reporter also stated that the day before there was an issue between the two residents about space and the residents were going to be separated into different rooms. Review of a facility document dated on 8/09/2017 identified a resident to resident altercation between Resident 15 and 161, however, an investigation report was not completed on the incident Interview with the DON (Director of Nursing) on 8/09/2017 at 1:30 PM revealed that the DON made the initial call to APS, but did not complete an investigative report nor send the report to the State Agency in Lincoln. Interview with the Administrator on 8/09/2017 at 2:20 PM confirmed that the DON made the initial call on the 7/13/2017 event. However, Administrator did not conduct an investigation nor turn in an investigation report to the State Agency because Administrator was not aware that was required. Administrator confirmed that an investigation should have been conducted and a completed form should have been sent to State Agency in Lincoln. E. Review of the APS Intake Worksheet on 7/15/2017, identified that ADON (Assistant Director of Nursing) reported a resident to resident altercation between Residents 18 and 70 on 7/15/2017 at 6:30 PM. ADON stated that Resident 70 was heading Resident 18's table and grabbed the salt shaker. Resident 18 tried to take it away, Resident 70 hit Resident 18 in the face and Resident 18 punched Resident 70 in the arm and chest. Neither had marks or bruises. Review of an untitled facility document, dated 7/15/2017, identified the resident to resident altercation between Residents 18 and 70. The document revealed that the facility conducted an investigation on the altercation. Interview with the Administrator on 8/09/2017 at 2:20 PM confirmed that the resident to resident altercation was reported to APS by the ADON, but that the investigative report was not completed and sent to State Agency because Administrator didn't know that was the requirement. The Administrator confirmed that the investigative report should have been completed and sent to State Agency within 5 working days.",2020-09-01
899,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,241,D,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observations and interviews, the facility failed to ensure that 1) the door was closed or the privacy curtain was utilized when a resident (Resident 96) was restless, not fully dressed and was on a mat on the floor by the bed, 2) residents were not transported in the hallways in a whirlpool transfer chair covered with a sheet to their knees for two residents (Residents 27 and 37) and 3) residents were assisted with hair care and changing clothes for one sampled resident (Resident 84) to promote the residents' dignity and comfort. The facility census was 107 with 40 current sampled residents. Findings are: [NAME] Observations on 8/10/17 at 2:15 PM revealed Resident 96 positioned on a mat on the floor next to the bed. Further observations revealed the resident calling out, rolling around on the mat and pulled pajama bottoms off of hips and up to knees, exposing the resident's disposable brief. The resident's door was open and the resident could be observed by anyone in the hallway and residents and a family member seated in the lobby area across from the resident's room. Further observations revealed RN (Registered Nurse) - V, Charge Nurse and NA (Nursing Assistant) - W did not close the door or utilize the privacy curtain to promote dignity for the resident when they responded to the resident's call light and provided cares. Interview on 8/10/17 at 2:15 PM with RN - V revealed that the resident often positions self on the mat on the floor. Interview on 8/14/17 at 2:25 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the staff should utilize the privacy curtain when the resident is on the mat on the floor and should close the resident's door when they respond to the call light and provide care to promote the residents' dignity. B. Observations on 8/7/17 at 3:30 PM revealed NA- X transported Resident 27 in a bathing transport chair on the 200 wing hallway. Further observations revealed a sheet draped around the resident's shoulders to the resident's thighs with bare knees, legs and feet exposed. Interview on 8/14/17 at 3:45 PM with the Interim Director of Nursing confirmed that staff should not transport residents from their rooms to the bathing room covered with a sheet to promote the resident's dignity and comfort. C. Observation on 08/09/2017 at 9:19 AM of Resident 37 revealed being pushed through the hallway in a bath chair through the 200 wing wrapped in a sheet with lower legs exposed. D. Observation on 8/10/2017 at 9:30 AM of Resident 84 revealed the resident wearing a soiled dress. Observation on 8/14/2017 10:30 AM of Resident 84 revealed the resident wearing the same dress as on 8/10/17.",2020-09-01
900,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,246,D,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.18B2 Based on observations, record reviews and interviews; the facility failed to provide a larger bed as requested to promote independence with repositioning and comfort for one current sampled resident (Resident 37). The facility census was 107 with 40 current sampled residents. Findings are: Review of the Admission Record, printed 8/9/17, revealed that Resident 37 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/8/17 at 9:30 AM with the resident revealed that had asked the staff several weeks ago for a larger bed. The resident stated that the staff said they would find a larger bed weeks ago but hadn't heard any more about it. Further interview revealed that the resident could not reposition self from side to side because the bed was too narrow. The resident stated that hips and legs hurt every morning from lying on back all night. Observations on 8/10/17 at 1:00 PM revealed LPN (Licensed Practical Nurse) - R and LPN - C positioned the resident on right side for wound care and personal cares. Further observations revealed the resident was just a few inches from the wall when positioned on side. Review of the Care Plan, goal date 10/22/17, revealed that the resident required extensive assistance with bed mobility. Interview on 8/14/17 at 8:00 AM with the resident revealed that had asked LPN - Y, Restorative Care Coordinator, for a larger bed weeks ago. Interview on 8/14/17 at 8:15 AM with LPN - Y revealed that there had been discussions about a larger bed for the resident when readmitted from the hospital. LPN - Y stated that there wasn't enough room in the resident's current room for a larger bed and the resident refused the offer to move to another room that would accommodate a larger bed. Further interview revealed that they would look for a larger bed for the resident. Observations on 8/14/17 at 4:00 PM revealed a larger bed placed in the resident's room. Interview on 8/15/17 at 7:30 AM with the resident revealed that the larger bed was more comfortable and it was a lot easier to move around.",2020-09-01
901,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,250,D,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.09D5a Based on observations, interviews, and record reviews; the facility failed to involve the Social Services Director as an intervention to address one sampled resident's (Resident 84) ongoing refusals of care and treatment regarding bathing and hygiene needs. Sample size was 28 residents. Facility census was 107. Findings are: Observations on 8/8/17 at 11:00 a.m., 8/9/17 at 10:00 a.m., and on 8/10/176 at 9:30 a.m. revealed the resident exhibited an odor and was seen wearing the same clothing between 8/8/17 and 8/9/17. The clothing was observed to be soiled. Further observation of Resident 84 on 8/14/2017 at 10:30 AM revealed the resident continued to exhibit an odor, the resident's hair was oily and uncombed and the resident was wearing the same dress as observed on 8/8; 8/9; and 8/10/17. Interview with Bath Aide-K the facility staff had not bathed the resident for (MONTH) and (MONTH) of (YEAR). The bath aide stated the resident independently cleaned self from the sink. Interview with Licensed Practical Nurse-R on 8/14/2017 at 9:30 AM revealed Licensed Practical Nurse-R stated it was difficult to assess Resident 84's skin because the resident refused allowing nurses to do a skin assessment. Further interview confirmed the resident had not taken a bath or shower for the months of (MONTH) and (MONTH) in (YEAR). Record review of Resident 84's electronic medical record revealed no documentation the facility Social Services Director was involved in assisting the resident regarding refusals of care and hygiene. Interview with the Social Services Director on 08/22/2017 at 9:36:56 AM confirmed that the Social Services Director hadn't been involved in addressing Resident 84's issues with refusal of care and treatments. When asked if the Social Services Director was aware of ongoing refusal of treatments, refusal of bathing and physical and mental decline of the resident, the Social Service Director revealed they weren't away of the issues. The Social Service Director was not aware of the resident's issues with odors and was not aware the resident hadn't bathed in the months of (MONTH) and (MONTH) of (YEAR).",2020-09-01
902,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,252,E,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.18 Based on observations and interviews the facility failed to ensure that 1) the walls in the west dining room were painted where 25 residents dined; 2) the floor in the East Dining room was not damaged and discolored where 44 residents dined; and 3) the walls in the 400 wing dining room were not damaged and had chipped paint where 11 residents dine. The facility census was 107, 40 residents were sampled. Findings are: Observations conducted on 8/7/2017 at 9:00 AM and on 8/10/2017 at 9:30 AM revealed the following. - The walls in the west dining area were partially painted. - The floor in the east dining area in front of the ice machine was damaged and discolored - The walls in the 400 dining area were damaged and the paint was chipped and worn off. Interviews with the Maintenance Director and the Administrator on 8/10/2017 at 9:30 AM, during the Environmental tour confirmed that the west dining room needed to be finished painting. The east dining room floor tiles were damaged and discolored and needed to be replaced, and the walls in the dining room on the 400 wing were damaged, scraped and chipped and were in need of repair.",2020-09-01
903,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,253,E,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.18B Based on observations and interviews, the facility failed to repair or clean damaged walls, floors, doors, molding, tub rooms, ceilings, floor tiles, heat registers, and carpet in the 100 wing, 200 wing, 300 wing, 400 wing, and 500 wing. This also affected resident Rooms 225, 104, 208, 217, 226, 302, 402, 404, 405, 406, 501, 505, and 510. Sample size was 40 residents and the facility census was 107. Findings are: [NAME] Observations conducted of the facility on the environmental tour on 8/7/2017 beginning at 9:00 AM revealed the following: -100 wing-carpet damaged from toilet bowl acid. -200 wing- carpet damaged, several room doors damaged, the entry way floor was damaged and entry way entrance room had damaged ceiling and walls. -300 wing- bath house had damage to the floor under the tub, the wall next to the tub had damage, the walls in the shower room were damaged and the floor molding was coming off. -400 wing- damaged outside doors. -500 wing-doors carpet and ceiling were damaged and were in need of repair. B. Observations conducted of resident rooms on 8/7/2017 and 8/8/2017 revealed the following: -Room 104 damage to lower wall in bathroom behind stool and sink. -Room 208 had damage to walls in room and ceiling in bathroom. -Room 217 damage to floor in bathroom cracked and stained. -Room 225 damage to floor tiles in bathroom cracked and stained, (Residents 146, 37 -Room 226 damage to wall and floor in bathroom, -[RM #]2 damage to wall in room and wall and scrapes on doors. (Residents 92, 109 -Room 402 wall around air conditioner in room was damaged, damaged wall behind sink in bathroom, heat register marred in bathroom. -Room 404 wall next to bed was damaged heat register was marred cove base was coming off between closet and bath room door, ceiling above night stand was discolored and stained. -Room 405 door to room and bathroom were both damaged, wall between closet and bathroom was damaged. -Room 406 wall damaged in room. -Room 501 Heat register in bathroom marred up, bathroom door damaged, Bathroom walls and ceiling paint discolored, damaged floor tiles in front of the bathroom door. -Room 505 heat registered marred up in room and bathroom, nail holes in walls in room. -Room 510 heat registers are marred up. Interviews with the Maintenance Director and the Administrator on 8/10/2017 at 9:30 AM, during the Environmental tour confirmed the facility had damaged floors, doors, walls, and ceilings throughout the facility and resident rooms as listed above.",2020-09-01
904,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,258,E,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.18A (3) Based on observations and interview, the facility failed to respond to a resident repeatedly screaming (Resident 16) in the north dining room to provide comfortable sound levels. The facility census was 107 with 11 residents who routinely eat in the north dining room. Findings are: Observations on 8/10/17 at 7:40 AM, when entering the 400 wing locked Special Care Unit revealed repeated loud repeated screaming. Further observations revealed Resident 16 seated in the north dining room with ten other residents waiting for breakfast. No staff members were responding to the screaming for several minutes. Interview on 8/10/17 at 7:40 AM with Resident 16 revealed that the resident wanted a drink of water. Interview on 8/14/17 2:20 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the staff should respond right away to a screaming resident in the dining room to promote a comfortable sound level for the other 11 residents in the dining room.",2020-09-01
905,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,279,E,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C1b Based on record reviews and interviews, the facility failed to develop care plans to address 1) Hypertension (high blood pressure) for one current sampled resident (Resident 89), 2) pain for one current sampled resident (Resident 90) and 3) behaviors for one current sampled resident (Resident 10). The facility census was 107 with 22 current sampled resident records reviewed. Findings are: [NAME] Review of Resident 89's MAR (Medication Administration Record), dated (MONTH) (YEAR) and printed on 8/9/17, revealed that the resident routinely received [MEDICATION NAME] and [MEDICATION NAME] (ordered 10/16/16) for Hypertension Review of the Care Plan, goal date 10/1/17, revealed no care plan to address high blood pressure. Interview on 8/14/17 at 1:30 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that a care plan should have been developed to address the resident's hypertension. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 90 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/8/17 at 7:50 AM with the resident revealed complaints of unrelieved right shoulder pain and the resident continued to rub the right shoulder during the interview. Interview on 8/9/17 at 10:00 AM with the resident revealed that the right shoulder continued to hurt and rated pain at 7 as it still hurts a lot. Interview on 8/10/17 at 7:15 AM with the resident revealed that the right shoulder and right leg hurt and the resident was rubbing the shoulder and leg. The resident stated that the pain pills help some, but it still hurts. Review of the Medication Administration Record, [REDACTED]. Pain rated 8 -10 indicated severe pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that orders were received on 8/8/17 for routine [MEDICATION NAME] every bedtime. Interview on 8/15/17 at 10:40 AM with LPN - C, Unit Coordinator, confirmed that a care plan should have been developed to address the resident's ongoing pain. LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09C C. Review of the quarterly 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.) for Resident 10 dated 6/30/2017, identified that the resident exhibited physical behaviors directed towards others and that other behavioral symptoms not directed towards others. Review of the Comprehensive Care Plan dated 7/06/217, did not identify resident behaviors that were noted on the 6/30/17 quarterly MDS. Interview with the Assistant Director of Nursing on 8/10/2017 at 12:00 PM confirmed that the care plan did not address Resident 60's behaviors that were noted on the 6/30/2017 quarterly MDS.",2020-09-01
906,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,280,E,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09C1c Based on record reviews and interviews, the facility failed to 1) update care plans related to changes in assistance needed with eating and behaviors for one current sampled resident (Resident 25) and blood in urine and painful urination for one current sampled resident (Resident 15), 2) ensure that residents were invited to attend or participate in care planning for three current sampled residents (Residents 113, 116 and 84) and 3) ensure that nursing assistants were included in care planning as required for four current sampled residents (Residents 53, 94, 163 and 23). The facility census was 107 with 22 current sampled residents. Findings are: [NAME] Review of Resident 25's current MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 6/16/17, revealed that the resident required limited assistance with eating and had behaviors directed towards others. Review of the Care Plan, goal date 9/20/17, revealed no care plan to include that the resident required assistance with eating. Further review revealed no care plan related to resident behaviors directed towards others. Interview on 8/14/17 at 2:30 PM with LPN (Licensed Practical Nurse) - Z, MDS Coordinator, confirmed that the care plan should have been updated to include the resident's need for increased assistance with eating. Further interview confirmed that the resident's changes in behaviors directed towards others should have been addressed in the care plan. B. Review of Resident 25's Admission Record, printed 8/9/17, revealed that Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurts so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complains of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed bright red blood in the toilet. Review of the physician's orders [REDACTED]. Interview with the LPN (Licensed Practical Nurse) - C, Unit Coordinator, on 8/15/17 at 10:30 AM, confirmed that the care plan should have been updated to address the resident's increased pain and blood with urination. C. Interview on 8/8/2017 at 7:40 AM with Resident 113 revealed that the facility failed to include or invite the resident to the care plan conference meeting. D. Interview on 8/8/2017 at 9:15 AM with Resident 116 revealed that the facility failed to include or invite them to the care plan conference meeting. E. Interview 8/9/2017 at 1:30 PM with Resident 84 revealed that the facility failed to include or invite them to the care plan conference meeting. Interview with the Social Services Director on 8/9/2017 at 3:00 PM revealed that the facility had no record of Resident 84,113, or 116's Care Plan Conference attendance F. Record review of care plan Conference minutes for 4 sampled residents (Residents 23, 53, 94, and 163) revealed that the facility failed to have Nurse Aides as members of the care plan conference team. Interview on 8/16/2017 at 9:30 AM with the facility Administrator confirmed that the facility failed to have Nurse Aides on the Care Plan Team.",2020-09-01
907,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,282,D,1,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C Based on record reviews and interview, the facility failed to ensure that care plan interventions related to assistance with repositioning were followed to ensure comfort and to promote healing of pressure ulcers for one closed record sampled resident (Resident 173). The facility census was 107 with three closed records reviewed and 22 current sampled residents. Findings are: Review of Resident 173's Admission Record, printed 8/9/17, revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 7/29/17, revealed that the resident had pressure ulcers and interventions included Turning and repositioning schedule per assessment. Review of the Documentation Survey Report v2, dated (MONTH) (YEAR), revealed no documentation that the resident was repositioned on the evening shift from 7/10/17 through 7/14/17. Further review revealed that the resident repositioned self on the night shift on 7/13/17 and 7/14/17. Interview on 8/15/17 at 3:00 PM with LPN (Licensed Practical Nurse) - C, Unit Coordinator, confirmed that the resident was not routinely repositioned as care planned for comfort or to promote healing of the pressure ulcers.",2020-09-01
908,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,309,H,1,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) thorough skin assessments were completed at least weekly and dressings were changed as ordered to promote healing of open wounds with ongoing drainage for one current sampled resident (Resident 84), 2) pain was assessed and controlled during wound care for one current sampled resident (Resident 169), 3) ongoing severe pain was identified and managed for one current sampled resident (Resident 15), 4) pain rated severe was assessed and controlled for one closed record (Resident 173) and two current sampled residents (Resident 90 and 10), 5) a resident with an abnormal blood pressure reading was assessed and follow up completed to ensure that the resident didn't experience any adverse effects for one current sampled resident (Resident 84) and 6) a decline in behaviors was assessed and a plan to manage behaviors was developed for two current sampled residents (Residents 29 and 25). The facility census was 107 with 22 current sampled residents and three closed records. Findings are: A Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/8/17 at 11:00 AM revealed the resident seated in the wheelchair with ongoing foul odors noted from dressings at lower extremities. Interview on 8/8/17 at 11:00 AM with the resident revealed they don't change my dressings like they're supposed to. Observations on 8/9/17 at 9:30 AM revealed the resident seated in room in a wheelchair and noted a strong foul smelling odor in the room and the hallway by the resident's room. Interview with the resident on 8/9/17 at 9:30 AM revealed my legs are bleeding, they're supposed to change my dressings two times a day and put some cream on my legs and lucky to get it done every 2-3 days. Further observations revealed the resident removing the dressings from the right lower legs and noted leg swollen with clear, foul smelling weeping drainage dripping down the leg. Observations on 8/9/17 at 1:30 PM revealed the resident seated in the wheelchair in the room for the scheduled treatment and dressing changes to the legs. Noted the foul smelling drainage continued to weep from the lower legs bilaterally and the dressings were removed from the lower legs. The dressing/wraps were intact at the thighs. Further observations revealed LPN (Licensed Practical Nurse) - R, Charge Nurse (assisted by LPN - C, Unit Coordinator), while sitting on the floor in front of the resident, removed the wrap and dressings from the right thigh, cleansed the back of the thigh with a disposable washcloth and then the front of the thigh, applied [MEDICATION NAME] cream as ordered to the back and front of the thigh, wrapped gauze around the thigh and then an ace wrap. Noted that the back of the thigh was not visible to the nurse to assess the resident's skin as the treatment was done. LPN - R removed the ace wrap and dressing from the left thigh and performed the treatment in the same manner. The resident complained of soreness behind the left knee. LPN - R could not visualize the skin at the back of the thigh for an assessment. The resident stated my legs have been bleeding for two days. The resident also complained of pain at the left thigh and lower legs, moaning and grimacing, while the treatments were done at the left thigh and lower legs. Interview on 8/10/17 at 8:00 AM with LPN - R revealed that the resident often removed the dressings from the lower legs and often refused routine bathing. Observations on 8/10/17 at 8:00 AM revealed the resident seated in a recliner in room with legs elevated about ten inches, strong foul odor remained in room. Further observations at 11:00 AM and 2:15 PM revealed the resident seated in the wheelchair, legs not elevated and the strong foul odor remained in the room and into the hallway. Review of the Weekly Skin Check, dated 7/12/17, revealed that the resident had [MEDICAL CONDITION] at the right and left thighs (rear), right lower and left lower front legs, and right lower and left lower legs rear. [MEDICAL CONDITION] is a condition of abnormal accumulation of tissue fluid (potential lymph) in the interstitial spaces. The resident refused to have skin assessment completed. Review of the Weekly Skin Check, dated 7/19/17, revealed that the resident had bilateral lower [MEDICAL CONDITION], right and left thighs (rear), right and left lower legs (front and rear) and dressings were applied as ordered. The resident also had excoriation under both breasts and under the abdominal fold and a wound at the buttock which measured two by two centimeters. The resident had no other areas of concern. Review of the Weekly Skin Check, dated 8/9/17, (none received to review for 8/2/17), revealed that the resident had excoriation under both breasts and under the abdominal fold, and [MEDICAL CONDITION] to the right and left thigh (rear), right and left lower legs (front and rear). Further review revealed no measurements of the swelling to evaluate worsening or improvement. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 1/30/17, for compression wraps to both legs, change every 12 hours for [MEDICAL CONDITION] and [MEDICATION NAME] cream to bilateral legs every 12 hours. Further review revealed no documentation that the treatment was done on the day shift on 8/4/17, 8/5/17 and 8/6/19. The treatment was documented as refused on the day shift on 8/7/17 and on the evening shift on 8/2/17, 8/3/17, 8/4/17, 8/6/17, 8/7/17 and 8/8/17. Further review revealed an order, dated 6/6/17, to check buttocks and coccyx daily for skin breakdown and an order dated 7/20/17, for [MEDICATION NAME] cream to buttock every shift. Review of the Progress Notes, dated (MONTH) (YEAR), revealed no documentation of the resident's ongoing refusal of thorough skin assessments or treatments to the legs. Further review revealed no documentation of the ongoing foul smelling weeping drainage from the legs or the status of the open area on the buttock. Interview on 8/15/17 at 9:00 AM with LPN - C, Unit Coordinator, confirmed that complete skin assessments were not completed at least weekly to determine whether or not the treatments were effective. LPN - C confirmed that a complete assessment of the resident's skin condition could not be done while the resident was seated in a wheelchair. Further interview confirmed that the ongoing foul smelling drainage from the legs was not documented or addressed. B. Observations on 8/9/17 at 1:00 PM revealed Resident 169 resting on the bed, positioned on back for wound care. Further observations revealed LPN - Q lifted the resident's right foot to remove the protective boot and the resident complained of pain as the foot was lifted up. The resident said ouch, that is so tender and the resident grimaced and had labored breathing. The resident continued to complain of pain when the right foot was moved for the treatment on the pressure ulcer at the heel with continued verbal complaints of pain, facial grimacing and labored breathing. LPN - Q continued with the treatment and encouraged the resident to take deep breaths. LPN - Q and RN (Registered Nurse) - P turned the resident to left side to continue treatments to pressure ulcers at the right buttock and sacral area. The resident groaned again with pain when the right foot was lifted while repositioned to side. The resident also complained of hip pain when repositioned, when the treatment was done to the sacral area and when positioned again on back. Interview on 8/9/17 at 2:00 PM with the resident revealed that those treatments are so painful. Review of the Medication Administration Record, [REDACTED]. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that the resident should have been offered pain medication before the wound care in anticipation of pain. LPN - C confirmed that the nurses should have stopped the treatment when the resident complained of pain, medicated the resident and then continue with the treatment to promote comfort for the resident. C. Interview with Resident 15 on 8/8/17 at 11:20 AM revealed that the resident had back and neck pain. The resident stated that takes pain medications but it still hurts. Observations during the interview revealed that the resident had pained facial expressions and a clenched jaw. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurts so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Interview on 8/9/17 at 10:00 AM with RN (Registered Nurse) - P, Charge Nurse, revealed that the resident had chronic neck pain and usually requested a pain pill in the morning. RN - P did not mention the resident's back pain or blood in urine. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complains of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed the resident had bright red blood in the toilet. Interview on 8/9/17 at 11:30 AM with RN - P revealed that no urology appointment had been made yet to evaluate the resident. Further interview revealed would have the Nurse Practitioner check the resident. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident had a routine [MEDICATION NAME] (narcotic [MEDICATION NAME]). Further review revealed that the resident received [MEDICATION NAME] (Opioid [MEDICATION NAME]), ordered as needed for pain, on 8/7/17 at 8:22 AM, on 8/8/17 at 8:38 AM and 7:12 PM and on 8/9/17 at 8:43 AM for pain rated 9 (severe) on the 1-10 pain scale. Further review revealed documentation that the 8/8/17 at 8:38 AM and the 8/9/17 at 8:43 AM doses were ineffective in relieving the resident's pain. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the LPN - C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that the medical provider should have been notified of the resident's ongoing unrelieved pain and blood with urination sooner to relieve the resident's pain. D. Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident received the first dose on 7/11/17 at 1:00 AM for pain rated 7 (on a pain scale of 1-10 with 10 as the worst possible pain) for right shoulder pain per the Progress Notes. The resident received the next doses at 7:34 AM for right shoulder pain rated 8 and at 4:44 PM for all over pain rated 9. The resident received the pain medication again on 7/12/17 at 4:51 AM for pain rated 7 for right shoulder and right arm pain, at 1:11 PM for right shoulder pain rated 10 and at 9:09 PM for right shoulder pain rated 7. Review of the Progress Notes, dated 7/12/17 at 9:55 AM, revealed that the resident complained on continuous pain to the left upper extremity and the right lower extremity and pain medication offered as needed was effective for a short amount of time, but then the pain returned. The resident was to have an x-ray of the right ankle today due to severe pain. Review of the Progress Notes, dated 7/13/17 at 2:36 PM revealed a new order for [MEDICATION NAME] 10/325 milligrams every 6 hours for pain. Review of the Medication Administration Record, [REDACTED]. Further review of the Medication Administration Record [REDACTED]. Further review revealed no documentation on 7/14/17 or 7/15/17 of how the resident rated the pain. Review of the Progress Notes, dated 7/15/17 at 4:10 PM, revealed that the resident was continuously pulling on the call light cord screaming in sleep, noted body tremors, when the resident was awake was confused and hallucinating about chickens. The on call provider was notified of the resident's change in condition and stated it is probably the dosage increase of [MEDICATION NAME] and new orders were received to discontinue the routine scheduled [MEDICATION NAME] and change back to every eight hours as needed for pain. Further review revealed that at 8:00 PM, the resident continued to have episodes of twitching with [MEDICAL CONDITION] off and on during the day, was unresponsive and grimaced with pain during movement. The provider was notified and orders were received to transport the resident to hospital emergency room for evaluation and then admission. Interview on 8/15/17 at 3:00 PM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed, including causal factors and non- pharmacological interventions in place to control the resident's pain. Further interview confirmed that pain assessments should have continued when the [MEDICATION NAME] was changed to routine dosing to ensure that pain was managed effectively for the resident's comfort. E. Review of the Admission Record, printed 8/9/17, revealed that Resident 90 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/9/17 at 10:00 AM with the resident revealed that the right shoulder continued to hurt and rated pain at 7 as it still hurts a lot. Interview on 8/10/17 at 7:15 AM with the resident revealed that the right shoulder and right leg hurt and the resident was rubbing the shoulder and leg. The resident stated that the pain pills help some, but it still hurts. Review of the Medication Administration Record, [REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that orders were received on 8/8/17 for routine [MEDICATION NAME] every bedtime. Interview on 8/15/17 at 10:40 AM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed to include potential causal factors and non - pharmacological interventions to manage the resident's pain. F. Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed the resident's blood pressure was 195/75 on 7/28/17. Review of the medical record, including the progress notes, revealed no assessment of the resident on 7/28/17 or follow up blood pressure until 8/2/17 with a reading on 163/73. Interview on 8/14/17 at 1:30 PM with LPN - D, Unit Coordinator, confirmed that an assessment and follow up vital signs should have been completed and documented with the abnormally high blood pressure reading on 7/28/17. Further interview confirmed that the resident's condition should have been monitored closely to ensure that the resident's needs were met. [NAME] Review of Resident 29's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 6/10/17, revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the resident had a documented episode of hitting and kicking staff in the nursing assistant documentation during the assessment period. Further interview confirmed that there was no documentation that the care plan team reviewed the incident, considered the potential causal factors related to the behaviors or developed a plan to reduce the risk for further behaviors. H. Review of Resident 25's MDS, dated [DATE], revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the care plan team did not address the resident's decline in behaviors, identify potential causal factors or develop a plan to manage any further behaviors directed towards others. I. Interview with Resident 10 revealed the resident had pain that would not go away and the facility hadn't intervened to assist in alleviating the pain. Observation on 8/8/17 at 10:20 a.m. revealed the resident grimaced throughout the interview. Record review of the MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop care plans) revealed the resident was assessed with [REDACTED]. Record review of the resident's care plan revealed the resident had right knee pain. Record review of Nurses notes revealed Resident 10 had knee injections for pain on 8/9/17 at the physician's clinic. Record review of facility documentation revealed no pain assessments for Resident 10 were completed before and after knee injection on 8/9/17. Record review of Resident 10's Medication Administration Record [REDACTED]. Record review of Resident 10's electronic medical record revealed there were no formal pain assessments completed since 6/30/17. Interview with LPN (Licensed Practical Nurse)-C on 8/15/17 at 3:00 p.m. revealed LPN-C was the unit coordinator and worked routinely with Resident 10. LPN-C confirmed there were no follow up formal pain assessments or documentation for Resident's pain since 6/30/17.",2020-09-01
909,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,312,D,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D1c Based on observations, record reviews and interviews; the facility failed to ensure that 1) a decline in assistance required for eating was evaluated and a plan was put in place to restore eating abilities for one current sampled resident (Resident 25) and 2) one current sampled resident (Resident 84), dependent on staff for assistance with activities of daily living, had clean and groomed hair and changed clothing as needed. The facility census was 107 with 40 sampled residents. Findings are: [NAME] Review of Resident 25's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning, dated 5/16/17, revealed that the resident required supervision with eating (oversight, encouragement or cueing). Review of the current MDS, dated [DATE], revealed that the resident required limited assistance with eating (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance). Interview on 8/14/17 at 2:30 PM with LPN (Licensed Practical Nurse) - Z, MDS Coordinator, revealed that the care plan team did not complete further assessments related to the residents decline in eating to determine potential causal factors. Further interview confirmed that no interventions or plan was developed or implemented to restore the residents ability to eat with supervision. B. Observation on 8/8/2017 at 11:00 AM of Resident 84 revealed the resident exhibited an odor. Observation on 8/14/2017 at 9:24 AM of Resident 84 revealed the resident had an odor that persisted and the resident was wearing the same clothes as worn on 8/8/2017. Interview with Bath Aide K about Resident 84 revealed the resident was not bathed for several months and that Resident 84 was provided a bed bath to self independently by standing at the sink in the bathroom. Record Review of the bath schedules of (MONTH) and (MONTH) (YEAR) revealed that Resident 84 hadn't received a bath or shower for the months of (MONTH) and August. Interview on 8/14/2017 at 9:24 AM with Licensed Practical Nurse-R confirmed that it was difficult to assess Resident 84's skin because the resident refused to let the nurse do a skin assessment. Further interview confirmed that Resident 84 had not taken a bath or shower for the months of (MONTH) and (MONTH) (YEAR).",2020-09-01
910,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,314,G,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12-006.09D2a 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to ensure that 1) a turning/repositioning schedule was developed and implemented, a pressure relieving mattress was provided and set at a therapeutic and comfortable level, a nutrition assessment was completed to obtain a supplement to promote wound healing, the recommendation made for a supplement was ordered and administered timely, ongoing diarrhea was managed to reduce the risk of cross contamination at the pressure ulcers, linens and clothing layers were minimized to ensure the therapeutic benefits of the pressure relieving mattress and interventions were evaluated and changed when the pressure ulcers deteriorated and before more pressure ulcers developed for one current sampled resident (Resident 169)admitted with pressure ulcers and subsequently developed more pressure ulcers and 2) a turning/repositioning schedule was developed and implemented, a larger bed was provided to enhance self repositioning in bed, a nutrition evaluation was completed to evaluate the need for a supplement to promote healing of a facility acquired pressure ulcer, layers of linens and clothing between the resident's skin and the mattress was minimized to ensure the therapeutic pressure relieving properties of the mattress and treatments were evaluated and changed when the pressure ulcer worsened for one current sampled resident (Resident 37). The facility census was 107 with 22 current sampled residents and three closed records reviewed. Findings are: [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/14/17, revealed that the resident was at risk for the development of pressure ulcers. Review of the Admission Nursing Assessment, dated 7/7/17, revealed that the resident had a Stage 2 pressure ulcer at the right buttock which measured 4 cm. (centimeters) length x 4.5 cm. width x 0.1 cm. depth. Review of the Care Plan, goal date 9/25/17, revealed that the resident required extensive assistance of two staff members for bed mobility and transfers. Further review revealed that the resident was admitted with a Stage 2 pressure ulcer at the right buttock related to assistance required in bed mobility and the presence of [MEDICAL CONDITION] (swelling). Interventions included turning and repositioning schedule and weekly skin assessments. Review of the Weekly Wound Assessment, dated 7/27/17, revealed that the pressure ulcer at the right buttock was identified on 7/7/17. Further review revealed that the ulcer measured 6 cm. length; 9 cm. width, and 0.1 cm. depth, with a moderate amount of serosanguinous (serum and blood) drainage, painful and 10 % necrotic (dead) tissue. Interventions in place included a pressure redistribution mattress and wheelchair cushion. Interventions did not include a specific turning or repositioning program, nutritional supplements, positioning devices, protein supplements or heel boots or the need for a pressure relieving mattress. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the pressure ulcer at the right buttock measured 8 cm. length, 4.2 cm. width, depth not marked and Stage is now Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) and/or eschar (tan, brown, or back) in the wound bed). Further review revealed that the ulcer contained a moderate amount of serosanguinous, foul smelling drainage with 100% slough (dead matter or necrotic tissue separated from living tissue or an ulceration). Review of the Weekly Wound Assessment, dated 7/26/17, revealed that a Suspected Deep Tissue Injury at the right heel (facility acquired) was identified on 7/25/17 which measured 3.5 cm. length, 3 cm. width with a small amount of serosanguinous drainage and no odor and painful. Current preventative interventions included pressure redistribution mattress, wheelchair cushion and heel boots. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the pressure ulcer at the right heel was Unstageable and measured 3.5 length and 3 cm width, with a moderate amount of foul smelling serosanguinous drainage, painful, with 100% black slough with maceration (softening from fluid) at the surrounding skin. Interventions added included nutritional and protein supplements. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that an Unstageable pressure ulcer was identified on 8/2/17 at the coccyx which measured 4.0 cm. length by 3.7 cm. width, with a moderate amount of foul smelling serosanguinous drainage, painful and 100% slough. Further review of the Care Plan, goal date 9/25/17, revealed interventions added on 7/25/17 including air mattress (pressure relieving) set at weight for comfort, protective boots or float heels with a pillow, wound clinic consult. Interventions added on 8/2/17 included treatments as ordered and to see wound clinic. Review of the Progress Notes, dated 8/3/17, revealed that the resident went to a wound clinic and new treatment orders were received for the heel and sacral wounds. Observations on 8/9/17 at 1:00 PM revealed the resident resting on the bed, boot on the right foot, airflow mattress set at 4 (175 pounds) and noted a sheet and blanket between the resident's skin and the airflow mattress. LPN (Licensed Practical Nurse) - Q stated that the resident's dressings at the right buttock and coccyx were removed earlier as the resident had been incontinent of stool which saturated the dressings. LPN - Q removed the protective boot from the right foot, the resident complained of pain when the boot was removed and began breathing harder because of the pain. The resident repeatedly complained of pain throughout the treatment when the right foot was moved with facial grimacing and labored breathing. LPN - Q noted increased swelling on the foot and lower leg, removed the dressing from the right heel and noted reddish brown colored foul smelling drainage on the dressing. LPN - Q continued with the treatment as ordered. Further observations revealed LPN - Q and RN (Registered Nurse) - P repositioned the resident on the left side for the treatments to the pressure ulcers at the right buttock and coccyx. The resident stated that bottom hurts, too. LPN - Q removed the resident's slacks and disposable brief and continued with the treatment and dressings as ordered. LPN - Q and RN - P performed perineal care to remove feces from skin. LPN - Q and RN - P applied a disposable brief, pulled up the resident's slacks and positioned the resident on back. Observations on 8/10/17 at 7:00 AM revealed the resident resting in bed, positioned on back and the air mattress set at 4. Interview with the resident on 8/10/17 at 2:00 PM revealed that was not able to reposition self, those treatments are so painful, the mattress was not very comfortable and continued to have diarrhea stools. Review of the resident's admission weight was 152 pounds and weight on 8/4/17 was 149 pounds. Interview on 8/14/17 at 9:00 AM with RN - P, Charge Nurse, revealed was not aware that the air mattress was set at 4 for a resident who weighed 175 pounds. RN - P confirmed that the resident did not weigh 175 pounds so the air mattress was not set at the therapeutic weight for pressure relief. Interview on 8/14/17 at 9:15 AM with LPN - Y, Restorative Care Nurse, confirmed that the air mattress was set at 4. Further interview revealed would lower the rate to 3 (145 pounds) which was closer to the resident's weight to achieve the therapeutic benefits of the air mattress and to promote comfort. Interview on 8/15/17 at 7:30 AM with the resident revealed that the mattress was now more comfortable and not so hard. Review of the Documentation Survey Report v2, dated (MONTH) (YEAR), revealed that the resident repositioned self on the day shift on 7/20, 7/21, 7/25, 7/27 and 7/28; repositioned self on the evening shift on 7/20, 7/21, 7/24 and 7/25; and repositioned self on the night shift on 7/8, 7/13, 7/14 and 7/29. Further review revealed no documentation that the resident was repositioned every two hours while in bed on the evening shift on 7/10 - 7/14, 7/17 - 7/19 and 7/26 and on the night shift on 7/10, 7/22, 7/24, 7/26 and 7/31. Review of the Documentation Survey Report v2, dated (MONTH) (YEAR), revealed that the resident repositioned self on the day shift on 8/1, 8/4 and 8/6, on the evening shift on 8/1 - 8/5, 8/7 - 8/9 and 8/13 - 8/14, and on the night shift on 8/5, 8/12 and 8/14. Review of the Nutrition Assessment described as Admission, dated 7/26/17, (Resident admitted [DATE]) revealed that the resident had a surgical wound and a stage 2 pressure ulcer and a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). Further review revealed that the resident's [MEDICATION NAME] (protein) level was low on 7/15/17 and recommendation was made for 2 cal supplement two times a day to promote wound healing. Review of the Nutrition Assessment, dated 8/10/17, revealed that the resident had a weight loss, surgical wound and pressure ulcers to coccyx and right heel. Recommendations were made to increase the 2 cal supplement to four times a day to increase calories and promote wound healing. Review of the physician Order Summary Report, printed 8/15/17, revealed an order, dated 7/31/17, for 2.0 calorie supplement three times a day related to a pressure ulcer at the right heel. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR) and printed 8/9/17, revealed that the resident did not receive any nutritional supplement until 7/31/17. Further review revealed that the air mattress was initiated on 7/19/17. Review of the MAR, dated (MONTH) (YEAR) and printed 8/9/17, revealed an order, dated 8/2/17 for Prostat supplement two times a day for wound healing and the 2 calorie supplement remained at three times a day. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that care plan interventions were effective to promote healing of the pressure ulcer on the right buttock or to evaluated and changed to prevent the development and to promote healing of the pressure ulcers at the right heel and the coccyx area. Further interview confirmed that the pressure ulcers contributed to the resident's pain, a turning and repositioning schedule was not developed or implemented consistently, the pressure relieving air mattress was not implemented until the pressure ulcer at the right heel developed, the air mattress was not set at the therapeutic level based on the resident's weight and comfort and layers of linens and clothing were not minimized to ensure the therapeutic benefits of the mattress. LPN - C confirmed that a nutrition assessment was not completed on admission and RD (Registered Dietician) recommendations were delayed in being ordered and administered to promote healing of the pressure ulcers. Further interview confirmed that ongoing diarrhea was not controlled to reduce the risk of cross contamination of the pressure ulcers on the right buttock and coccyx area. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] post treatment for [REDACTED]. Review of the MDS, dated [DATE], revealed that the resident had no pressure ulcers. Review of the Care Plan, goal date 10/22/17 and printed 8/9/17, revealed that the resident required extensive assistance with activities of daily living including bed mobility, toileting and personal cares and transferred with a mechanical lift. Further review revealed a care plan, dated 7/17/17, for a stage 2 pressure ulcer at the coccyx. Interventions included pressure reducing wheelchair seat cushion, pressure reduction/relieving mattress and treatments as ordered. Observations on 8/9/17 at 2:30 PM revealed the resident seated in the wheelchair in room. Interview on 8/9/17 at 2:30 PM with the resident revealed had been up in the wheelchair since 7:30 AM. The resident stated will usually try to lay down in bed in the mornings. The resident also stated that the staff don't reposition me at night, the bed is too narrow for me to turn over by myself and my bottom hurts so bad in the morning because I've been on my back all night. Further interview revealed I have sores on my bottom. Review of the Progress Notes, dated 7/15/17, revealed that the resident had a wound at the coccyx which measured approximately 3 x 1 cm and a wound to the inside cleft of the right buttock which measured 2 x 2.5 cm. Further review revealed that [MEDICATION NAME] cream was applied to the areas. Review of the Weekly Wound Assessment, dated 7/26/17, revealed that the resident had a Stage 2 pressure ulcer at the coccyx which measured 1.0 cm. length, 0.3 cm. width and 0.1 cm. depth with a small/minimal amount of serosanguinous drainage. Further review revealed that current pressure redistribution mattress and wheelchair cushion. Specific turning/repositioning program, nutritional supplements, positioning devices or protein supplements not checked. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the Stage 2 pressure ulcer at the coccyx measured 1.5 cm. length, 0.5 cm. width and 0.1 cm. depth with the same drainage. Interventions added included a protein supplement but no specific turning/repositioning program. Review of the Nutrition Assessment, dated 7/27/17, revealed that the resident had two, Stage 2 pressure ulcers and the RD (Registered Dietician) recommended Prostat supplement daily. Review of the TAR (Treatment Administration Record), dated (MONTH) (YEAR), revealed an order, dated 7/25/17, for [MEDICATION NAME] three times a day coccyx cleft wound and left lower buttock. Further review revealed no previous treatment orders for the pressure ulcers and no orders for a nutritional supplement. Review of the TAR, dated (MONTH) (YEAR), revealed an order, dated 8/8/17, for Prostat supplement daily for wound healing. Review of the Documentation Survey Report v2, dated (MONTH) (YEAR), revealed that the resident repositioned self on the day shift on 7/19, 7/26 and 7/30 and on the night shift on 7/6, 7/11, 7/12, 7/14 and 7/25. Further review revealed no documentation that the resident was repositioned on the day shift on 7/6, 7/14, and 7/23; evening shift on 7/22, 7/23 and 7/30; and on the night shift on 7/16, 7/27 and 7/29. Review of the Documentation Survey Report v2, dated (MONTH) (YEAR), revealed that on the day shift the resident repositioned self on 8/6 and 8/7 and on the night shift on 8/3 and 8/12. Observations on 8/10/17 at 1:00 PM revealed the resident on bed positioned on back for wound care. LPN - R, Charge Nurse, stated that the resident's disposable brief was just changed due to urinary incontinence and skin care was done. LPN - R positioned the resident on right side and noted that the bed was too narrow and the resident's face was inches from the wall when repositioned. Further observations revealed LPN - R cleansed the open area at the coccyx with saline, noted red drainage from the wound, and applied [MEDICATION NAME] cream to the ulcer and reddened skin at the left buttock area. LPN - R and LPN - C turned the resident from side to side to apply the disposable brief and then positioned the resident on back. Further observations revealed that the resident was placed on top of two sheets, a quilted bedspread and the disposable brief which was four layers of material between the resident's skin and the therapeutic mattress. The resident was in the same position at 4:00 PM. Interview on 8/15/17 at 9:30 AM with LPN - C, Unit Coordinator, confirmed that the resident developed a facility acquired pressure ulcer and interventions were not in place to prevent the development of the pressure ulcer. Further interview confirmed that the resident required assistance with repositioning and should be repositioned at least every two hours which wasn't consistently done. LPN - C stated that the resident often refused to lay down during the day and often sat in the wheelchair all day. Further interview confirmed that there was a delay in receiving orders to treat the pressure ulcer and no nutrition assessment was completed until 7/27/17 and the recommendations for a supplement received that day was not ordered and administered to the resident until 8/8/17 to promote wound healing. LPN - C confirmed that layers of linen and clothing and the resident's skin should be minimized to enhance the therapeutic benefits of the pressure reducing mattress and the resident should have had a larger bed to allow more independence with repositioning. Review of the facility Skin Integrity Guideline, not dated, revealed the following including: Purpose: To provide a comprehensive approach for monitoring skin conditions, to decrease pressure ulcer and/or wound formation by identifying those residents who are at risk and implementing appropriate interventions, to promote healing of wounds of any etiology, whether admitted or acquired. Documentation and Care Interventions for Skin Integrity included: - interventions will be documented in the care plan; - pressure redistribution mattresses will be in place and will be reviewed for appropriateness is there is a decline in skin integrity; - reposition every two hours, or as needed and tolerated; - positioning schedule to minimize concentrated pressure to skin; - minimal linen under prone skin areas; - nursing notifies dietary of any resident admitted with pressure ulcers or newly identified pressure ulcers; - nutritional assessment determines the need for nutritional interventions.",2020-09-01
911,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,315,D,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D3 (2) Based on record reviews and interviews, the facility failed to ensure that a decline in bladder continence, identified on the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), was evaluated and further assessments were completed to determine possible causal factors and then develop a plan to restore bladder continence for one current sampled resident (Resident 146). The facility census was 107 with 22 current sampled residents. Findings are: Review of Resident 146's MDS, dated [DATE], revealed that the resident was always continent of bladder. Review of the MDS, dated [DATE], revealed that the resident was occasionally incontinent of bladder. Interview on 8/14/17 at 2:40 PM with LPN (Licensed Practical Nurse) - Z, MDS Coordinator, revealed that there was no documentation in the medical record of further assessments completed related to the resident's occasional bladder incontinence that was identified on the MDS, including causal factors, or a plan to restore bladder continence.",2020-09-01
912,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,323,H,1,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and a subsequent fractured finger for one current sampled resident (Resident 26) and 2) oxygen concentrators were turned off when not in use to reduce the risk of fires for five current sampled residents (Residents 25, 66, 40, 15 and 71). The facility census was 107 with 22 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7b (3) [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident also had [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/3/17, revealed that the resident was at risk for falls related to poor safety awareness and self-determination related to transfers. Further review revealed that the resident fell getting out of the wheelchair on 4/24/17, slid self out of the wheelchair to the floor on 6/29/17 and had an unwitnessed fall out of the wheelchair on 7/25/17. Review of the Progress Notes, dated 7/25/17 at 1:49 PM, revealed that the resident was found to be on the floor next to the wheelchair in the dining room and no injuries were noted. Further review revealed at 2:09 PM, bruising which measured 5 cm. (centimeters) by 2 cm. was noted on the 3rd digit. At 6:14 PM, swelling was noted at the finger. On 7/27/17 at 2:45 PM, an x ray showed that the resident had a fractured right third finger and orders for a splint were received. Observations on 8/9/17 at 7:40 AM revealed the resident resting in bed and a splint in place at the right third finger. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 7/26/17, for Epsom salt treatment two times a day for swelling and bruising of the right hand. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed an order, dated 8/1/17, to take the splint off and check skin daily and reapply the splint daily until 9/7/17. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the resident received Hydrocodone - Acetaminophen (narcotic analgesic) for pain on 7/24/17 and 7/26/17. Interview on 8/14/17 at 1:45 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the care plan interventions were not effective to prevent further falls from the wheelchair and the subsequent fractured finger. Licensure Reference Number: 175 NAC 12-006.09D7 B. Observations on 8/8/17 at 8:30 AM revealed Resident 15 (Room 104 B) and Resident 17 (Room 215 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 7:45 AM revealed Resident 25 (Room 220 B), Resident 66 (219 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 8:00 AM revealed Resident 40 sleeping in bed with the oxygen concentrator on and the mask on the bed. Interview on 8/14/17 at 8:15 AM with the Interim Director of Nursing confirmed that the oxygen concentrators were to be turned off when not in use to reduce the risk of accidental fires and to promote safety.",2020-09-01
913,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,328,D,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D6 (7) Based on observations, record reviews and interviews; the facility failed to administer oxygen as ordered by the physician for two current sampled residents (Residents 43 and 37). The facility census was 107 with 22 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/9/17 at 10:00 AM revealed the resident sleeping in recliner with no supplemental oxygen. Observations on 8/9/17 at 2:30 PM revealed the resident seated in recliner with no supplemental oxygen. Observations on 8/10/17 at 7:45 AM revealed the resident seated in the dining room with no supplemental oxygen. Observations on 8/14/17 at 8:00 AM revealed the resident sleeping on bed with no supplemental oxygen in place. Review of the Medication Administration Record, [REDACTED]. Interview on 8/14/17 at 1:50 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the oxygen order was not followed. LPN - D stated that the resident hadn't used the oxygen for quite a while. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/9/17 at 12:40 PM revealed the resident seated in the wheelchair in therapy with no supplemental oxygen in place. Observations on 8/9/17 at 2:30 PM revealed the resident seated in the wheelchair in room with no supplemental oxygen in place. Observations on 8/10/17 at 1:00 PM revealed the resident resting on the bed with no supplemental oxygen in place. Observations on 8/14/17 at 8:00 AM revealed the resident seated in the wheelchair in the dining room with no supplemental oxygen in place. Interview with the resident on 8/14/17 at 8:00 AM revealed doesn't use the oxygen anymore. Review of the Medication Administration Record, [REDACTED]. Interview on 8/15/17 at 9:30 AM with LPN - C, Unit Coordinator, confirmed that the resident does not use the oxygen continuously as ordered.",2020-09-01
914,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,329,D,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to ensure that 1) specific behaviors were identified and documented, 2) non-pharmacological interventions were provided and documented, 3) nurses were consulted before as needed antipsychotic medications were administered by medication aides and 4) follow up assessments were done to ensure the therapeutic benefits of the medications for two current sampled residents (Residents 43 and 143). The facility census was 107 with 22 current sampled residents. Findings are: Review of Resident 43's Medication Administration Record, [REDACTED]. Review of the Progress Notes dated 8/2/17 and 8/3/17, revealed no documentation of the resident's behavior, non- pharmacological interventions provided, an assessment from a nurse or a follow up assessment including the resident's response to the medication. Interview on 8/14/17 at 1:50 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that a nurse should have assessed the resident and gave the medication aide permission to administer the as needed antispychotic medication. Further interview confirmed that assessments should have been documented to include the resident's specific behaviors, non - pharmacological interventions provided before medications were considered. Further interview confirmed that follow up of the resident's response to the medication should be documented to ensure that the resident received the therapeutic benefits of the medication and no adverse effects. Based on observation and interview, the facility failed to post the Nurse Staffing Hours as required. This failure could have the potential to affect all the residents. Census was 107 Findings are: Observation on the initial environmental tour of the facility on 8/7/2017 at 9:00 AM revealed that the facility hadn't posted the Nurse staffing hours. Interview with the DON (Director of Nursing) on 8/7/2017 at 9:45 AM confirmed that the Nurse staffing hours were not posted.",2020-09-01
915,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,356,B,0,1,2T4P11,"Based on observation and interview, the facility failed to post the Nurse Staffing Hours as required. This failure could have the potential to affect all the residents. Census was 107 Findings are: Observation on the initial environmental tour of the facility on 8/7/2017 at 9:00 AM revealed that the facility hadn't posted the Nurse staffing hours. Interview with the DON (Director of Nursing) on 8/7/2017 at 9:45 AM confirmed that the Nurse staffing hours were not posted.",2020-09-01
916,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,361,D,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.04D1a Based on record reviews and interview, the facility failed to ensure that the RD (Registered Dietician) completed nutrition assessments when 1) one current sampled resident (Resident 169) was admitted with a surgical incision and a pressure ulcer and 2) one current sampled resident (Resident 37) developed a pressure ulcer to ensure that nutritional interventions were considered to promote healing of pressure ulcers. The facility census was 107 with 22 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment, dated 7/7/17, revealed that the resident had a Stage 2 pressure ulcer at the right buttock which measured 4 cm. (centimeters) length x 4.5 cm. width x 0.1 cm. depth and a surgical incision at the right hip. Review of the Weekly Wound Assessment, dated 7/27/17, revealed that the pressure ulcer at the right buttock was identified on 7/7/17. Further review revealed that interventions in place included a pressure redistribution mattress and wheelchair cushion. Interventions did not include nutritional supplements or protein supplements. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the pressure ulcer at the right buttock measured 8 cm. length, 4.2 cm. width, depth not marked and Stage is now Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) and/or eschar (tan, brown, or back) in the wound bed). Review of the Weekly Wound Assessment, dated 7/26/17, revealed that a Suspected Deep Tissue Injury at the right heel was identified on 7/25/17. Current preventative interventions listed did not include nutritional supplements to promote wound healing. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that an Unstageable pressure ulcer was identified on 8/2/17 at the coccyx. Review of the Nutrition Assessment described as Admission, dated 7/26/17, (Resident was admitted on [DATE]) revealed that the resident had a surgical wound and a stage 2 pressure ulcer and a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). Further review revealed that the resident's [MEDICATION NAME] (protein) level was low on 7/15/17 and a recommendation was made for 2 cal supplement two times a day to promote wound healing. Review of the physician Order Summary Report, printed 8/15/17, revealed an order, dated 7/31/17, for 2.0 calorie supplement three times a day related to a pressure ulcer at the right heel. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR) and printed 8/9/17, revealed that the resident did not receive any nutritional supplement to promote healing of the pressure ulcers until 7/31/17. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that a nutrition assessment was not completed on admission and RD (Registered Dietician) recommendations were delayed in being ordered and administered to promote healing of the pressure ulcers. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] post treatment for [REDACTED]. Review of the Progress Notes, dated 7/15/17, revealed that the resident had a wound at the coccyx which measured approximately 3 x 1 cm and a wound to the inside cleft of the right buttock which measured 2 x 2.5 cm. Review of the Weekly Wound Assessment, dated 7/26/17, revealed that the resident had a Stage 2 pressure ulcer at the coccyx which measured 1.0 cm. length, 0.3 cm. width and 0.1 cm. depth. Further review revealed interventions including nutritional supplements or protein supplements were not checked. Review of the Nutrition Assessment, dated 7/27/17, revealed that the resident had two, Stage 2 pressure ulcers and the RD (Registered Dietician) recommended Prostat supplement daily. Review of the TAR (Treatment Administration Record), dated (MONTH) (YEAR), revealed no orders for Prostat or any other nutritional supplements. Review of the TAR, dated (MONTH) (YEAR), revealed an order, dated 8/8/17, for Prostat supplement daily for wound healing. Interview on 8/15/17 at 9:30 AM with LPN - C, Unit Coordinator, confirmed that the nutrition assessment was not completed until 7/27/17. Further interview confirmed that the recommendations for a supplement received that day was not ordered and administered to the resident until 8/8/17 to promote wound healing.",2020-09-01
917,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,371,F,0,1,2T4P11,Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interview the facility failed to ensure that 1) sprinkler heads were free from gray fuzzy build-up 2) that the ceiling vent was free from gray fuzzy build up. 3) Employees AA and BB failed to wash their hands in between taking off their gloves while serving the meals on the 400 and 500 wing. 4) Dietary Aide BB failed to cover beard with a hair net while serving the meals on the 400 and 500 wing. These failures have the potential to affect all the residents in the facility. Census was 107 Findings are: [NAME] Observation on the initial kitchen tour on 8/7/2017 at 9:00 AM and follow up observation on 8/15/2017 revealed the following: - Sprinkler heads and ceiling vent had gray fuzzy matter on them. B. Observations conducted on 8/10/2017 at 11:15 AM to 11:45 and 8/14/2017 at 11:15 to 11:45 revealed the following: - Employees AA and BB failed to wash their hands in between taking their gloves off while serving the meals on the 400 and 500 wings - Employee BB failed to cover their beard with a hair net while serving the meals on the 400 and 500 wings. Interview with the Dietary Manager on 8/15/2017 at 10:30 confirmed that there was gray matter on the sprinkler heads and ceiling vent and also confirmed that the servers were required to wash their hands in between changing gloves while serving meals and beards need to be covered with a hairnet.,2020-09-01
918,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,425,E,1,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews; the facility failed to ensure that 1) medications were available to administer for a newly admitted resident (Resident 173) closed record, 2) Medication Aides reported a discrepancy with a prescription label and the doctor's order to a nurse before administering the medication for two current sampled residents (Residents 143 and 75) and 3) medication aides checked the prescription labels with the current medication order at least three times before administration of medications to reduce the risk for errors for five sampled residents observed for medication administration (Residents 53, 19, 143, 75 and 8). The facility census was 107 with five residents sampled for observation of medication administration and three closed records reviewed. Findings are: Licensure Reference Number: 175 NAC 12-006.12A [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the evening doses of Bumetanide and Carvedilol (ordered for heart failure) and Florajen and Sennosides (ordered for bowel maintenance) were not administered. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed that the evening treatment of [REDACTED]. Interview on 8/15/17 at 3:00 PM with LPN (Licensed Practical Nurse) - C, Unit Coordinator, confirmed that the evening doses of medications were not administered because the medications were not delivered to the facility from the pharmacy until late that evening. Licensure Reference Number: 175 NAC 12-006.10A3 B. Observations on 8/10/17 at 7:45 AM revealed MA (Medication Aide) - T prepared to administer morning medications for Resident 143. MA - T removed the medication card for Metoprolol. Further observations revealed that the prescription label had instructions to administer 25 mg. (milligrams) one tablet two times a day. Review of the electronic MAR indicated [REDACTED]. daily. MA - T did not identify the discrepancy with the prescription label and the medication order. MA - T did not clarify the order with a nurse when the discrepancy was questioned, administered 25 mg. and documented that 75 mg. were administered. Observations on 8/10/17 at 8:50 AM revealed MA - M prepared to administer Flonase nasal spray for Resident 75. Further observations revealed MA - M compared the prescription label with the order on the electronic MAR indicated [REDACTED]. MA - M did not clarify the order with a nurse when the discrepancy was questioned and administered the medication. Interview on 8/10/17 at 9:30 AM with the Interim Director of Nursing confirmed that the Medication Aides were to identify discrepancies with prescription labels and current orders. Further interview confirmed that the Medication Aides were to notify a nurse to clarify the orders before administration of the medications to reduce the risk for errors. C. Observations on 8/9/17 at 3:00 PM revealed MA - FF prepared to administer Oxycodone for Resident 19. Further observations revealed MA - FF removed the medication card from the medication cart, compared the prescription label with the order on the electronic MAR indicated [REDACTED]. D. Observations on 8/10/17 at 7:40 AM revealed MA - GG prepared to administer morning medications for Resident 53. Further observations revealed MA - GG removed the medication cards from the medication cart, compared the prescription label with the orders on the electronic MAR indicated [REDACTED]. MA - GG removed stock medications from the medication cart, checked the labels one time, poured the medications and returned them to the medication cart. MA - GG administered the medications and returned to the medication cart to sign off the medications administered. E. Observations on 8/10/17 at 7:45 AM revealed MA - T prepared to administer morning medications for Resident 143. Further observations revealed MA - T removed the medication cards from the medication cart, compared the prescription label one time with the orders on the electronic MAR, poured the medications, placed the medication cards back into the medication cart and administered the medications. Further observations revealed that MA - T returned to the medication cart and signed off the medications administered. F. Observations on 8/10/17 at 8:50 AM revealed MA - M prepared to administer Flonase nasal spray for Resident 75. Further observations revealed MA - M compared the prescription label with the order on the electronic MAR indicated [REDACTED]. Observations on 8/10/17 at 9:00 AM revealed MA - M administered medications for Resident 8 in the same manner described above. Review of the facility policy Medication Administration, revised 5/1/11, revealed the following including Procedure: . 8. Read the Medication Administration Record [REDACTED]. 10. Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR. If there is a discrepancy, check the original physician's order and notify the pharmacy. Do not give the medication until clarified. 11. Verify that any further medication identifiers match the label and the medication . 12. Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR before administering. Interview on 8/14/17 at 3:45 PM with the Interim Director of Nursing confirmed that the Medication Aides were to compare the prescription label at least three times with the medication order before administration of medications to reduce the risk of errors.",2020-09-01
919,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,431,E,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews; the facility failed to ensure that 1) medication refrigerator temperatures were monitored and documented to ensure the integrity of the medications stored in the refrigerators for several residents with insulin on the 100 wing, 2) prescription labels matched new orders for three sampled residents (Residents 53, 143 and 75) and 3) a prescription label was on an insulin pen for one resident (Resident 142). The facility census was 107. Findings are: Licensure Reference Number: 175 NAC 12-006.12E1 [NAME] Observations of the 100 wing medication room refrigerator on 8/10/17 at 3:00 PM revealed a Temperature Log taped on the refrigerator. Further review revealed no documentation of the refrigerator temperature on 8/5/17 and 8/6/17. Several vials of insulin and insulin pens were stored in the refrigerator. Interview on 8/14/17 at 3:45 PM with the Interim Director of Nursing confirmed that the refrigerator temperature should be obtained and documented at least daily to ensure the integrity of the medications. Licensure Reference Number: 175 NAC 12-006.12E7 B. Observations on 8/10/17 at 7:20 AM revealed MA (Medication Aide) - GG prepared to administer medications for Resident 53. Review of the prescription label for Hydrocodone revealed instructions to administer one tablet every four hours as needed for pain. Review of the physician's orders [REDACTED]. Review of the MAR, dated (MONTH) (YEAR), revealed an order, dated 10/4/16, for Hydrocodone one tablet every six hours as needed for pain. Further review revealed an order, dated 7/30/17, for Hydrocodone two tablets every six hours as needed for pain. Interview on 8/10/17 at 7:25 AM with LPN (Licensed Practical Nurse) - R, Charge Nurse, confirmed that the prescription label was not accurate with the current orders. C. Observations on 8/10/17 at 7:45 AM revealed MA - T prepared to administer medications for Resident 143. Review of the prescription label for Metoprolol revealed instructions to administer 25 mg. (milligrams) two times a day. Review of the order on the electronic MAR indicated [REDACTED]. Interview on 8/10/17 at 7:45 AM with MA - T confirmed that the prescription label did not match the order on the MAR. Review of the MAR, dated (MONTH) (YEAR), revealed an order, dated 8/7/17, for Metoprolol 75 mg. daily. D. Observations on 8/10/17 at 8:50 AM revealed MA - M prepared to administer medications for Resident 75. Review of the prescription label for Flonase revealed instructions to administer two sprays to each nostril two times a day. Review of the electronic MAR indicated [REDACTED]. Interview on 8/10/17 at 8:50 AM with MA - M confirmed that the prescription label did not match the order on the MAR. Review of the MAR, dated (MONTH) (YEAR), revealed an order, dated 10/5/16, for Flonase one spray in both nostrils two times a day. E. Observations of the 100 wing medication room refrigerator on 8/10/17 at 3:00 PM revealed a Novolog insulin pen for Resident 142 with no prescription label or a box with a prescription label. Further observation revealed the resident's name and the date opened written on the pen. Interview on 8/10/17 at 3:00 PM with LPN - Q confirmed that the Novolog insulin pen should have a prescription label which included the administration orders.",2020-09-01
920,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,441,E,0,1,2T4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews; the facility failed to ensure that 1) respiratory equipment was cleaned and covered after use for three sampled residents (Residents 46, 44 and 90), 2) glucometers were cleaned and disinfected before use for two current sampled residents (Residents 107 and 142), 3) linens were not stored on the floor for one sampled resident (Resident 46), 4) personal care items were not stored on the bathroom floor for one sampled resident (Resident 71), 5) an opened container of distilled water in the 100 wing medication room was dated when opened and 6) hand washing was performed after disposable gloves were removed during wound care for one sampled resident (Resident 169) and during medication administration for one sampled resident (Resident 75) before continuing with other tasks to reduce the risk of cross contamination. The facility census was 107 with 40 sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.17B [NAME] Observations of Resident 46's room on 8/8/17 at 8:20 AM, on 8/9/17 at 10:00 AM and on 8/14/17 at 7:00 AM revealed respiratory equipment, including a nebulizer mouth piece and an oxygen mask uncovered on the dresser. Observations of Resident 44's room on 8/9/17 at 10:00 AM revealed uncovered respiratory nebulizer equipment, including the mouth piece, on the window sill in the bathroom. Observations on 8/10/17 at 2:00 PM revealed the respiratory equipment uncovered on the bedside table. Observations of Resident 90's room on 8/8/17 at 8:30 AM, on 8/9/17 at 10:00 AM and on 8/14/17 at 7:00 AM revealed uncovered respiratory equipment, including a face mask, uncovered on the bedside table. B. Observations on 8/10/17 at 11:15 AM revealed LPN (Licensed Practical Nurse) - R, Charge Nurse, prepared to check a blood sugar for Resident 107. Further observations revealed LPN - R wiped the glucometer with an alcohol wipe for a few seconds before and after utilizing it for the blood sugar test. Observations on 8/10/17 at 11:45 AM revealed RN (Registered Nurse) - P, Charge Nurse, prepared to check a blood sugar for Resident 142. Further observations revealed RN - P wiped the glucometer off with an alcohol wipe for a few seconds before and after utilizing it for the blood sugar test. Review of the facility policy Blood Glucose Monitor/[MEDICATION NAME] Time Meter Device Cleaning and Disinfecting, dated 9/2014, revealed the following including: The blood glucose monitor/[MEDICATION NAME] equipment will be cleaned and disinfected between resident use, utilizing a disposable disinfectant cloth per the manufacturer's recommendations. Interview on 8/10/17 at 3:15 PM with RN - P revealed that Clorox Bleach Germicidal Wipes were to be used to clean and disinfect the glucometers. Review of the Cleaning and Disinfecting Procedures presented revealed the following instructions including: - Cleaning: Pull out one towelette, wipe the entire surface of the meter three times horizontally and three times vertically using one towelette to clan blood and other body fluids. The meter should be cleaned prior to each disinfection step. - Disinfecting: Pull out one new towelette and wipe the entire surface of the meter three times horizontally and three times vertically using a new towelette to remove blood-borne pathogens, dispose of the used towelette in a trash bin, allow exteriors to remain wet for the corresponding contact time for each disinfectant (three minutes). C. Observations of Resident 46's room on 8/8/17 at 8:20 AM, on 8/9/17 at 10:00 AM and on 8/14/17 at 7:00 AM revealed uncovered linens stored on the floor by the dresser. Interview on 8/14/17 at 7:00 AM with the Interim Director of Nursing, Infection Control Nurse, confirmed that respiratory equipment was to be cleaned and covered after use to reduce the risk of cross contamination. Further interview confirmed that linens were not to be stored on the floor to reduce the risk of cross contamination. D. Observations of the bathroom, adjacent to Resident 71's room, on 8/8/17 at 8:40 AM revealed an unlabeled spray container of periwash and a pair of tongs stored on the floor beside the toilet. Interview on 8/8/17 at 8:40 AM with LPN - DD, Unit Coordinator, confirmed that the periwash was not to be stored on the bathroom floor to reduce the risk of cross contamination. E. Observations of the 100 wing medication room on 8/10/17 at 3:15 PM revealed an opened and undated plastic gallon container of distilled water on the counter. Interview on 8/10/17 at 3:15 PM with LPN - Q, Charge Nurse, confirmed that the container should have been dated when opened so that it would be discarded after 30 days to reduce the risk for cross contamination. Licensure Reference Number: 175 NAC 12-006.17D F. Observations of wound care for Resident 169 on 8/9/17 at 10:00 PM revealed LPN - Q removed disposable gloves after a dressing was applied to pressure ulcers at the coccyx and right buttock. Further observations revealed LPN - Q did not wash hands and donned another pair of gloves to perform personal cares for the resident. [NAME] Observations of medication administration for Resident 8 on 8/10/17 at 9:00 AM revealed MA (Medication Aide) - M donned gloves to administer eye drops, removed the gloves and did not wash hands before administering nasal spray. Interview on 8/14/17 at 3:30 PM with the Interim Director of Nursing, Infection Control Nurse, confirmed that hand washing was to be performed after disposable gloves were removed and before continuing with other tasks to reduce the risk for cross contamination.",2020-09-01
921,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,469,F,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.18 A Based on observations and interview, the facility failed to ensure that 1) flies and other insects were removed from overhead lights in the kitchen. These failures had the potential to affect all the residents in the facility. Census was 107. Findings are: Observations conducted on 8/7/2017 at 9:30 AM and 8/15/2017 at 10:15 revealed the following: -dead insects in the light fixtures. -dead insects in the light fixtures. Interview with the Dietary Manager on 8/15/2017 at 10:30 AM confirmed that there were dead insects in the light fixtures in the kitchen.",2020-09-01
922,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,518,F,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.04B1 Based on record reviews and interviews, the facility failed to ensure that staff were trained to respond to emergencies for 3 (Employee DD, EE and V) out of the 10 employees sampled. This failure has the potential to affect all the residents in the facility. Census was 107. Finding are: Record Review of Employee files revealed that Employees DD, EE, and V had not received emergency preparedness training. Interview on 08/22/2017 at 11:24:24 AM with the facility Administrator confirmed that the facility failed to ensure on going emergency preparedness training was provided for employees.",2020-09-01
923,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2017-08-22,520,E,0,1,2T4P11,"Licensure Reference Number: 175 NAC 12-006.07C Based on observations, interviews, and record reviews; the facility's QA (Quality Assurance) Committee (QA) failed to develop and implement plans of actions to correct multiple issues of deficient practice relevant to resident care and services. The facility failed to implement effective plans of action to maintain correction for 19 previously cited areas of deficient practice identified. The failure could potentially affect all facility residents. Census was 107. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance after the standard annual survey completed on 8/22/2017. The facility failed to maintain correction for the regulations identified as repeat deficiencies: F164,F223,F225,F241,F252,F253,F279,F280,F309,F314,F323,F329,F371,F425,F431,F441,F469,F520. Following observations, record reviews and interviews for resident and facility task reviews, the facility failed to ensure compliance with the following areas. Cross Reference to: F164-Personal privacy taking vitals in public places' F223-Failed to protect residents from abuse, F225-Abuse report was not submitted, F241-Dignity of residents, F252-Homelike environment, damage to walls in dining room, F253-Multiple environment issues that need repairs, damage to doors, walls, floors throughout the facility, F279-Failed to develop a comprehensive care plans, F280-Failed to give residents the right to participate in care planning, F309-failed to have interventions in place to prevent skin injuries, F314-Failed to prevent pressure ulcers, F323-Failed to have interventions in place to prevent accidents, F329-Drug regime is free from unnecessary drugs, F371-Dusty vents in the kitchen F425-Perscription labels were not checked at least 3 times with medication orders, F431-Tempitures in medication freezers were not monitored, F441-Distilled water stored on the floor and not dated. F469-Ceiling light fixtures had insects in them. F520-Multple repeat deficiencies not corrected from last year.",2020-09-01
924,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2018-08-27,690,D,1,0,MBVI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licesure Reference Number 175 NAC 12-006.09D3 Based on observation, record review, and interview the facility failed to provide care and treatment for [REDACTED]. Census: 87. Sample size 3 residents. Findings are: On 8/27/18 at 1:10 PM an observation of NA-A (Nurse Aide-A) and NA-D performed peri and catheter care for Resident 1 and revealed that NA-A and NA-D knocked and introduced themselves when entering the room. NA-D explained the procedure, gathered the needed supplies, and provided privacy for Resident 1. NA-A explained the procedure to Resident 1. NA-D removed old/soiled brief from resident, NA-A cleansed the peri-area, the catheter tubing from meatus out, and applied the clean brief. Hand hygiene was performed approatiately throughout the procedure. The foreskin was not pulled back for cleaning and therefore, the entirety of peri-care was not completed property. On 8/27/18 at 2:00 PM, a review of the facility policy/procedure for Perineal care revealed that proper peri care was not performed for Resident 1. On 8/27/18 at 1:30 PM, an interview with NA-A and NA-D confirmed that proper peri-care was not performed for Resident 1. Interview on 8/27/18 at 2:15 PM, with the Administrator confirmed proper peri-care was not performed for Resident 1.",2020-09-01
925,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-08,689,D,1,0,VZ7311,"> Licensure Reference Number: 175 NAC 12-006.09D7 Based on observations, record reviews and interview; the facility failed to ensure that a call light was within reach and interventions were in place to prevent falls and injuries for one current sampled resident (Resident 1) identified at high risk for falls. The facility census was 84 with seven current sampled residents. Findings are: Observations on 10/3/19 at 2:00 PM revealed Resident 1 seated in a recliner in the room with the call light on the floor and not within reach of the resident. Interview with LPN (Licensed Practical Nurse) - C on 10/3/19 at 2:00 PM confirmed that the resident needed to have access to the call light to call for assistance and placed the call light near the resident. Review of the care plan, goal date 10/29/19, revealed that the resident had impaired vision with a right sided deficit due to a stroke, required assistance of one staff member and a walker for ambulation and transfers and was confused at times. Further review revealed that the resident was a high risk for falls related to confusion, deconditioning, gait and balance problems, medications, history of a stroke and not always aware of safety needs. Interventions included (initiated 10/8/18) to ensure that the call light is within reach and encourage the resident to use it for assistance. Review of the Progress Notes, dated 8/12/19 at 4:31 AM, staff assisted the resident to the bathroom, the resident lost balance and fell forward and bumped forehead on the grab bar next to the toilet. The resident complained of a headache and medication was administered. Bruising was noted at the forehead, right arm and right thigh. The resident was sent to the emergency room at 7:00 PM due to increased pain. Scans and x-rays were clear and the resident returned to the facility. Staff received education on safety when transferring and walking with the resident. Interview with the Director of Nursing on 10/8/19 at 10:00 AM confirmed that the resident was to have the call light in place at all times to access staff when needed. Further interview confirmed that staff were to ambulate with the resident with a gait belt (belt applied at the resident's waist for staff to hold to ensure stability and safety during transfers and ambulation) and walker to ensure the resident's safety and stay with the resident while in the bathroom.",2020-09-01
926,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-08,745,D,1,0,VZ7311,"> Licensure Reference Number: 175 NAC 12-006.09D5a Based on record reviews and interview, the facility failed to ensure that broken dentures were repaired or replaced and a dental appointment was made when requested for one sampled resident (Resident 2) closed record. The facility census was 84 with seven current sampled residents and five closed records reviewed. Findings are: Review of the facility Grievance/Concern Form, dated 3/5/19, revealed that Resident 2's representative reported that the residents dentures had been broken since (MONTH) (YEAR). The representative requested a dental appointment to get the dentures fixed. Further review revealed that the Resolution Action taken to resolve grievance/complaint, dated 3/12/19, stated that a clinic was called to make an appointment, no appointment was made yet. Interview with the Social Services Director on 10/7/19 at 3:00 PM confirmed that the there was no further follow up with the grievance. Further interview confirmed that the resident's dentures were not repaired or replaced and an appointment was not made with a dentist as requested by the resident's representative.",2020-09-01
927,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,568,D,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.05(19) Based on record reviews and interviews, the facility failed to ensure that quarterly statements of personal funds accounts were sent to residents/residents' representatives as required for three current sampled residents (Resident 17, 18 and 1). The facility census was 85 with 10 current sampled residents. Findings are: Review of the complaint information, dated 10/23/19, (complainant requested to remain anonymous) revealed that the facility did not send a quarterly statement of personal funds account as required. [NAME] Interview with Resident 17 on 10/29/19 at 1:15 PM revealed had not received a quarterly personal funds account statement for a long time and used to get them regularly. B. Interview with Resident 18 at 1:30 PM revealed had not received the quarterly personal funds account statement like the facility used to so is not sure how much money is in the account. C. Interview with Resident 1 on 10/29/19 at 1:45 PM revealed not sure if the quarterly personal funds account statement was received. The resident stated would like to have that statement at least quarterly. Interview with the Business Office Director on 10/29/19 at 2:45 PM confirmed that the quarterly personal funds account statement had not been sent to the residents or residents' representatives as required for the last quarter.",2020-09-01
928,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,600,D,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.05(9) Based on record reviews and interview, the facility failed to ensure that potential neglect related to a fall with injuries for was reported, identified and investigated for one current sampled resident (Resident 2). The facility census was 85 with 10 current sampled residents. Findings are: Review of the facility report Fall During Staff, revealed that on 10/17/19 at 8:08 PM, the resident was in a sit to stand mechanical lift to transfer from the chair to the bed. The resident stated was feeling like (gender) was going to faint. As the nursing assistant lowered the bed the resident stated I'm going down. The resident fell through the sling and hit head on the bed. The resident had bleeding from a scalp laceration and a skin tear on the right forearm. Further review revealed no evidence that potential neglect was identified for further investigation. Review of the Progress Notes, dated 10/17/19 at 8:14 PM, revealed that the resident was sent to the emergency room for evaluation of the injuries. Interview with NA (Nursing Assistant), who requested to remain anonymous, on 10/30/19 at 8:45 AM revealed that the resident had been transferred with a full body lift for a couple of days before the fall as the resident was too weak to stand safely in the sit to stand lift. Interview with LPN (Licensed Practical Nurse), who requested to remain anonymous, on 10/30/19 at 8:45 AM revealed that, before the fall, the resident was to be transferred with the full mechanical lift due to increased weakness and inability to stand in the sit to stand lift. The change in care was not passed on effectively to the next shifts to ensure safe transfers for the resident. Interview with the Director of Nursing on 10/30/19 at 10:40 AM confirmed that the investigation report related to the fall did not include that the incident was reported as potential neglect or identify potential neglect. Further interview confirmed that further investigation was not completed to evaluate potential neglect on the part of the staff who transferred the resident with the wrong mechanical lift. Review of the facility policy Abuse, Neglect and Exploitation, dated (MONTH) (YEAR), revealed the following including: . 7. 'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident hat are necessary to avoid physical harm, pain, mental anguish, or emotional distress.",2020-09-01
929,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,689,G,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.09D7 Based on observations, record reviews and interviews, the facility failed to ensure that 1) a safe transfer was provided for one current sampled resident (Resident 2) to prevent a fall with a scalp laceration and a skin tear to the arm, 2) one current sampled resident (Resident 1) was transferred with two staff assistance in a full mechanical lift as directed to ensure safe and comfortable transfers and 3) provide specific instructions for one current sampled resident (Resident 14) to ensure safe and consistent transfers. The facility census was 85 with 10 current sampled residents. Findings are: [NAME] Review of Resident 2's Care Plan, goal date 10/30/19, revealed that the resident was at risk for falls related to history of falls and had a physical functioning deficit related to mobility impairment, limitations in range of motion, history of a left knee fracture, and self care impairment. Interventions included 4/22/19 transfer assist of two with a sit to stand mechanical lift. Review of the facility report Fall During Staff, revealed that on 10/17/19 at 8:08 PM, the resident was in a sit to stand mechanical lift to transfer from the chair to the bed. The resident stated was feeling like (gender) was going to faint. As the nursing assistant lowered the bed the resident stated I'm going down. The resident fell through the sling and hit head on the bed. The resident had bleeding from a scalp laceration and a skin tear on the right forearm. Further review revealed that the skin tear at the right forearm measured 10 x 7 and the laceration to the back of the head measured 0.4 x 1.0. The resident also had multiple bruising on the upper extremities, abdomen, right arm and hand, and bilateral rib cages. Review of the Progress Notes, dated 10/17/19 at 8:14 PM, revealed that the resident was sent to the emergency room for evaluation of the injuries. Interview with NA (Nursing Assistant), who requested to remain anonymous, on 10/30/19 at 8:45 AM revealed that the resident had been transferred with a full body lift for a couple of days before the fall as the resident was too weak to stand safely in the sit to stand lift. Interview with LPN (Licensed Practical Nurse), who requested to remain anonymous, on 10/30/19 at 8:45 AM revealed that, before the fall, the resident was to be transferred with the full mechanical lift due to increased weakness and inability to stand in the sit to stand lift. The change in care was not passed on to the next shifts to ensure safe transfers for the resident. Interview with the DON (Director of Nursing) on 10/30/19 at 10:40 AM confirmed that the staff needed to communicate changes in resident care needs to the next shifts and update the care plan interventions when needed to ensure safe and consistent care. B. Review of Resident 1's Care Plan, goal date 12/30/19, revealed that the resident was at risk for falls related extensive assist with bed mobility, transfers using two assist and a full mechanical lift, history of falls and fracture and medication usage. Interventions included that staff will utilize two staff with transfers and the resident required a full mechanical lift for transfers. Interview with the resident on 10/29/19 at 1:30 PM revealed had been transferred in the lift with just one staff member and they are supposed to have two staff members transfer with the lift. Interview with the DON on 10/30/19 at 10:20 AM confirmed that the staff were to always use two staff to transfer residents in the mechanical lifts to reduce the risk for falls and injuries. C. Review of Resident 14's Care Plan, goal date 11/26/19, revealed that the resident required assistance with activities of daily living. Interventions included one assist transfers using a gait belt (belt placed around the resident's waist for staff to hold and guide the resident) and may require hoyer lift (full mechanical lift) at times. Observations on 10/29/19 at 11:50 AM revealed MA (Medication Aide) - D and MA - [NAME] transferred the resident from the wheelchair to the bed with the full mechanical lift. Interview with MA - D on 10/29/19 at 11:50 AM revealed that the resident had needed the full lift for transfers for a long time as the resident was not able to stand. Interview with the DON on 10/30/19 at 10:20 AM confirmed that the staff needed specific instructions for safe and consistent transfers.",2020-09-01
930,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,690,E,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.09D3 Based on observations, record reviews and interviews; the facility failed to provide effective incontinence supplies to manage urinary incontinence (inability to control bladder) for five current sampled residents (Residents 3, 4, 5, 6 and 7). The facility census was 85 with 10 current sampled residents. Findings are: [NAME] Review of Resident 3's Care Plan, goal date 12/31/19, revealed that the resident had an urge incontinence of the bladder. Interventions included to assist with incontinency cares as needed and use briefs and pads for incontinence protection. B. Review of Resident 4's Care Plan, goal date 11/27/19, revealed that the resident was incontinent of bladder and was dependent on staff for incontinence cares. C. Review of Resident 5's Care Plan, goal date 12/10/19, revealed that the resident was frequently incontinent of bladder and required staff assistance with toileting and skin care. D. Review of Resident 6's Care Plan, goal date 1/21/20, revealed that the resident was frequently incontinent of bladder and used briefs and pads for incontinence protection. E. Review of Resident 7's Care Plan, goal date 12/31/19, revealed that the resident was frequently incontinent of bladder and bowel and used briefs and pads for incontinence protection. Interviews with MA (Medication Aide) - F and MA - G on 10/30/19 at 5:30 AM confirmed that the residents listed above were incontinent and wore disposable briefs for protection during the night and were toileted, checked or changed every two hours during the night. Further interview revealed that the disposable briefs were inadequate to contain the urine which required several total bed changes for residents during the night. Observations of the disposable briefs on 10/30/19 at 5:30 AM confirmed that they were thin. Interview with the Director of Nursing on 10/30/19 at 10:10 AM confirmed that the incontinence products currently in use needed to be evaluated to provide comfort and meet the residents' needs.",2020-09-01
931,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,725,E,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.04 Based on record reviews and interviews, the facility failed to ensure adequate nursing staff to provide routine bathing as scheduled for seven current sampled residents (Residents 1, 18, 2, 3, 5, 6 and 7. The facility census was 85 with 10 current sampled residents. Findings are: [NAME] Review of Resident 1's Care Plan, goal date 12/30/19, revealed that the resident preferred a bath two times a week. Interview with the resident on 10/29/19 at 1:30 PM revealed that the resident does not receive a bath at least two times a week because they are short staffed. Review of the bath schedule revealed that the resident was scheduled for a bath on Tuesdays and Fridays. Review of the resident's bathing record, dated (MONTH) 2019, revealed that the resident received a bath on 10/9/19 and 10/26/19. B. Interview with Resident 18 on 10/29/19 at 1:30 PM revealed was not getting routine baths as scheduled every Tuesday and Friday because they were short staffed so often. C. Review of Resident 2's Care Plan, goal date 10/30/19, revealed that the resident preferred to have a bath two times a week. Review of the bath schedule revealed that the resident was scheduled to have a bath on Wednesdays and Saturdays. Review of the resident's bathing record, dated (MONTH) 2019, revealed that the resident received a bath on 10/23/19. D. Review of the bathing schedule revealed that Resident 3 was scheduled to have a bath on Fridays. Review of the resident's bathing record, dated (MONTH) 2019, revealed that the resident received a bath on 10/11/19 and 10/25/19. E. Review of Resident 5's Care Plan, goal date 12/10/19, revealed that the resident preferred a bath two times a week. Review of the bathing schedule revealed that the resident was scheduled for a bath on Tuesdays and Saturdays. Review of the resident's bathing record, dated (MONTH) 2019, revealed that the resident received a bath on 10/1/19, 10/12/19, 10/15/19 and 1022/19. F. Review of Resident 6's Care Plan, goal date 1/21/20, revealed that the resident preferred a bath two times a week. Review of the bathing schedule revealed that the resident was scheduled for a bath on Tuesdays and Fridays. Review of the resident's bathing record, dated (MONTH) 2019, revealed that the resident received a bath on 10/1/19, 10/4/19, 10/16/19 and 10/25/19. [NAME] Review of Resident 7's Care Plan, goal date 12/31/19, revealed that the resident preferred to have a bath two times a week. Review of the bathing schedule revealed that the resident was scheduled for a bath on Tuesdays and Fridays. Review of the resident's bathing record, dated (MONTH) 2019, revealed that the resident received a bath on 10/1/19 and 10/11/19. Interview with the Staff Development Director on 10/30/19 at 8:50 AM revealed that the Bath Aide was pulled to work on the floor, rather than give baths, on 10/16/19, 10/24/19, 10//25/19 and 10/29/19 due to staff call ins. Interviews with MA (Medication Aide) - D and MA - [NAME] on 10/29/19 at 11:50 AM revealed that they often worked short staffed on the day shift with not enough staff to get the work done. Interviews with MA - H and MA - I on 10/29/19 at 2:00 PM revealed that they often worked short staffed on the day shift and it was difficult to get the work done as scheduled. Interview with the Administrator on 10/30/19 at 8:30 AM confirmed that staffing patterns were not always in place as listed on the Facility Assessment to ensure adequate nursing staff to meet the resident's needs. Interview with the Director of Nursing on 10/30/19 at 10:30 AM confirmed that residents were to be given their baths as scheduled and per their preferences to ensure the resident's comfort and needs were met.",2020-09-01
932,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,745,D,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.04E3 Based on record reviews and interview, the facility failed to ensure that Social Services were provided including assistance with business mail when needed and notification to the representative when personal funds were needed for one current sampled resident (Resident 1). The facility census was 85 with 10 current sampled residents. Findings are: Review of Resident 1's Progress Notes, dated 10/22/19, revealed that the resident's representative called the SSD (Social Social Director) regarding issues with the resident's Medicare benefits. Interview with the SSD on 10/29/19 at 2:20 PM revealed that staff delivered business mail to the resident and did not report that the resident had many business letters unopened on the bedside table. The resident required assistance to manage financial and insurance business. Further interview revealed that staff did not report that the resident had insufficient funds in the personal funds account. The SSD confirmed that staff needed to report that information to the SSD so that the representative would be notified of the need to deposit money into the resident's account for the resident's use. Interview with the Administrator on 10/30/19 at 10:20 AM confirmed that staff needed to notify Social Services when resident's needed assistance with business mail and money in their personal funds account.",2020-09-01
933,MONUMENT REHABILITATION AND CARE CENTER,285095,111 WEST 36TH STREET,SCOTTSBLUFF,NE,69361,2019-10-30,835,E,1,0,H6V311,"> Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that there were enough full mechanical lifts to transfer residents timely when needed for five current residents on the 100 Wing (Residents 8, 9, 10,11 and 12) and six current residents on the 200 Wing (Residents 1, 2, 13, 14, 15 and 16). The facility census was 85 with 10 current sampled residents. Findings are: Observations on 10/29/19 at 11:50 AM revealed MA (Medication Aide) - D and MA - [NAME] revealed Resident 14 was transferred from the bed to the wheelchair with a full mechanical lift During the transfer, NA (Nursing Assistant) - J requested to borrow the mechanical lift for the 100 wing as the other one was in use for another resident. Interviews with MA - D, MA -E and NA - J on 10/29/19 at 11:50 AM revealed that there was one mechanical lift for the 200 wing and one for the 100 wing and resident's often had to wait until a lift was available when they needed transferred. MA - D stated that they used to have at least two full mechanical lifts on the 200 wing and they have several residents who need to transfer with the full lift. Review of the list of residents who require the full mechanical lift for transfers revealed five residents on the 100 wing (Residents 8, 9, 10,11 and 12) and six residents on the 200 Wing (Residents 1, 2, 13, 14, 15 and 16). Interview with Resident 1 on 10/29/19 at 1:30 PM revealed that had to wait to be transferred because the lift was being used by other residents. Interview with Resident 10 on 10/30/19 at 2:00 PM revealed that had to wait to be transferred because the lift was being used by other residents. Interview with the Director of Nursing on 10/30/19 at 8:10 AM revealed would evaluate the need for more full mechanical lifts so the resident's wouldn't have to wait as long to be transferred.",2020-09-01
934,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-07-03,657,E,1,0,5XJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility staff failed to review and revise 3 residents' care plans after falls to prevent further falls and potential injury. This affected 3 of 4 residents whose care plans were reviewed during the survey process (Residents 1, 3, and 4). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 1's quarterly MDS (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/11/2019 revealed an admission date of [DATE]. Resident 1 had no falls since prior assessment. Review of Resident 1's Fall reports revealed Resident 1 had falls documented on 3/2/2019 and 6/19/2019. Review of Resident 1's Care Plan dated 3/15/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 1 fell on [DATE] and 6/19/2019. Interventions were added to the care plan on 6/25/2019, 6 days after Resident 1 fell on [DATE]. B. Review of Resident 3's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 3 required extensive assistance with transfers. Resident 3 had 1 fall with injury since the prior assessment. Review of Resident 3's Fall report revealed documentation Resident 3 had a fall on 3/1/2019. Review of Resident 3's Care Plan dated 12/7/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 3 fell on [DATE]. C. Review of Resident 4's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 4 was rarely/never understood. Staff assessment for mental status revealed Resident 4 had short tern and long term memory problems and Resident 4 had moderately impaired cognitive skills for daily decision making. Resident 4 required limited assistance of 1 staff person for transfers. Resident had 2 falls with no injury since prior assessment. Review of Resident 4's Fall reports revealed documentation that Resident 4 had falls on 1/22/19, 2/13/19, 3/31/19, and 6/10/19. Review of Resident 4's Care Plan dated 2/16/2018 revealed no documentation of interventions implemented to prevent further falls and injuries after Resident 4 fell on [DATE], 2/13/19, 3/31/19, and 6/10/19. Interview with the MDS Coordinator on 7/3/2019 at 10:09 AM confirmed the fall interventions were not on the care plans and the care plans were not reviewed and revised. The MDS Coordinator revealed the care plans were supposed to be updated after falls and they were not. Interview with NA-B (Nurse Aide) on 7/3/2019 at 10:30 AM revealed they got the information they needed to care for the residents from the care plan.",2020-09-01
935,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2017-08-22,371,F,0,1,GG8P11,"Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility failed to utilize a facial hair restraint to prevent the potential for hair contact with food and failed to change gloves during food preparation in a manner to prevent the potential for food borne illness. This had the potential to affect 32 residents that ate food prepared in the facility kitchen. The facility census was 32. Findings are: [NAME] Observation on 08/16/2017 between 11:00:40 AM and 11:10 AM during the initial tour of the kitchen revealed Dietary Aide (DA) A had a goatee beard and mustache with no facial hair restraint in place during food preparation of the lunch meal. B. Observation on 08/16/2017 at 12:01:37 PM revealed DA A served lunch with no facial hair restraint in place. C. Observation on 08/21/2017 at 10:31:12 revealed DA A was in the food preparation area of the facility kitchen with no facial hair restraint in place. D. Record review of the 7/1/07 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: - 2.402.1(A) Food employees shall wear hair restraints such as beard restraints that are designed and worn effectively to keep hair from contacting exposed food, clean equipment, utensils and linens. E. Observation on 8/21/17 between 11:00 AM and 11:15 AM during food preparation revealed Cook B removed a box of ground beef patties from the freezer. Cook B washed hands and donned gloves. [NAME] removed 2 frozen ground beef patties from a bag and placed them on a pan. Cook B placed the meat soiled bag on top of the plastic wrap container. It remained in that position for the entire observation. Cook B repeated the process of removing the individual ground beef patties and placed them on the pan until the pan was full. With meat soiled gloves, Cook B touched the oven door handle and opened the oven door, placed the pan in the oven and closed the oven door. Cook B removed the gloves and performed hand washing, donned new gloves and repeated the process. While wearing meat soiled gloves, Cook B opened the oven door, placed the pan of beef patties in the oven and closed the oven door. While wearing the same meat soiled gloves, Cook B closed the box of leftover meat patties, labeled it with a pen taken from her pocket, placed the pen back into the pocket, picked up the box and touched and opened the storage and freezer doors. Still wearing the meat soiled gloves, Cook B returned to the food preparation area and carried 2 single onions to the food preparation table. Cook B removed the soiled gloves and performed hand washing. F. Record review of the 7/1/07 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: - 3-304.15: Gloves shall only be used for one task such as working with raw animal food and discarded when soiled. [NAME] Interview on 08/22/2017 at 8:21:59 AM with the Dietary Manager (DM) confirmed that DA A should have worn a beard and mustache hair restraint. The DM confirmed that Cook B should have removed the gloves and performed hand washing after the meat product was touched and before other items were touched. The DM confirmed all residents that resided in the facility ate food that had been prepared in the facility kitchen. H. Record review of the facility Policy and Procedure for Nutritional Services dated 5/19/14 for kitchen sanitation practices included the following employee requirements: - Beard restraints must be worn to keep hair from contacting the food and food contact surfaces. - Hands should be washed after handling raw foods (before and after). - Gloves should be changed after touching a source of contamination and when soiled.",2020-09-01
936,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2018-09-05,637,D,0,1,Y9XX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on observation, interview, and record review; the facility staff failed to complete a SCSA (Significant Change in Status Assessment) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) when Resident 8 was admitted to Hospice (care designed to give supportive care to people in the final phase of a terminal illness). This affected 1 of 16 residents whose MDS assessments were reviewed during the survey process. The facility identified a census of 22 at the time of survey. Findings are: Review of Resident 8's Annual MDS dated [DATE] revealed Resident 8 was admitted to the facility on [DATE]. Resident 8 had a terminal prognosis and received Hospice care during the assessment period. Observation of Resident 8's room on 8/30/18 at 3:59 PM revealed a Hospice aide was sitting in the Resident 8's room. Interview with the unidentified Hospice aide at this time revealed they provided Resident 8 Hospice care twice a week. Interview with NA-A (Nurse Aide) on 9/04/18 at 1:34 PM revealed Resident 8 received Hospice services. Review of Resident 8's Hospice Certification and Plan of Care dated 9/18/2017 revealed a start of Care Date of 9/14/2017. Review of Resident 8's MDS assessments revealed the following assessments were completed: 6/15/2018 Annual 3/15/2018 Quarterly 12/18/2017 Quarterly 9/18/2017 Quarterly 6/15/2017 Annual There was no documentation a SCSA MDS was completed after Resident 8 was admitted to Hospice on 9/14/2017. Review of the Centers for Medicare and Medicaid RAI (Resident Assessment Instrument) 3.0 manual revealed the following: A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. Interview with the DON (Director of Nursing) who was also the MDS Coordinator on 9/04/18 at 1:14 PM confirmed the SCSA MDS was not completed after Resident 8 was admitted to Hospice.",2020-09-01
937,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2018-09-05,641,E,0,1,Y9XX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09b Based on interview and record review, the facility staff failed to code the MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) to reflect the PASRR (Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) requirement. This affected 3 of 3 sampled residents (Residents 10, 21, and 1). The facility identified a census of 22 at the time of survey. Findings are: [NAME] Review of Resident 10's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 10 had an active [DIAGNOSES REDACTED]. Resident 10's admitted was 1/31/2011. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The federal definition for mental illness is designed to include individuals with a potential for and history of episodic changes in treatment and service needs. Federal guidelines include a three component definition that includes: [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Anxiety disorder may require further evaluation through PASRR depending upon their extent and severity. Review of Resident 10's [DIAGNOSES REDACTED]. Resident #21 B. Review of Resident 21's annual MDS dated [DATE] revealed a response to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?in section A1500 PASRR was marked No. Resident 21 had an active [DIAGNOSES REDACTED]. Resident 21's admitted was 9/14/2015. Review of the Ascend Nebraska Level 1 PASRR Screening Instructions revised 11/25/2015 revealed the following: The federal definition for mental illness is designed to include individuals with a potential for and history of episodic changes in treatment and service needs. Federal guidelines include a three component definition that includes: [DIAGNOSES REDACTED].These [DIAGNOSES REDACTED]. Review of Resident 10's [DIAGNOSES REDACTED]. Interview with the DON (Director of Nursing) on 9/04/18 at 1:15 PM confirmed the MDS assessments for Resident 10 and Resident 21 were not coded to reflect they had [DIAGNOSES REDACTED]. Findings are: C. Record review of Resident 1's comprehensive MDS dated [DATE] revealed Resident 1 had active [DIAGNOSES REDACTED].? in section A1500 PASRR was marked No. Interview on 09/05/18 at 09:33 AM with the DON (Director of Nursing) confirmed that Resident 1's MDS was not marked to reflect the [DIAGNOSES REDACTED].",2020-09-01
938,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2018-09-05,727,F,0,1,Y9XX11,"Licensure Reference Number 175 NAC 12-006.04C1 Based on record review and interview, the facility failed to provide 8 hours of RN (Registered Nurse) coverage for every 24 hour period. This had the potential to affect all the residents at the facility. The facility census was 22. Findings are: Record review of the facility nursing staff schedule revealed that the nursing staff schedule did not reflect 8 hour RN coverage on the following dates: (MONTH) 5, (MONTH) 18, (MONTH) 25, (MONTH) 1 and (MONTH) 2. Interview (MONTH) 4th, (YEAR) at 11:30 AM with the DON (Director of Nursing) confirmed there was no RN coverage on those dates.",2020-09-01
939,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2018-09-05,812,F,1,1,Y9XX11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to serve food in a manner to prevent potential cross contamination; failed to maintain cookware and dishes to prevent potential cross contamination; and failed to keep kitchen surfaces clean. This had the potential to affect all of the facility residents. The facility identified a census of 22 at the time of survey. Findings are: [NAME] Initial tour of the kitchen on 8/29/18 at 9:44 AM revealed the following: Mixing bowls, plate warmers and lids for room trays were stored on bottom shelves upright and uncovered. Plates were uncovered in the rack by the steam table. Refrigerator and freezer doors were visibly soiled with smears of white and brown material. A window air conditioner was blowing back behind the stove over the sink; the front cover had gray debris on it. B. Observation of evening meal service on 8/30/2018 at 5:30 PM revealed Cook-B wearing gloves. Cook-B grabbed the handles of 2 carts and wheeled them over to where the steam table was. At 5:37 PM Cook-B touched the buns for the riblet sandwiches with the same gloved hands that they had touched the cart handles with and the handles of the utensils. Cook-B did not change gloves. Cook-B then picked up trays off the bottom shelf of the food prep table and continued to serve. Cook-B also handled the diet cards. Cook-B then touched the ham sandwiches with the same gloved hands. At 5:42 PM Cook-B opened the cupboard door and got plastic cups out and put them on the condiment cart. Cook-B then grabbed more trays off the shelf. At 5:43 PM Cook-B put their fingers in the ramekins then put corn in them using the same gloved hands. Cook-B then served the corn to the residents. At 5:46 PM Cook-B got more trays off the shelf then continued to serve touching the buns with the same gloved hands and putting fingers in the ramekins. At 5:50 PM Cook-B got more trays and proceeded to touch the buns and put fingers inside the ramekins with the same gloved hands. At 5:56 PM Cook-B got more trays and proceeded to touch the buns and put fingers inside the ramekins. Cook-B did not change their gloves during the entire meal service. 16 residents received a riblet on a bun that Cook-B had touched with the soiled gloves. 5 residents received a ham sandwich that Cook-B had touched with the gloves. All of the residents received corn or creamed corn that was served in the ramekins. Interview with the FSS (Food Service Supervisor) on 8/30/2018 at 6:04 PM confirmed Cook-B should have used tongs to served the buns/sandwiches and should not have been touching the food with the gloves. The FSS revealed Cook-B should have changed their gloves and performed hand hygiene after touching the potentially contaminated surfaces (carts, cupboard doors, trays, diet cards). Review of the facility policy Hand Washing/Hand Hygiene revised (MONTH) 2014 revealed the following: The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility policy Nutritional Services Hand Washing dated 5/19/2014 revealed the following: Hands should be washed after the following occurrences: touching un-sanitized equipment, work surfaces, or wash cloths. C. Tour of the kitchen with the FSS on 9/05/18 at 10:44 AM revealed the following: There was a tub of plastic pitcher lids on the bottom shelf of one of the prep tables. The inside of the tub was soiled with a brown substance as well as one of the lids on top. There was another tub on the bottom shelf also that was uncovered and full of plastic pitcher lids. The rack with plates, bowls, ramekins, and pans with all stored upright was uncovered. Large plates were stored upright in a plate holder by the steam table and not covered. The room tray plate holder bottoms and lids were stored upright on the bottom shelf of one of the prep tables and the mixing bowls were stored upright on the bottom shelf of the prep table. There was visible debris on the shelf. The refrigerator doors were soiled with smears of brown and white substances on both of the large 3 door refrigerators and on the 3 door freezer. The cover on the air conditioner was soiled with gray debris. The lids for the steam table trays were sitting on the prep sink under the air conditioner. Interview with the FSS at this time revealed that the dishes should be stored to keep them clean and kitchen surfaces should be clean. Review of the Cleaning list received from the FSS for (MONTH) (YEAR) revealed the following: Cleaning list is due to be checked off by the FSS when you are ready for your item to be looked at with the FSS before (MONTH) 31st.",2020-09-01
940,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,582,E,0,1,DGFB11,"Based on record review and interview, the facility failed to ensure that residents were provided a Notice of Medicare Non coverage for 3 (Resident 8, Resident 124, and Resident 125) of 3 sampled residents. The facility census at the time of the survey was 21. Finds are: [NAME] Record review of Resident 8's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 9/1/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). B. Record review of Resident 124's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 6/22/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). C. Record review of Resident 125's Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) dated 5/28/19 resident was notified of discharge from skilled services but did not receive the required Notice of Medicare Non Coverage (NOMNC). An interview on 10/16/19 at 4:29 PM with the DON (Director of Nursing) revealed the DON issues the denial letters for SNFABN and NOMNC. The DON stated that Resident 8, Resident 124, and Resident 125 did not initiate their discharges and that each one had days remaining for Medicare A Services. The DON confirmed that the NOMNC letters were not given to Resident 8, Resident 124 or Resident 125.",2020-09-01
941,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,584,D,1,1,DGFB11,> LICENSURE REFERENCE NUMBER 175 NAC 12-007.04D Based on observation and interview the facility failed to ensure the vents in the bathroom were free from dirt and dust for 2 (Resident 10 and Resident 15) of 16 sampled residents. The census at the time of the survey was 21. Findings Are: [NAME] Observation on 10/10/19 at 8:40 AM of the bathroom for Resident 10 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. B. Observation on 10/10/19 at 8:43 AM of the bathroom for Resident 15 revealed that the ceiling vent was covered with a fuzzy gray debris that rained down when touched with a piece of toilet tissue. An interview on 10/16/19 at 5:28 PM with the HS (Housekeeping Supervisor) confirmed that the bathroom vents for Resident 10 and Resident 15 were covered with a fuzzy gray debris.,2020-09-01
942,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,602,D,1,1,DGFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 12-006.05(9) Based on interview and record review, the facility failed to protect residents from potential misappropriation by failing to conduct reference checks, a criminal background check, and licensure certification verification checks for RN-B (Registered Nurse) who subsequently diverted medications from the facility residents. This affected 2 of 21 residents in the facility (Resident 1 and 17) who received medication. The facility identified a census of 21 at the time of survey. Findings are: Review of the facility report Misappropriation dated 9/15/2019 revealed the current facility DON (Director of Nursing) and other nursing staff suspected there were medications missing from the medication cart that had belonged to Resident 1 and Resident 17. The report contained documentation of discrepancies in the amount of medications that were sent to the facility from the pharmacy for Residents 1 and 17, the amount of the medication that was administered to the residents, and the amount remaining in the supply. The facility discovered that 86 tablets of [MEDICATION NAME] (a narcotic like pain reliever) for Resident 17, 32 tablets of [MEDICATION NAME] (antianxiety medication) for Residents 1 and 17, and 51 tablets of [MEDICATION NAME] (an opioid or narcotic pain reliever) that were slated for destruction had potentially been diverted from the facility and residents' medication supply. Review of the facility report of the investigation into drug diversion dated 9/17/2019 revealed documentation RN-B (the DON at the time of the incident) was confronted about the missing medications. RN-B admitted to diverting the mediations from the facility medication cart for their own use including [MEDICATION NAME] and [MEDICATION NAME]. RN-B was suspended then terminated from the facility. Interview with the facility administrator on 10/16/19 at 4:46 PM confirmed the medications belonging to Resident 1 and Resident 17 were diverted from the medication cart by RN-B. RN-A was also present during the interview and confirmed this. No other active residents had medications missing and the facility replaced the medications immediately per the administrator. RN-A revealed Resident 1 and Resident 17 were not without the medications when they were needed so there was no harm done to these 2 residents. The [MEDICATION NAME] was supposed to be destroyed and was not being actively used by any residents. Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure verification check was completed. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it because they did not receive payment. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about the job application and the reference checks. The Administrator confirmed they did not have a job application or reference checks for RN-B. The Administrator confirmed the employment application and reference checks should have been done. Interview with the facility Administrator on 10/16/19 at 9:57 AM revealed RN-B's personnel file did not contain documentation their licensure certification had been checked. The Administrator confirmed it should have been completed. Review of RN-B's RN Licensure Certification form from the Licensure Certification website revealed RN-B's RN license was suspended from 2/21/2011 to 2/21/2012 and RN-B was on probation from 3/13/2014 to 3/13/2017. Review of RN-B's Disciplinary Information attached to their RN License Certification revealed RN-B had been suspended and placed on probation for theft of controlled substances from their place of employment. Review of the Nursing Staff schedules for (MONTH) through (MONTH) 2019 revealed RN-B was working in the facility during the time frame from when they were hired until they were terminated. Review of the facility policy Abuse, Neglect, and Exploitation dated 11/17 revealed the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference and credentials' checks should be conducted on employees prior to or at the time or employment, by facility administration in accordance with applicable state and federal regulations. Any person having knowledge that an employees license or certification is in question should report such information to the administrator.",2020-09-01
943,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,606,D,1,1,DGFB11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on interview and record review, the facility failed to maintain 3 of 6 personnel files with evidence the NA (Nurse Aide) registry was checked for adverse findings prior to employment for the HS (Housekeeping Supervisor) and DA-C (Dietary Aide), failed to ensure staff working did not have a criminal conviction involving misappropriation on their record prior to employment, failed to ensure personnel files contained evidence that prospective employees had not been found guilty of abuse, neglect, exploitation or misappropriation, failed to ensure reference checks were completed for RN-B, and failed to check licensure certification verification status for RN-B prior to employment. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about completing the reference checks and licensure certification. The Administrator confirmed they did not have a job application or reference checks for RN-B. The Administrator confirmed the employment application and reference checks should have been done. Interview with the facility Administrator on 10/16/19 at 9:57 AM revealed RN-B's personnel file did not contain documentation their licensure certification had been checked. The Administrator confirmed it should have been completed. Review of RN-B's RN Licensure Certification form from the Licensure Certification website revealed RN-B's RN license was suspended from 2/21/2011 to 2/21/2012 and RN-B was on probation from 3/13/2014 to 3/13/2017. Review of RN-B's Disciplinary Information attached to their RN License Certification revealed RN-B had been suspended and placed on probation for theft of controlled substances from their place of employment. Review of the Nursing Staff schedules for (MONTH) through (MONTH) 2019 revealed RN-B was working in the facility during the time frame from when they were hired until they were terminated for diverting medications from the facility residents. B. Review of the personal file for HS with a DOH (Date of Hire) of 4/10/2019 and DA-C with a DOH of 7/12/2019 revealed no documentation the NA Registry checks were completed. Interview with the facility Administrator on 10/10/2019 at 10:25 AM confirmed that the HS and DA-C had been working in the facility since they were hired and they confirmed the NA registry checks were not completed. Review of the untitled documents received from and identified by the facility Administrator as the Housekeeping staff schedule and the Dietary staff schedule revealed documentation the HS and DA-C had been working in the facility since they were hired. Review of the facility policy Abuse, Neglect, and Exploitation dated 11/17 revealed the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference and credentials' checks should be conducted on employees prior to or at the time or employment, by facility administration in accordance with applicable state and federal regulations. Any person having knowledge that an employees license or certification is in question should report such information to the administrator.",2020-09-01
944,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,607,E,1,1,DGFB11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3b Based on interview and record review, the facility staff failed to follow the facility policy for screening 3 of 6 employees RN-B (Registered Nurse), HS (Housekeeping Supervisor), and DA-C (Dietary Aide) for abuse, neglect, and misappropriation prior to employment. This had the potential to affect all of the facility residents. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Review of RN-B's General Orientation Checklist revealed a hire date of 2/4/2019. Review of RN-B's Separation Acton Form dated 9/17/2019 revealed their last day worked was 9/13/2019. Review of the personnel file for RN-B revealed their date of hire was 2/4/2019 and their day of separation (termination date) was 9/17/2019. RN-B's last day worked was listed as 9/13/2019. There was no documentation a criminal background check, reference checks, or nursing licensure check was completed upon hire. RN-B's employment application was also missing from the file. Review of the document Employment Profile Form dated and signed by RN-B on 1/24/2019 revealed documentation RN-B had a conviction 2010/2011 of misdemeanor attempt to possess narcotics. There was documentation the form had been faxed to the criminal background check company, but there was no documentation of the results of the criminal background check. Interview with the facility Administrator on 10/15/19 at 10:08 AM revealed they could not find the criminal background check for RN-B. The administrator revealed the criminal background check had been completed but they did not have access to the results because the company would not release it. The administrator confirmed they didn't have any way of knowing what the results were of the criminal background check. The administrator confirmed it should have been completed/results available so they could act on it. Interview with the facility Administrator on 10/15/19 at 11:23 AM revealed the BOM (Business Office Manager) had a misunderstanding about completing the reference checks and licensure certification. The Administrator confirmed they did not have a job application or reference checks for RN-B. The Administrator confirmed the employment application and reference checks should have been done. Interview with the facility Administrator on 10/16/19 at 9:57 AM revealed RN-B's personnel file did not contain documentation their licensure certification had been checked. The Administrator confirmed it should have been completed. Review of RN-B's RN Licensure Certification form from the Licensure Certification website revealed RN-B's RN license was suspended from 2/21/2011 to 2/21/2012 and RN-B was on probation from 3/13/2014 to 3/13/2017. Review of RN-B's Disciplinary Information attached to their RN License Certification revealed RN-B had been suspended and placed on probation for theft of controlled substances from their place of employment. Review of the Nursing Staff schedules for (MONTH) through (MONTH) 2019 revealed RN-B was working in the facility during the time frame from when they were hired until they were terminated for diverting medications from the facility residents. B. Review of the personal file for HS with a DOH (Date of Hire) of 4/10/2019 and DA-C with a DOH of 7/12/2019 revealed no documentation the NA Registry checks were completed. Interview with the facility Administrator on 10/10/2019 at 10:25 AM confirmed that the HS and DA-C had been working in the facility since they were hired and they confirmed the NA registry checks were not completed. Review of the untitled documents received from and identified by the facility Administrator as the Housekeeping staff schedule and the Dietary staff schedule revealed documentation the HS and DA-C had been working in the facility since they were hired. Review of the facility policy Abuse, Neglect, and Exploitation dated 11/17 revealed the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Background, reference and credentials' checks should be conducted on employees prior to or at the time or employment, by facility administration in accordance with applicable state and federal regulations. Any person having knowledge that an employees license or certification is in question should report such information to the administrator.",2020-09-01
945,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,657,D,0,1,DGFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility failed to include 2 residents and their responsible party in planning their care (Residents 3 and 13). This affected 2 of 14 residents whose care plans were reviewed during the survey process. The facility identified a census of 21 at the time of survey. Findings are: Interview with Resident 3 on 10/09/19 at 2:43 PM revealed they had not been invited to a care plan meeting nor had been involved in the planning of their care. Review of Resident 3's quarterly MDS (MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) revealed an admission date of [DATE]. Resident 3 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Review of Resident 3's Care Plan dated 1/27/2019 revealed no documentation Resident 3 had participated in their care plan meeting. Review of Resident 3's Progress Notes revealed no documentation Resident 3 or their responsible party was invited to the care plan meeting. B. Interview with Resident 13 on 10/10/19 at 11:33 AM revealed they had not had a care plan meeting for 6-7 months. Review of Resident 13's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 13 had a BIMS score of 12. Interview with Resident 13's responsible party on 10/16/19 at 2:00 PM confirmed they have not had a care plan meeting for quite some time. They had one set up after the first of the year and the facility canceled it for some reason; they were unable to have it. Resident 13's responsible party said the facility staff had tried to schedule it on a Friday and the responsible party said they were here every Wednesday and Saturday and they had told the facility staff they would like to have the meeting when they were here. I am here. We could have the meeting. Review of Resident 13's Progress Notes revealed no documentation Resident 13 or their responsible party had been invited to or had attended a care plan meeting in the past 6-7 months. Interview with the DON (Director of Nursing) on 10/16/19 at 2:16 PM confirmed was no recent documentation Resident 13 or their responsible party had been to a care plan meeting in the past 6-7 months. Review of Resident 13's Care Plan dated 12/28/2016 revealed no documentation Resident 13 or their responsible party had been invited to or had attended a care plan meeting in the past 6-7 months. Interview with the DON on 10/16/19 on 3:14 PM revealed RN-D (Registered Nurse) had sent out invitations for care plans but they did not keep a copy of the invitation or document they sent them out. Review of the facility policy Care Plan Process dated 9/2019 revealed the following: The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Interim care plans are developed within 24 hours of admission for high-risk problems, including major medications or diagnoses. The resident' family or legal representative is involved if the resident is unable to participate and/or the resident approves. Team member may include but is not limit to resident, family/legal representative. At the resident's option, every effort will be made to involve the resident and family or responsible party including private duty or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident plan of care. The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the resident's medical record. Residents, families, or legal representatives will be notified of the care planning conference in writing at least 7 days prior to the conference. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Participation in the resident care planning process will be documented by obtaining the signature of the resident, family, or legal representative.",2020-09-01
946,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,688,D,0,1,DGFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on observation, interview, and record review; the facility failed to offer a restorative nursing program to Resident 13 to restore or prevent further contractures. This affected 1 of 2 residents reviewed for restorative care. The facility identified a census of 21 at the time of survey. Findings are: Review of Resident 13's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/16/2019 revealed an admission date of [DATE]. Resident 13 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognitive impairment. Resident 13 required extensive assistance from 2 staff for bed mobility and Resident 13 was dependent upon staff for transfer and locomotion. No therapy or nursing restorative minutes were documented. Resident 13 had a functional limitation in range of motion on one side both upper and lower extremity. Interview with Resident 13 on 10/10/19 at 11:36 AM revealed they only had use of their right arm and leg. Resident 13 revealed the facility had not offered a restorative nursing program. Observation of Resident 13 on 10/15/19 at 10:00 AM, 10/16/2019 at 7:59 AM, and 10/16/2019 at 2:00 PM revealed both of Resident 13's hands had contractures (permanent shortening of tissue, such as muscle, tendon or skin, as a result of disuse, injury or disease. Contracture leads to the inability to straighten joints fully and to permanent deformity and disability). Resident 13's left hand was misshapen: it was curled over and their thumb was sticking out of the opposite side of their hand through their fingers. Resident 13's right hand was misshapen and fixed in a bent manner without the ability to perform spontaneous movement. Interview with the DON (Director of Nursing) on 10/16/19 at 10:03 AM revealed at one time Resident 13 was receiving a restorative nursing program for range of motion but they were refusing it. The DON revealed there was no documentation of Resident 13 refusing restorative care. Interview with Resident 13's responsible party on 10/16/19 at 2:00 PM revealed that Resident 13 had splints for their hands but they did not have any insurance so they could not pay for any more therapy. Resident 13's responsible party revealed they did not know if therapy staff had showed the nurses how to use the braces. Resident 13's responsible party said the facility staff had not offered any nursing restorative program after their therapy had ended and Resident 13 said they would like to have a nursing restorative program. Review of Resident 13's OT (Occupational Therapy) Plan of Care dated 9/4/2018 revealed Resident 13 was referred for a decline in ROM (Range of Motion) and functional abilities following hospitalization . Resident 13 would benefit from skilled OT interventions to improve function ROM and assess for proper wheelchair positioning to maximize patient's independence and engagement in daily activities. Goal: facility staff will follow positioning protocol and properly don splints with independence in order to prevent deformity and/or skin breakdown. Review of Resident 13's OT Plan of Care dated 10/22/2018 revealed Resident 13 was referred for a new wheelchair. Resident 13 had a limitation in range of motion documented on the OT plan of care. Review of Resident 13's [DIAGNOSES REDACTED]. Review of Resident 13's Care Plan dated 11/21/2016 revealed Resident 13 had a physical functioning deficit related to an [MEDICAL CONDITIONS]. Resident 13 had self care, mobility and ROM limitations and required staff assist with all ADL's (Activities of Daily Living). An intervention was to monitor and report changes in ROM ability. Review of Resident 13's Progress Notes revealed no documentation of a nursing restorative program implemented after Resident 13's skilled Medicare A therapy services ended in (YEAR). Interview with the DON 10/16/19 on 2:43 PM revealed they thought Resident 13 did use the splints a few times and refused but they cannot find any documentation as such. Interview with DON on 10/16/19 at 3:11 PM revealed the facility staff did exercises with Resident 13's right hand and they used the ball for that. The DON confirmed there was no documentation the therapists recommendations for the splints were communicated to the nursing staff. Review of Resident 13's Medical Record revealed no documentation of any restorative nursing being completed for Resident 13. Review of the facility policy Restorative Nursing Services dated 5/1/2017 revealed the following: Residents will be evaluated for Restorative Nursing Services to maintain/attain their highest practicable level of function. Assessment for restorative needs is initially accomplished through the nursing evaluation which is completed upon admission, quarterly, and with a significant change. Therapy or Nursing develops care plans designed to reflect resident strengths, risk factors, and preferences.",2020-09-01
947,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,689,D,0,1,DGFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E43-8-17 Based on observation, record review, and interview; the facility failed to ensure hazardous/poisonous chemicals in the housekeeping close were stored to prevent accidental ingestion, inhalation or consumption by one wandering resident (Resident 11) out of one wandering resident on the unit. The facility census at the time of the survey was 21. Findings Are: Observation on 10/09/19 at 11:42 AM the housekeeping storage room was left unlocked. No staff were observed in the hallway. Chemicals inside the unlocked storage room were: -Multi-Surface Peroxide, an agent according to the MSDS (Material Safety Data Sheet) was harmful if swallowed or came into contact with the skin. Causes [MEDICAL CONDITION] eye damage. Avoid breathing dust/fume/gas/mist/vapors/spray. -Kling Toilet Bowl and Urinal Cleaner, an agent according to the MSDS was dangerous causing [MEDICAL CONDITION] eye damage. If swallowed immediately call a Poison Center or a Physician. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning) dated 8/8/19 revealed that wandering behavior occurred daily. Behavior of pacing and rummaging were observed. Review of Resident 11's Progress Notes revealed documentation of Resident 11 wandering the hallways and not being easily redirected. An interview on 10/9/19 at 11:42 AM with the HS (House Supervisor) revealed that the door was unlocked and residents could have wandered into the room. The HS confirmed that harmful and dangerous chemicals were being stored in the storage room.",2020-09-01
948,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,700,D,1,1,DGFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observations, interviews, and record reviews; the facility failed to assess Resident 11 and Resident 21 for the use of bed rails. This affected 2 of 2 sampled residents. The facility census at the time of the survey was 21. Findings are: [NAME] Observation of Resident 11's bed on 10/9/19 at 10:51 AM revealed a bed rail in the raised position with a 13.5 gap between the head of the bed and the rail. There was greater than a 4 gap between the mattress and the bed rail. A closed fist could be placed between the mattress and the rail. An interview on 10/9/19 at 11:20 AM with the ADM (Administrator) revealed that the bed in the room to the right should have been appropriate for Resident 11 just in case Resident 11 wanted to lay in the bed. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the bed in room [ROOM NUMBER] on the right side of the room had a space between the mattress and the bed rail of greater than 4. Review of the Side Rail Assessment for Resident 11 revealed the only assessment completed was dated 10/9/19. B. Observation of Resident 21's bed on 10/9/19 at 10:59 AM revealed a side rail on the exit side of the bed with no cover over the rail and a 7 gap in the rail. A head could easily fit into this space. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the side rail in room [ROOM NUMBER] on the exit side of the bed had a space that Resident 21 could have put Resident 21's head through the opening. An interview on 10/09/19 at 11:55 AM with the MS (Maintenance Supervisor) revealed that the side rail did not belong to the facility. The maintenance man was informed by RN- A (Registered Nurse) that the rail needed to be remove immediately. The MS then slid the rail off of the bed which had been attached to a wooden board and place under the mattress. Review of the Side Rail Assessment for Resident 21 revealed the only assessment completed was dated 10/9/19. Review of the policy Proper Use of Side Rails revealed: This facility prohibits the use of side rails as a restraint. The Policy Explanation and Compliance Guidelines: 1. Side rails are considered a restraint when they limit the resident's freedom of movement depending upon the individual's condition and circumstances. 2. An assessment of the resident' symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rails, and will be documented in the residents' record. 3. The physician will also review and order side rails usage as he deems necessary. 4. Side rails may only be used in order to assist in mobility and transfer of residents. 5. If the resident is using the side rail for positioning, turning and getting out of bed assistance it is not considered a restraint. 6. The use of side rails as an assistive device will be will be addressed in the residents' care plan.",2020-09-01
949,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,909,E,1,1,DGFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observation, interview, and record review; the facility staff failed to have a program in place to ensure residents' beds were maintained to prevent a potential entrapment hazard for Residents 3, 5, 20, 22, 11, and 21. This affected 6 of 16 residents' beds evaluated during the survey process. The facility identified a census of 21 at the time of survey. Findings are: [NAME] Observation of Resident 3's bed on 10/09/19 at 11:49 AM revealed the bed was up against the wall and the mattress was not secured to the bed. The mattress could be slid off the bed frame creating a gap between the wall and the bed that created a potential entrapment hazard. B. Observation of Resident 5's bed on 10/09/19 at 11:48 AM revealed the bed was up against the wall. The mattress was not secured to the bed and could be slid off the bed frame creating a gap between the wall and the bed and a potential entrapment hazard for Resident 5. C. Observation of Resident 20's bed on 10/09/19 at 11:50 AM revealed the mattress was not secured to the bed and could be slid off the creating a gap between the wall and the bed creating a potential entrapment hazard. Resident 20's bed was up against the wall. There are mattress stops on the bed but the mattress did not fit into the stops as the mattress was too big for the bed. D. Observation of Resident 22's bed on 10/09/19 at 11:45 AM revealed Resident 22's bed was against the wall. The mattress was not secured to the bed and could be slid off the bed frame creating a gap between the wall and the bed and a potential entrapment hazard. Interview with RN-A (Registered Nurse) 10/09/19 at 3:03 PM confirmed the facility should have a program in place to ensure the beds did not create a potential entrapment hazard for the residents. Interview with the facility Administrator on 10/09/19 at 5:10 PM confirmed the beds could potentially create an entrapment hazard for the residents and needed to be corrected. The Administrator did not have documentation the facility staff had a program in place to monitor the resident beds for potential entrapment hazards. Review of the facility document Environmental Education 10/9/19 revealed the following: it is the expectation that all beds will be routinely checked to ensure that mattresses are secure, there are no gaps between headboards, footboards or rails that could cause entrapment, and that rails are securely fastened to the bed frame. Beds, mattresses and rails will be checked on preventative maintenance rounds weekly, and bed data sheets will be completed at a minimum of quarterly to ensure that beds are in proper working order. E. Observation of Resident 11's bed on 10/9/19 at 10:51 AM revealed a bed rail in the raised position with a 13.5 gap between the head of the bed and the rail. There was greater than a 4 gap between the mattress and the bed rail. A closed fist could be placed between the mattress and the rail. An interview on 10/9/19 at 11:20 AM with the ADM (Administrator) revealed that the bed in the room to the right should have been appropriate for Resident 11 just in case Resident 11 wanted to lay in the bed. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the bed in room [ROOM NUMBER] on the right side of the room had a space between the mattress and the bed rail of greater than 4. Review of the Side Rail Assessment for Resident 11 revealed the only assessment completed was dated 10/9/19. F. Observation of Resident 21's bed on 10/9/19 at 10:59 AM revealed a side rail on the exit side of the bed with no cover over the rail and a 7 gap in the rail. A head could easily fit into this space. 10/09/19 11:51 AM Interview with RN-A (Registered Nurse) revealed that the side rail in room [ROOM NUMBER] on the exit side of the bed had a space that Resident 21 could have put Resident 21's head through the opening. An interview on 10/09/19 at 11:55 AM with the MS (Maintenance Supervisor) revealed that the side rail did not belong to the facility. The maintenance man was informed by RN- A (Registered Nurse) that the rail needed to be remove immediately. The MS then slid the rail off of the bed which had been attached to a wooden board and place under the mattress. Review of the Side Rail Assessment for Resident 21 revealed the only assessment completed was dated 10/9/19. Review of the policy Proper Use of Side Rails revealed: This facility prohibits the use of side rails as a restraint. The Policy Explanation and Compliance Guidelines: 1. Side rails are considered a restraint when they limit the resident's freedom of movement depending upon the individual's condition and circumstances. 2. An assessment of the resident' symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rails, and will be documented in the residents' record. 3. The physician will also review and order side rails usage as he deems necessary. 4. Side rails may only be used in order to assist in mobility and transfer of residents. 5. If the resident is using the side rail for positioning, turning and getting out of bed assistance it is not considered a restraint. 6. The use of side rails as an assistive device will be will be addressed in the residents' care plan.",2020-09-01
950,ARBOR CARE CENTERS-FRANKLIN LLC,285096,1006 M STREET,FRANKLIN,NE,68939,2019-10-16,921,F,1,1,DGFB11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure a clean dining environment for all the residents, eating in the main dining room, due to fuzzy gray matter on the blades of the ceiling fans. This had the potential to affect all 21 residents in the main dining room. The census at the time of the survey was 21. Findings Are: Observation on 10/09/19 at 10:30 AM of the dining room revealed that the lighting fixtures in the main dining room which consisted of units in the center of the dining room with fans. The blades of these 3 fans had gray fuzzy debris on the fan blades. Resident tables were placed close to and below the fans. An interview and tour of the dining room on 10/16/19 at 5:28 PM with the HS (Housekeeping Supervisor) revealed the fans in the dining room were covered with gray fuzzy debris.",2020-09-01
951,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2018-01-24,695,D,1,0,C24911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > License Reference Number: 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility failed to maintain oxygen and respiratory treatment tubing in a manner to prevent cross-contamination for 2 residents (Residents 6 and 7) of 4 residents reviewed. The facility census was 72. Findings are: [NAME] Observation on 1/24/2018 at 1:45 of Resident 7 receiving a respiratory treatment revealed Resident 7 had a mask on dated 1/3/2018. Observation on 1/24/2018 at 2:00 PM revealed Resident 7's respiratory treatment was completed and Medication Aide (MA)-A had removed the mask and placed it on the bedside table. Moisture remained present in the mask. Interview with Licensed Practical Nurse (LPN)-B revealed the nebulizer mask should have been rinsed after use. Review of the facility policy dated 5-1-2011 Titled Respiratoy Practices-Nebulizer revealed on completion of the treatment: - Rinse the mouthpiece, and T piece with tap water and dry. - Place the mask in a treatment bag labeled with patients name and date. B. Observation on 1/24/2018 at 12:55 PM revealed Resident 7's oxygen tubing and nasal cannula on the floor of Resident 7's room. No indication of the date the tubing was last changed could be located on the tubing. Observation on 1/24/2018 revealed Resident 7 had a nebulizer treatment mask and tubing attached to the nebulizer machine (used for respiratory treatments) dated 1/3/2018. Review of the facility policy dated 5-1-2011 revealed Replace and date the Nebulizer mask set up every seven days. Review of Resident 7's treatment sheet revealed an order to change the oxygen tubing and nebulizer mask every 7 days . Review of Resident 7's treatment sheet revealed no initials to indicate the tubing and mask were changed. C. Review of Residents 6's face sheet revealed Resident 6 was admitted on [DATE]. Review of Resident 6's treatment sheet revealed an order to change the oxygen tubing and nebulizer mask every 7 days. Review of Resident 6's treatment sheet revealed no initials to indicate the tubing and mask were changed. Interview with the DON revealed Resident 6's oxygen tubing and nebulizer mask should have been changed since Resident 6's admission.",2020-09-01
952,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2018-01-24,812,F,1,0,C24911,"> Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure kitchen staff wore hair restraints to contain all head and facial hair to prevent the potential for food borne illness for 68 of 72 residents that eat out of the kitchen. The facility census was 72. Findings are: [NAME] Observation on 1/24/2018 at 12:00 PM of meal service revealed three dietary staff were serving the lunch meal and entering and exiting the kitchen area. Observation on 1/24/2018 at 12:00 PM of Dietary Aide (DA)-D serving drinks in the dining room revealed DA-D was wearing a hair net that covered only the top of DA-D's head. Observed the hairnet did not cover the sides of DA-D's hair and did not cover DA-D's ponytail. DA-D had facial hair that was not covered. Observation on 1/24/2018 at 12:05 PM of DA-D entered the kitchen to retrieve supplies and did not adjust hair restraints to cover all hair. At 12:15 DA-D again entered the kitchen with no additional hair covering. Observation on 1/24/2018 at 12:00 PM Dietary cook-C exited the kitchen area and was wearing a hair cover that covered the back of Cook-C's hair however, hair was not contained on Cook-C's forehead. Cook-C then returned to the kitchen to assist with serving without adjusting hair restraint. Observation on 1/24/2018 at 12:00 PM DA-E was serving food in the kitchen and hair restraint device was not containing all hair with sides of hair exposed. Interview on 1/24/2018 at 2:45 PM with the Dietary Manager (DM) revealed hair restraints should cover all hair when staff are in the kitchen to include facial hair. Interview on 1/24/2018 at 4:40 PM with the Administrator revealed 68 of 72 residents eat prepared and served from the kitchen.",2020-09-01
953,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-01-28,660,D,1,0,ZNPV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C2 Based on record review and interview; the facility staff failed to develop discharge planning for 2 (Resident 2 and 3) of 3 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of a Admission Record sheet dated 12- 8 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Orders Summary sheet dated 1-02-2019 revealed orders for Physical Therapy, occupational Therapy and Speech Therapy. Record review of Resident 2's Comprehensive Care Plan (CCP) printed on 11-15-2018 revealed there was not evidence the facility staff had completed a discharge plan with Resident 2. B. Record review of a Admission Record sheet dated 11-14-2018 revealed Resident 3 was admitted to the facility on [DATE]. Record review of Resident 3's CCP printed on 10-31-2018 revealed there was not evidence the facility staff had completed a discharge plan with Resident 3. On 1-14-2019 at 2:15 PM an interview was conducted with the Medical Records Director (MRD). During the interview the MRD reported Resident 2 and Resident 3 did not have discharge plans.",2020-09-01
954,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-01-28,684,D,1,0,ZNPV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on record review and interview; the facility staff failed to implement treatment orders for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of a Admission Record sheet printed on 1-21-2019 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Treatment Administration Record (TAR) for (MONTH) 2019 revealed Resident 1's practitioner had ordered Drysol or equivalent to be applied to Resident 1's abdominal fold. Staff were to changed the dressing every other day for moisture prevention. Further review of Resident 1's (MONTH) 2019 TAR revealed Resident 1 did not receive the ordered treatment on 1-14-2019, 1-18-2019 and 1-20-2019. B. Record review of a After Visit Summary sheet dated 1-16-2019 revealed Resident 1's Practitioner ordered Resident 1 Pt (patient) must be turned in bed every 2 hours. Review of Resident 1's medical record that included Resident 1's TARs, Nurses Notes and Comprehensive Care Plan revealed the was not evidence the facility staff were repositioning the resident while in bed every 2 hours as ordered. On 1-28-2019 at 11:32 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed the treatment of [REDACTED].",2020-09-01
955,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-01-28,689,D,1,0,ZNPV11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed thoroughly evaluate casual factors for a fall during the use of a mechanical lift for 1 (Resident 1) of sampled residents at risk for falls. The facility staff identified a census of 66. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 12-14-2018 revealed Resident 1 required the use of a mechanical lift for transfers of 2 to 3 staff members. Record review of a Falls sheet dated 12-15-2018 revealed Resident 1 was found on the floor. According to the Falls sheet dated 12-15-2018, Resident 1 reported sliding out of the wheelchair. Further review of the Falls sheet dated 12-15-2018, resident 1 had been hooked up to a EX stand (type of mechanical lift) when the fall occurred. Review of Resident 1's record revealed there was not evidence the facility staff had conducted and thoroughly completed an evaluation of why Resident 1 had fallen. On 1-28-2019 at 11:32 AM an interview was conducted with the Director of Nursing (DON) and the Facility Administrator. During the interview, the DON and Administrator confirmed an evaluation of casual factors for the fall had not been completed.",2020-09-01
956,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-01-28,692,D,1,0,ZNPV11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUNBER 175 NAC 12-006.09D8 Based on record review and interview; the facility staff failed to obtain daily weights for 1 (Resident 1) of 1 sample resident. The facility staff identified a census of 66. Findings are: Record review of a Admission Record sheet printed on 1-21-2019 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of an Active Orders sheet as of 1-21-19 revealed Resident 1's practitioner ordered on 1-2-2019 for the facility staff to obtain daily weights. Record review of Resident 1's Medication Administration Record [REDACTED] -1-3-2019. -1-7-2019. -1-9-2019. -1-10-2019. -1-14-2019. -1-18-2019. -1-20-2019. On 1-28-2019 at 11:32 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 1's daily weights were not obtained as ordered by Resident 1's practitioner.,2020-09-01
957,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2018-02-07,580,D,1,0,DEPM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.04C3a (6) Based on record review and interviews, the facility failed to notify the resident representative of a change of condition and treatment for 1 resident (Resident 5) of 4 residents reviewed. The facility census was 70. Findings are: Review of Resident 5's care plan revealed Resident 5 had [DIAGNOSES REDACTED]. Review of Progress note dated 1/29/2018 revealed Resident 5 had a wound on the right lateral foot that had culture results of multi drug resistant Staphylococcus Aureus (MRSA). Resident 5 was started on an antibiotic for the infection. No documentation of Resident 5's family being notified of the change in condition or the initiation of the antibiotic. Review of Resident 5's progress note dated 2/5/2018 revealed a diabetic wound to Resident 5's right lateral foot had deteriorated slightly and a small amount of drainage was noted. Resident 5 received orders to continue on the antibiotic and a new treatment to Resident 5's wound was initiated. Review of Resident 5's progress notes for the months of (MONTH) and (MONTH) (YEAR) revealed no notation of Resident 5's representative was notified of order changes or updated on any change of condition. Review of Resident 5's profile revealed Resident 5 does have a representative listed to be notified. Interview on 2/7/2018 at 4:00 PM with the ADON revealed Resident 5's representative should have been updated when new treatments or medication are started.",2020-09-01
958,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,223,G,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to ensure 1 (Resident 133) of 1 resident reviewed were free from involuntary seclusion. The facility staff identified a census of 85. Findings are: Record review of an Admission Record sheet printed on 6-15-2017 revealed Resident 133 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 133's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 5-10-17 revealed the facility staff had assessed Resident 133 with a Brief Interview of Mental Status (BIMS) of 15. According to the MDS Manuel, a BIMS of 13 to 15 indicates a person is cognitively intact. Record review of Resident 133's Comprehensive Care Plan (CCP) dated 4-28-2017 revealed Resident 133 was placed into a private room for isolation related to poor hygiene, touching private parts and touching everything else. Record review of Resident 133's medical record revealed there was no evidence that the facility had completed observations with Resident 133 to determine what additional education Resident 133 would need for hand hygiene including demonstrating for nursing staff Resident 133's understanding of hand hygiene. Record review of Resident 133's Progress Notes (PN) dated 4-27-2017 revealed Resident 133 was assessed as having no open areas. Record review of a physician review sheet dated 4-28-17 revealed Resident 133's physician had seen Resident 133 for a review of the hospital discharge and review of medications. Further review of the physician review sheet revealed the plan was for the resident to be admitted to the facility with the same medications and treatments. There was no indications or orders for Resident 133 to be placed into isolation. Review of Resident 133's PN dated 5-09-2017 revealed Resident 133 was in contact isolation. Review of Resident 133's PN dated 5-18-2017 revealed Resident 133 was eating meals in (gender) room as Resident 133 was in isolation. On 6-26-2017 at 7:42 AM an interview was conducted with Resident 133. During the interview, Resident 133 reported no understanding what the reason for isolation was or how isolation procedures were to be implemented. Resident 133 reported during the interview that Resident 133 was in isolation for almost 2 months. Resident 133 reported I was very bored, nothing to do. On 6-27-2017 at 4:25 PM a follow up interview was completed with Resident 133 related to Resident 133's isolation in room. Resident 133 reported during the interview the facility staff had reported Resident 133 had [MEDICAL CONDITION], Resident 133 stated I don't have [MEDICAL CONDITION]. Resident 133 reported not being able to come out of the room. Resident 133 stated when I would open my door, they would yell at me, you can't come out, you can't come out. Resident 133 stated it made me feel very very badly. Resident 133 reported during the interview about being very upset about not being able to leave the room and stated I cried a lot. It bothered me. On 6-27-2017 at 7:49 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported there was no education provided to Resident 133 for the isolation and further reported that the DON was not sure why Resident 133 was in isolation. On 6-28-2017 at 6:30 AM an interview was conducted with Licensed Practical Nurse (LPN) H and LPN I who both worked on the unit Resident 133 resided on. During the interview when asked why Resident 133 had been in isolation, LPN H and LPN I reported being told Resident 133 had [MEDICAL CONDITION]. LPN H stated I wasn't sure about that. LPN I reported after a while the [MEDICAL CONDITION] issue was dropped. When asked if LPN H and LPN I knew why Resident 133 was in isolation, Both LPN H and LPN I stated not really, we don't make that decision. LPN I reported LPN I's understanding was that Resident 133 had poor handwashing and did scratching of self in peri area. LPN I reported not being aware of anyone teaching Resident 133 about hand hygiene.",2020-09-01
959,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,248,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5b Based on observation, record review and interview; the facility staff failed to implement an individualized activity program for 1 (Resident 5) of 3 residents reviewed. The facility staff identified a census of 85. Findings are: Record review of Resident 5's Comprehensive Care Plan (CCP) dated 10-06-2016 revealed Resident 5 required facility staff to assist and escort Resident 5 with activities. According to Resident 5's CCP, staff were to offer activities that were familiar and to offer new things Resident 5 would like to do, special music entertainment groups and socials. The goal identified on the CCP was that Resident 5 would attend scheduled activities one time a week. Record review of a Recreation Services assessment dated [DATE] revealed Resident 5 was assessed as like TV news, music channel TV, westerns and all kinds of movies, in addition, Resident 5 was evaluated as liking to watch the birds in the lobby area, religious/spiritual activities. Observation on 6-21-2017 at 11:37 AM revealed Resident 5 was asleep in bed with the TV on. Observation on 6-26-2017 at 10:36 AM revealed Resident 5 was in a wheelchair asleep. Observation on 6-26-2017 at 4:32 PM revealed Resident 5 was in bed asleep, Resident 5's TV was on and not on music. Record review of Resident 5's 4-2017 Activity Attendance Record (AAR) revealed Resident 5 had attended 2 activities for the month. Record review of Resident 5's 5-2017 AAR revealed there were no activities identified that Resident 5 had participated in. Record review of Resident 5's AAR from 6-01-2017 through 6-26-2016 revealed Resident 5 had attended 1 activity. On 6-26-2017 at 2:06 PM an interview was conducted with the Activity Director (AD). During the interview the AD confirmed Resident 5 did not have any individualized activities.",2020-09-01
960,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,253,D,1,1,GRW111,"> Licensure Reference Number 175 NAC 12-006.18A(1) Based on observation and interview, the facility failed to ensure floors and walls were clean and in good repair in Room 509. Facility census was 85. Findings are: Observation on 9/27/17 from 10:00 AM until 10:40 AM with the facility Director of Nursing (DON), Maintenance Supervisor and the Laundry Supervisor, revealed that the bathroom in room 509 had gouged walls, the floor was stained and the flooring that had continued up the wall, was pulled away from the wall. Interview with the Maintenance Supervisor revealed that the stains were permanent and that the flooring did need to be replaced and that the walls did have deep gouges that would require repair. Interview with the DON confirmed that the bathroom flooring and walls were not in good repair.",2020-09-01
961,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,285,D,1,1,GRW111,"> Based on record review and interview; the facility staff failed to implement recommendations from the Pre-Admission Screening and Resident Review (PASRR) for 1 (Resident 91) of 1 resident reviewed. The facility staff identified a census of 85. Findings are: Record review pf a PASRR Level 2 dated 2-28-2017 revealed recommendation were that Resident 91 have on going medication reviewed by a Psychiatrist and a Physician, as well, as Physical Therapy and Occupational Therapy. Record review of Resident 91 record revealed there was not evidence that a Psychiatrist had been reviewing Resident 91's medications. On 6-26-2017 at 10:45 AM an interview was conducted with the Social Services Director (SSD). During the interview when asked if a Psychiatrist had been reviewing Resident 91's medication, the SSD stated no.",2020-09-01
962,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,309,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09 Based on interview and record review, the facility failed to re-evaluate the effectiveness of an antibiotic related to the culture findings which resulted in rehospitalization for Resident 132. Facility census was 85. Findings are: Review of Resident 132's progress note dated 5/9/2017 at 3:25 AM revealed Resident 132 to be alert and oriented, and able to make needs known to staff. Lungs were clear, no cough, no shortness of breath. The resident needed minimal assist of 1 staff for ambulation. Review of Resident 132's Admission record dated 4/27/2017 revealed Resident 132 had a [DIAGNOSES REDACTED]. Review of Resident 132's Nursing Notes dated 5/9/2017 at 1:23 PM revealed Resident 132 had thick green secretions from the [MEDICAL CONDITION] (an artificial opening in the windpipe to breathe through) and an occasional dry cough. Nursing Note dated 5/12/2017 at 09:53AM revealed Resident 132 continued to expel moderate amounts of thick secretions and had a harsh cough. A sputum culture was obtained and sent to the Lab for testing. Nursing Note dated 5/13/2017 at 9:44 AM revealed the facility received a call from the lab regarding that Resident 132 was positive for [MEDICAL CONDITION] (MRSA-an antibiotic resistant bacteria). Resident 132 was started on [MEDICATION NAME] (an antibiotic) until the culture and sensitivity results were reported. Review of the Microbiology report received 5/14/2017 revealed Resident 132 [MEDICAL CONDITION] positive and was resistant to specific antibiotics. Review of Resident 132's Medication Administration Record [REDACTED]. Review of the Nursing Note dated 5/18/2017 at 3:26 AM revealed Resident 132 had shortness of breath with exertion. Review of Resident 132's Nursing Note dated 5/19/2017 at 3:29 AM revealed Resident 132 had a productive cough, with thick dark brown phlegm throughout the evening and night. Review of Resident 132's Nursing Note dated 5/20/2017 at 6:28 AM revealed Resident 132's Oxygen Saturation level (the measure of the amount of oxygen in the blood) was 70% and the resident was short of breath. The resident was given a breathing treatment that was not affective. Resident 132 was sent to the hospital and admitted . Interview on 06/28/2017 at 9:21 AM with the facility Nurse Practitioner revealed the culture results indicated the need to change the antibiotic from [MEDICATION NAME] to an antibiotic both [MEDICAL CONDITION] and the Pseudomonas was resistant to.",2020-09-01
963,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,312,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, interviews, and record review; the facility failed to ensure 1 resident (Resident 43) of 3 residents sampled received oral care and face and hand hygiene. The facility staff identified the census as 85. The findings are: A review of Resident 43's Admission Record dated 6/26/17 revealed that Resident 43 was admitted to the facility on [DATE] and had the following [DIAGNOSES REDACTED]. An observation conducted on 6/21/17 at 11:25 AM revealed Resident 43 had a growth of facial hair. An observation conducted on 6/26/17 at 6:59 AM revealed Resident 43 was laying in bed on their back with their legs bent upwards and turned to the right side with their thighs coming in contact with the mattress. An observation conducted on 6/26/17 at 8:42 AM revealed Resident 43 was laying in bed on their back with their legs bent upwards and turned to the right side with their thighs coming in contact with the mattress. An observation conducted on 6/26/17 at 9:44 AM revealed Resident 43 was laying in bed on their back with their legs bent upwards and turned to the right side with their thighs coming in contact with the mattress. An observation conducted on 6/26/17 at 10:42 AM revealed Resident 43 was laying in bed on their back with their legs bent upwards and turned to the right side with their thighs coming in contact with the mattress. An observation conducted on 6/26/17 at 11:04 AM of Nursing Assistant (NA) A and NA B performing morning cares with Resident 43 revealed Resident 43's incontinence brief was noticeably wet and that Resident 43 was not offered oral care, shaving, facial wash, or hand hygiene. An observation conducted on 6/26/17 at 11:31 AM of Resident 43 revealed the resident had a growth of facial hair, a thick white coating on their teeth and inside of their lips, two areas of yellow crusty material on their chest at the base of the neck, and a foul odor to their hands. An observation conducted on 6/26/17 at 12:22 PM of Resident 43 revealed the resident had a growth of facial hair, a thick white coating on their teeth and inside of their lips, two areas of yellow crusty material on their chest at the base of the neck, and a foul odor to their hands. An observation conducted on 6/26/17 at 1:44 PM of Resident 43 revealed the resident had a growth of facial hair, a thick white coating on their teeth and inside of their lips with white slimy looking matter in their mouth, two areas of yellow crusty material on their chest at the base of the neck, and a foul odor to their hands. An interview conducted on 6/26/17 at 2:34 PM with Licensed Practical Nurse (LPN) C confirmed that Resident 43 had a thick white coating on their teeth and inside of their lips with white slimy looking matter in their mouth, two areas of yellow crusty material on their chest at the base of the neck, and a foul odor to their hands. An interview conducted on 6/26/17 at 3:10 PM with the Director of Nursing (DON) revealed that the NA assigned to Resident 43 had left for the day and had not documented any cares for Resident 43. The DON reported the NA on shift at the time performed oral cares on the resident and the nurse was contacting the physician to get an order for [REDACTED].>An observation conducted on 6/27/17 at 10:43 AM of Resident 43 in hallway revealed Resident 43 had a white slimy looking matter in their mouth with a piece of white matter on their face near the left corner of their mouth. A review of Resident 43's Comprehensive Care Plan revealed an intervention to provide assistance with oral cares on the morning, at bedtime, and as needed. A review of Resident 43's dental appointment progress note dated 12/9/16 revealed that oral hygiene was poor with heavy buildup on Resident 43's back teeth. A review of Resident 43's Dental Hygienist assessment dated [DATE] revealed the dental hygienist suggested staff provide daily oral cares twice a day.",2020-09-01
964,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,314,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D2b Based on observations, interviews, and record reviews; the facility failed to evaluate the development and obtain treatment of [REDACTED]. The facility staff identified the census at 85. The findings are: A review of Resident 55's Admission Record dated 6/26/17 revealed Resident 55 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 55's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 3/14/17 revealed Resident 55's Brief Resident Interview for Mental Status (BIMS) score was 15 which indicated Resident 55 was cognitively intact. Resident 55 was dependent with bed mobility and bathing, and required extensive assistance with toileting and hygiene. A review of Resident 55's Progress Notes revealed a nurse's note dated 6/16/17 with documentation that Resident 55 had skin breakdown to their buttocks, but the resident refused to turn without a specific nurse aide present to assist with turning. The note stated the nurse would try again later that day. A review of Resident 55's Progress Notes from 6/16/17 to 6/20/17 revealed no documentation that addressed the resident's skin breakdown. A review of Resident 55's Progress Notes revealed a nurse's note dated 6/20/17 with documentation that Resident 55 was evaluated for skin breakdown and was found to have a stage 2 pressure ulcer (partial thickness skin loss related to prolonged pressure on an area) to their coccyx that measured 2 centimeters (cm) by 0.3 cm with a depth of 0.2 cm. The note also stated the resident would need to be set up with an appointment with the wound clinic. A review of Resident 55's Physicians Orders revealed the facility staff obtained an order on 6/21/17 from the resident's primary care physician for a treatment to use on the wound until the resident saw the physician at the wound clinic. An interview conducted on 6/27/17 at 3:26 PM with Registered Nurse (RN) G revealed that RN G had asked another RN to evaluate Resident 55 for skin breakdown on 6/16/17 which was a Friday, but the resident refused. RN G reported they then evaluated Resident 55 for skin breakdown when they returned to work the following week. A review of Resident 55's Activities of Daily Living (ADL) Documentation for (MONTH) (YEAR) revealed that Resident 55 received personal hygiene, toileting, and repositioning assistance on night shift on 6/16/17, all three shifts on 6/17/17, day shift on 6/18/17, and all three shifts on 6/19/17. An interview conducted on 6/27/17 at 3:49 PM with the Director of Nursing (DON) revealed that any nurse that worked in the facility could evaluate a resident for skin breakdown and could get a treatment order from the physician not just the designated wound nurse. An interview conducted on 6/27/17 at 4:31 PM with the DON revealed that Resident 55 did receive hygiene cares and repositioning cares 6/16/17 to 6/20/17 and the DON did not know why Resident 55's wound had not been evaluated and a treatment put into place during that time. B. A review of Resident 55's medical record revealed a physician's visit progress note dated 6/23/17 from the wound clinic that diagnosed the wound as a stage 2 pressure ulcer with measurements of 2cm by 1cm with a depth of 1cm. The progress note contained the following orders [MEDICATION NAME] AG (a highly absorbent antimicrobial dressing that contains silver) and bordered foam dressing to be changed every 48 hours, Turn resident every 2 hours, and check skin head to toe every other day. The progress note revealed that Resident 55 had stated to the wound clinic that they felt neglected at the facility and that a letter had been written to the wound nurse to ensure Resident 55 was on an appropriate offloading mattress and was on a turning schedule. C. An observation conducted on 6/26/17 at 1:49 PM of Licensed Practical Nurse (LPN) C performing a dressing change to the wound on Resident 55's coccyx revealed the following: LPN C placed a cut piece of [MEDICATION NAME] AG into the coccyx wound and then lightly squirted the [MEDICATION NAME] AG with saline prior to placing a bordered foam dressing over the wound. An interview conducted on 6/26/17 at 2:31 PM with LPN C confirmed that LPN C had dampened the [MEDICATION NAME] AG with saline. An interview conducted on 6/26/17 at 2:38 PM with the DON confirmed that the order for Resident 55's dressing change did not state to dampen the [MEDICATION NAME] AG with saline. D. An interview conducted on 6/26/17 at 10:52 AM with RN F revealed that Resident 55 had just received morning hygiene cares and was repositioned. RN F reported that when the resident rolls they do not roll far. RN F reported that Resident 55 had been educated on rolling side to side, but had been refusing to roll to the side because they could not use their computer when on their side. RN F reported they were unsure if anyone had worked with Resident 55 and their computer to see if it was possible to adapt the environment to allow Resident 55 to be on their side and still use the computer. An interview conducted on 6/26/17 at 10:57 AM with Resident 55 revealed that the resident was talked to in the past about turning and repositioning. Resident 55 reported that they felt the nursing assistant staff were not aware that the resident needed to be turned on a frequent schedule. Resident 55 reported that they felt they would still be able to do what they needed to on their computer if turned on their side, but that they were not sure as they had not been fully turned to their side to try. A review of Resident 55's ADL Documentation for (MONTH) (YEAR) for Resident 55's turning and repositioning assistance revealed that of the 81 shifts so far that month that 17 shifts lacked documentation, 4 shifts the resident refused repositioning, and 11 shifts Resident 55 was not assisted to reposition. A review of Resident 55's Medication Administration Record [REDACTED]. An interview conducted on 6/28/17 at 9:51 AM with LPN P revealed that the nursing assistants were responsible for repositioning Resident 55 and documenting in the medical record. LPN P reported that it was the nurse's responsibility to ensure that the resident was repositioned every 2 hours and to ensure that the nursing assistants had documented repositioning. LPN P reported that there should have been a place in the MAR indicated [REDACTED]. An interview conducted on 6/28/17 at 10:09 AM with the DON revealed that the nurse was responsible to ensure that Resident 55 was being repositioned and that since it was an order from the physician that they thought it would be reflected on the MAR indicated [REDACTED]. An interview conducted on 6/28/17 at 10:36 AM with the DON confirmed there was not a turning schedule in the MAR indicated [REDACTED]. E. A review of Resident 55's Alteration in skin integrity care plan dated 1/26/16 revealed that Resident 55 was to be repositioned approximately every two hours and as needed and that Resident 55 could be noncompliant with this at times. A review of the facility's undated Skin Care Pathway revealed the following: Prevention: Monitor- Inspection during ADLs. Assessment: Documentation- Upon identification. Include assessment, treatments. A review of the facility's Wound Management Review Process dated 4/14/17 revealed the following 7. All residents with Pressure or Stasis Ulcers must be on the priority list for Department Manager rounds to ensure pressure relieving interventions are followed according to the specific resident plan of care .",2020-09-01
965,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,315,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D3 Based on record review and interview, the facility staff failed to evaluate, identify and implement new interventions related to a decline in bladder continence for Resident 6 and 29, and failed to implement a toileting program for Resident 91. Sample size was 4 residents. The facility census was 85. Findings are: [NAME] Review of the facility Incontinence Management/Bladder Function Guideline, dated as reviewed on 8/10/16, revealed the following: The purpose of a bladder management program was to: -Enable the resident to control urination without a catheter whenever possible; -Avoid possibility of urinary infection; -Prevent skin problems such as pressure areas and excoriation; -Improve the morale of resident; -Restore the resident's dignity; -Manage urinary incontinence, restore or maintain as much normal bladder function as possible. Procedures included -Bowel and Bladder Tracking tool completed to identify any trends or patterns that the resident may have in relation to incontinence. -Complete the Bladder Evaluation Form and the Bowel Evaluation form. Identification of potentially reversible causes of urinary incontinence. Identification of contributing diagnosis/medical condition. Identification of medications that may be contributing to bladder dysfunction. Continuing evaluation that includes past medical history, lab results, etc. Depiction of the incontinence symptoms that the resident is presenting with, such as stress, urge, mixed, overflow and functional. Upon completion of this evaluation as well as the tracking tool, the toileting/bladder program can be determined. A note to summarize the findings documented. Review of Resident 6's Face sheet, dated (MONTH) 27, (YEAR), revealed that the resident was admitted initially to the facility on [DATE] and their last re-admission was 6/12/17. Resident 6's [DIAGNOSES REDACTED]. Review of Resident 6's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning), signed 6/13/17, revealed the following: -Resident 6 Brief Interview for Mental Status (BIMS) was 13/15. (According to the RAI Manual Version 3.0. The BIMS of 13-15 indicates Cognitively Intact, 8-12 indicates moderately impaired cognition , 0-7 indicates severe cognitive impairment) -Resident 6 required limited assistance of one person for toilet use. -Resident 6 was not on a urinary toileting program -Resident 6 was occasionally incontinent -Resident 6 was always continent of bowel. Review of Resident 6's MDS, signed 6/21/17, revealed the following: -Resident 6 BIMS was 15/15 -Resident 6 required Extensive assist of two for toilet use. -Resident 6 was not on a urinary toileting program -Resident 6 was always incontinent of urine -Resident 6 was not rated for bowel continence. Interview with Resident 6, on 6/26/17 at 4:29 PM, revealed Resident 6 had fallen and fractured their right ankle and this had made the resident dependent on staff for toileting. Resident 6 revealed that prior to the fall, toileting had been performed without assistance. Resident 6revealed that the resident was not able to bear weight on their right leg related to the recent fracture and was now dependent on staff. Interview with Nursing Assistant (NA) J on 6/27/17 at 5:25 AM revealed that, prior to the fall with fracture Resident 6 had been continent of urine and bowel. Resident 6 had been able to ambulate to the toilet. NA J revealed that Resident 6 was not able to get up by self related to no weight bearing to the fractured ankle. NA J revealed that Resident 6 was not taken to the toilet since the fracture occurred and that the plan of care was to change the resident during the night. NA J confirmed that Resident 6 was not offered a bed pan or to be transferred to the toilet with a mechanical lift. Interview with the MDS Coordinator on 6/27/17 at 12:25 PM confirmed Resident 6's MDS dated [DATE] was accurate related to Resident 6 being occasionally incontinent. The MDS Coordinator confirmed Resident 6's MDS dated [DATE] was accurate that Resident 6 was always incontinent of urine. Record review of a Progress Note dated 6/20/17 revealed Resident 6 was incontinent of bowel and bladder related to needs more assistance from staff for transfers, was now a total mechanical lift. Record review of Resident 6's Bladder and Bowel Retraining Assessment, dated on 6/13/17, revealed Resident 6, was a candidate for a scheduled toileting program. Record review of Resident 6's Bowel and Bladder Program Screener, dated 6/13/17, revealed Resident 6 was a candidate for a scheduled toileting program. Record review of Resident 6's Comprehensive Plan of Care revealed that on 6/21/17, an intervention for elimination of bladder did not reveal a Bowel and Bladder Retraining Program. Interview with the facility Director of Nursing (DON) on 6/27/17 at 12:17 PM revealed that the facility was not able to provide evidence of a bladder tracking tool for Resident 6. The facility DON confirmed that the facility did not develop a Bowel and Bladder Retraining Program for Resident 6. The DON confirmed that the facility failed to develop and implement a plan of care to prevent a decline in continence of bowel and bladder for Resident 6. B. Record review of Resident 29's Face Sheet, dated 5/2/17 revealed that Resident 29 was admitted to the facility on [DATE]. Record review of Resident 29's MDS dated [DATE] revealed: -Resident 29's BIMS was 01. -Resident 29 required limited assist of one person for toilet use. -Resident 29 was occasionally incontinent of urine and bowel. Record review of Resident 29's MDS dated [DATE] revealed: -Resident 29's BIMS was not completed -Resident 29 required extensive assistance of two persons for toilet use. -Resident 29 was frequently incontinent of urine and occasionally incontinent of bowel. Record review of Resident 29's Bladder and Bowel Retraining assessment dated [DATE] revealed Resident 29 was a possible candidate for a scheduled toileting plan. Record review of Resident 29's Comprehensive Plan of Care revealed no focus, goal or interventions for elimination of bladder or a Bowel and Bladder Retraining Program. Interview with the facility DON on 6/27/17 at 12:17 PM revealed the facility was not able to provide evidence of a bladder tracking tool for Resident 29. The facility DON confirmed that the facility did not develop a Bowel and Bladder Retraining Program for Resident 29. The DON confirmed that the facility failed to develop and implement a plan of care to prevent a decline in continence of bowel and bladder for Resident 29. C. Record review of Resident 91's Comprehensive Care Plan (CCP) printed on 3-09-2017 revealed Resident 91 was admitted to the facility on [DATE]. Record review of Resident 91's MDS dated [DATE] revealed Resident 91 was frequently incontinent of urine and was not on a toileting program. Review of a Bladder and Bowel Assessment (BBA) sheet dated 4-20-2017 revealed Resident 91 was identified as a possible candidate for a scheduled toileting plan. Further review of the BBA dated 4-20-2017 revealed Resident 91 was frequently incontinent of bladder. Review of Resident 91's record revealed there was not any evidence Resident 91 was on a toileting program On 6-27-2017 at 2:59 AM an interview was conducted with Registered Nurse (RN) F. During the interview RN F reported Resident 91 was not on a toileting program.",2020-09-01
966,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,323,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, record review and interviews; the facility failed to implement interventions to prevent falls for Resident 6. Facility census was 85. Findings are: Record review of the facility policy titled Falls Management, dated 4/2015 revealed: A risk reduction, Falls and Injuries Program will be used to assess residents to determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries, while maximizing dignity and independence. 1. Assess and review resident risk factors for falls and injuries upon admission, with a significant change in condition or after a fall. 2. Implement goals and interventions with resident/patient /family, based on individual needs. 3. Communicate interventions to the care giving teams. 5. Review and revise Interdisciplinary Plan of Care (P[NAME]). Fall Injury Prevention - Post Fall: 4. Review the P[NAME] for Fall Risk Reduction 6. Adjust/add interventions on the P[NAME] 8. Review and revise P[NAME] Review of Resident 6's Face sheet, dated (MONTH) 27, (YEAR), revealed that Resident was admitted initially to the facility 02/15/11, and last re-admission was 6/12/17. Resident 6's [DIAGNOSES REDACTED]. Observation of Resident 6 on 6/26/17 at 10:06 AM revealed Resident 6 in wheelchair with right foot in cast. Interview with Resident 6 on 6/21/17 at 10:49 AM revealed Resident 6 had failed and fractured the right ankle, ambulating from the toilet on 6/3/17. Record review of Progress note, dated 6/3/17, revealed Resident 6 had a fall with right knee and right ankle pain Record review of Progress note, dated 6/6/17 revealed Resident 6 returned from hospital and had a right ankle fracture, no weight bearing to right leg. Record review of Fall Risk Assessment, dated 6/2/17 revealed Resident 6 was a low risk for falls. Record review of Quarterly Nursing Evaluations, signed 6/13/17 revealed Resident 6 was a high risk for falls. Record review of P[NAME] for Resident 6 revealed no new intervention to prevent falls for Resident 6 post fall, or increased fall risk. Interview with the facility Director of Nursing (DON) on 6/27/17 at 12:17 PM confirmed that the facility failed to implement new interventions to prevent falls, post fall, for Resident 6.",2020-09-01
967,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,364,E,1,1,GRW111,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, record review and interview; the facility staff failed to serve food hot for residents who received room trays and failed to ensure food had a good flavor and texture. This had the potential to effect 17 residents who received room trays. The facility staff identified a census of 85. Findings are: Observation on 6-26-2017 at 1:08 with the Dietary Manager (DM) revealed Cook Q had completed meal service in the dining room and completed setting up the last of the meal trays for those resident who ate in their room including a meal test tray. Observation on 6-26-2017 at 1:11 PM revealed the last of the resident meal tray was delivered to the residents and with the DM using the facility thermometer obtained the follow temperatures of the test meal tray: -Pureed taco 136 degrees. -Pureed rice was 126 degrees. -Pureed corn was 129 degrees. -Regular texture rice was 134 degrees. -Regular taco was 101 degrees. -Milk was 45 degrees. -Apple juice was 58 degrees. -Taste testing of the Pureed taco revealed it to be warm, extremity salty, to the point almost coughing. It had a salty burning feel. The DM tasted the pureed taco and confirmed it was extremely salty and difficult to eat. -Tasting testing of the pureed rice revealed it to be cold, with a putty like consistency that stuck to the roof of the mouth. -Taste testing of the regular textured rice revealed it was slightly warm, very pasty like and stuck to the roof of the mouth when eaten. The DM confirmed food was served cold and the taste and consistency of the food tasted was not palatable.",2020-09-01
968,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,371,E,1,1,GRW111,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation and interview; the facility kitchen staff failed to maintain food temperatures to prevent potential food borne illness, failed to ensure unpasteurized eggs were not served soft, failed to complete hand hygiene and failed to handle drinking glasses to prevent the potential for food borne illness. The facility staff identified 76 residents who ate out of the kitchen. Findings are: [NAME] Observation on 6-21-2017 at 8:25 AM revealed breakfast was being served to the facility residents that included resident's egg of choice. Observation of the carton of eggs revealed there was no indication the eggs were pasteurized. Further observation revealed over easy eggs were available for the facility resident. An interview was conducted with the Dietary Manager (DM) on 6-21-2017 at 8:40 AM. During the interview the DM confirmed the eggs were unpasteurized and soft eggs were being served to the residents. B. Observation on 6-26-2017 at 1:08 with the DM revealed Cook O had completed meal service in the dining room and completed setting up the last of the meal trays for those resident who ate in their room including a meal test tray. Observation on 6-26-2017 at 1:11 PM revealed the last of the resident meal tray was delivered to the residents and with the DM using the facility thermometer obtained the follow temperatures of the test meal tray: -Pureed taco 136 degrees. -Pureed rice was 126 degrees. -Pureed corn was 129 degrees. -Regular texture rice was 134 degrees. -Regular taco was 101 degrees. -Milk was 45 degrees. -Apple juice was 58 degrees. On 6-26-2017 at 1:11 PM the DM confirmed hot foods were to cold and milk and apple juice were to warm. C. Observation of the meal service on 6-26-2017 between 11:23 AM to 1:11 PM revealed Cook Q prepared to serve the lunch meal that consisted of tacos, rice, lettuces, tomato, cookies for desert. Observation revealed Cook Q had pre-assembled the soft taco shell and taco meat resulting in that Cook Q would need to add the cheese, tomatos and lettuce. Further observation revealed Cook Q touched several of the tacos with bare hands. On 6-21-2017 at 1:118 PM an interview was conducted with Cook Q. During the interview Cook Q confirmed tacos were touched with bare hands. Observation on 6-26-2017 at 12:17 PM revealed cook R was cooking addition taco meat for the resident. During the observation Cook R had donned gloves touched the counters and stove and without changing the gloves and handwashing, started to assemble addition tacos for the resident. Observation on 6-26-2017 at 12:40 PM revealed Cook R had a request for a grilled cheese sandwich. Cook R had donned gloves and took 2 slices of bread, buttered them and placed them into a pan. Cook R without changing the gloves, went to the refrigerator, touched the handled, opened the door and removed several pieces of cheese with the soiled gloves. Cook R placed the slices of cheese onto the 2 slices of bread in the pan. Cook R then began to assemble additional tacos for the lunch meal. Further observations revealed Cook R without changing the soiled gloves, removed the grill cheese sandwich from the pan and touched the sandwich with the soiled gloves. On 6-26-2017 at 1:35 PM an interview was conducted with Cook R. During the interview Cook R confirmed soiled gloves were not changed and food was touched. D. Observation on 6/21/17 at 11:46 AM, revealed Nursing Assistant (NA) D was observed with un-gloved hand to pick up a drink using her hand over the top of the opening, causing her fingers to touch the area of the glass that the resident would be drinking from. This observation continued during the serving of drinks to multiple residents. Observation on 6/26/17 at 12:01 PM, revealed dining serving, staff performing serving were observed with un-gloved hand to pick up a drink using her hand over the top of the opening, causing her fingers to touch the area of the glass that the resident would be drinking from. Dietary Manager was observed to speak to the staff and request that only drinking glasses be placed on the tray by herself. Interview with Dietary Manager confirmed that staff had been using un-gloved hand to pick up a drink using her hand over the top of the opening, causing her fingers to touch the area of the glass that the resident would be drinking from and that this had the potential to spread of food borne illness.",2020-09-01
969,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,425,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.12E7 Based on observation, record review, and interviews; the facility failed to ensure that the medication labels matched the current physician order [REDACTED]. Findings are: Observation on 6/26/17 at 7:10 AM revealed the labile on Resident 5's Lantus Insulin bottle read to administer 25 units of insulin subcutaneous in am and in PM. Observation on 6/26/17 at 7:10 AM revealed Licensed Piratical Nurse (LPN) E, draw up 23 units from the insulin bottle labeled 25 units, and administer the 23 units of insulin to Resident 5. Interview with LPN [NAME] on 6/26/17 at 7:10 AM confirmed that the physician current order was to administer 23 units of Lantus insulin in the morning and 25 units of insulin in the evening. LPN [NAME] confirmed that the pharmacy label did read to administer 25 units of insulin to Resident 5 in the am and in the PM. Interview with Facility consultant on 6/26/17 confirmed that the pharmacy label on the insulin did not match the current physician order.",2020-09-01
970,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,441,D,1,1,GRW111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on record review and interview; the facility staff failed to have defined indicators for Isolation procedures and failed to provide education and demonstration of hand hygiene procedures for 1 (Resident 133) of 1 residents. The facility staff identified a census of 85. Findings are: [NAME] Record review of the facility Policy for Initiating Isolation dated 5-01-2010 revealed the following information: Policy: To provide guidance for isolation precautions when residents have or are suspected to have an infectious or communicable disease. The facility is committed to providing a safe and healthy environment for the residents and to minimize or prevent the spread of infection. Procedure: 1. The charge nurse notifies the Infection control Nurse or designee and the residents attending physician for appropriate isolation instructions when there is reason to believe that a resident has an infectious or communicable disease. 2. The charge nurse obtains a physician's order for isolation; the Infection Control Nurse or designee can approve implementing isolation in the vent of a physician delay. B. Record review of a Admission Record sheet printed on 6-15-2017 revealed Resident 133 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 133's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 5-10-17 revealed the facility staff had assessed Resident 133 with a Brief Interview of Mental Status (BIMS) of 15. According to the MDS Manuel, a BIMS of 13 to 15 indicate a person is cognitively intact. Record review of Resident 133's Comprehensive Care Plan (CCP) dated 4-28-2017 revealed Resident 133 was placed into a private room for isolation related to poor hygiene, touching private parts and touching everything else. Record review of Resident 133's medical record revealed there was not evidence that the facility had completed observations with Resident 133 to determine what additional education Resident 133 would need for hand hygiene including demonstrating for nursing staff Resident 133's understanding of hand hygiene. Record review of Resident 133's Progress Notes (PN) dated 4-27-2017 revealed Resident 133 was assessed as having no open areas. Record review of physician review sheet dated 4-28-17 revealed Resident 133's physician had seen Resident 133 for a review of the hospital discharge and review of medications. Further review of the physician review sheet revealed the plan was for the resident to be admitted to the facility with the same medications and treatments. There was no indications or orders for Resident 133 to be placed into isolation. Review of Resident 133's PN dated 5-09-2017 revealed Resident 133 was in contact isolation. Review of Resident 133's PN dated 5-18-2017 revealed Resident 133 meal were eating in (gender) room as Resident 133 was in isolation. On 6-26-2017 at 7:42 AM an interview was conducted with Resident 133. During the interview, Resident 133 reported no understanding what the reason for isolation was or how isolation procedures were to be implemented. On 6-27-2017 at 7:49 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported there was not education provided to Resident 133 for the isolation and further reported was not sure why Resident 133 was in isolation. On 6-28-2017 at 6:30 AM an interview was conducted with Licensed Practical Nurse (LPN) H and LPN I who both worked on the unit Resident 133 resided on. During the interview when asked why Resident 133 had been in isolation, LPN H and LPN I reported being told Resident 133 had herpes. LPN H stated I wasn't sure about that. LPN I reported after a while the herpes issue was dropped. When asked if LPN H and LPN I knew why Resident 133 was in isolation, Both LPN H and LPN I stated not really, we don't make that decision. LPN I reported LPN I's understanding was that Resident 133 had poor handwashing and did scratching self in peri area. LPN I reported not being aware of anyone teaching Resident 133 about hand hygiene or any follow up with the resident.",2020-09-01
971,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2017-06-28,520,D,1,1,GRW111,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record review and interviews; the facility Quality Assurance/Quality Improvement committee failed to identify and correct ongoing issues related to F223, F248, F253, F285, F309, F312, F314, F315, F323, F364, F371, F425, F441 and failed to implement effective plans of actions to correct the deficient practice and maintain correction resulting in repeat citations at F242, F253, F309, F441. The facility staff identified a census of 85. Findings are: [NAME] Record review of the facility Quality Assurance Process Improvement (QAPI, also known as QA) dated 8-2016 revealed the following information: -The QAPI Committee monitors and sustains Living Center operational performance in clinical and non-clinical systems through self-identification and improvement in areas where opportunities for improvement (OFI's) have been identified. According to a diagram on the information sheet revealed OFI's are identified via data reviews, trends and observations. B. On 6-27-2017 at 3:45 PM an interview was conducted with Registered Nurse (RN) N. During the interview RN N reported being aware of the QA program and that basic items were reviewed. RN N reported not being aware of specific of what was being worked on by the QA committee. C. On 6-27-20 at 3:50 PM an interview was conducted with the Maintenance Director. During the interview, the Maintenance Director reported not being aware of what the QA committee was working on. Record review of a Qa &A Committee Agenda/Minutes sheet dated 6-13-2017 identified the Maintenance Director as a member of the QA Committee. D. On 6-27-2017 at 3:55 PM an interview was conducted with Nursing Assistant (NA) O. During the interview NA O reported not being aware of what the QA Committee was and what they were doing. E. On 6-28-2017 at 7:20 AM an interview was conducted with Licensed Practical Nurse (LPN) H. During the interview LPN H reported being aware of the QA committee and how it function. LPN H reported not being aware of what specifically the QA committee was working on. LPN H reported routine things.",2020-09-01
972,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2018-09-11,550,D,1,1,NUV611,"> Licensure Reference Number 175 NAC 12-006.05(21) Based on observation and interview the facility failed to ensure resident dignity in the dining area for three of thirty two sampled residents (Residents 4, 21, and 31) who received meals in the Dining Room. The facility census was 53. Findings are: Observations on 09/05/18, during service of noon meal, from 11:45 AM to 12:30 PM, revealed thirty two residents seated at tables received meal service. Several residents were noted to be positioned in wheelchairs with white colored lift slings (an essential part of a mechanical patient lift which is placed under and around patients who have mobility issues to assist them to be lifted and transferred safely from a bed, wheelchair, toilet, or shower) in place and visible to the public. An interview, on 09/06/18 at 11:35 AM, with Resident 4 revealed a full body mechanical lift was required for staff to assist the resident to transfer from one surface to another. Resident 4 reported that lift slings are left in place under the resident, visible to others, while seated in the wheelchair, for up to 9 hours daily. Resident 4 considered the practice a dignity issue, reporting that everyone was aware of the Resident's need for mechanical assistance during the provision of personal care. An interview, on 9/6/18 at 11:40 AM with the Occupational Therapist (OT) revealed the facility had not identified that the practice of leaving lift slings in place and visible to others was a dignity concern. The OT acknowledged the concern voiced by Resident 4, reporting (gender) would discuss with the Care Team to determine a remedy for the issue. B. Observation on 09/05/18 at 2:01 PM revealed Resident 21 and 31 in the dining room and they had slings exposed for public visibility. Observation on 09/11/18 at 9:06 AM revealed Resident 21 and 31 in the dining room and they had slings exposed for public visibility. Interview with the Director of Nursing on 09/11/18 at 10:49 AM confirmed that Resident 31 and 21 had slings exposed in the Dining Room and it was a dignity issue.",2020-09-01
973,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2018-09-11,726,E,0,1,NUV611,"Licensure Reference Number 175 NAC 12-006.04B2b Based on observation, record review and interview the facility failed to ensure training and competencies were completed for medication aides for preforming an Accu check (a procedure to check blood sugar levels). This had the potential to affect 18 residents (Resident 36, 51, 38, 45, 32, 41, 31, 57, 42, 40, 34, 50, 39, 4, 43, 259, 18, 13) The facility census was 53. On 09/10/18 at 11:05AM an observation revealed MA (medication aide) A preformed an Accu check on Resident 36. On 9/11/18 at 9:00AM Record review revealed no training or competency for Accu checks for MA [NAME] On 09/11/18 at 09:46 AM an interview with the DON (Director of Nursing) confirmed there was no training or competency for preforming Accu checks for MA [NAME]",2020-09-01
974,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2018-09-11,812,F,0,1,NUV611,"Licensure Reference Number 175 NAC 12.006.11E Based on observation, record review, and interview; the facility failed to ensure food was served in a manner to prevent the potential of cross contamination related to: lack of hand hygiene during food service in the Dining Room, having the potential to affect 32 residents receiving meals in the Dining Room; food items being transported to resident rooms were not covered, having the potential to affect 4 residents (Residents 7, 13, 15, and 33) who routinely received meals in their rooms. The facility census was 53. Findings are [NAME] Observations on 09/05/18, during service of noon meal, from 11:45 AM to 12:30 PM, revealed thirty two residents were seated at tables and received meal service in the Dining Room. Dietary Staff (DS)-B was observed to be filling and serving drinking devices with liquids and delivering the devices to individual residents bare handed and without evidence of hand sanitation. DS-B was also noted to: wipe (gender) face and nose area with hands without evidence of hand sanitation before going back to filling cups; reach into a pocket on the Staff Member's uniform and retrieve a thermometer and without sign of disinfection, used the thermometer to assess the temperature of coffee in an insulated mug. The thermometer was then placed on to the surface of the service area in use. Several minutes later, DS-B was noted to use uncovered fingers to wipe the thermometer prior to using the thermometer to assess the temperature of another cup of coffee. DS-B was observed to deliver requested fluids to residents through out the Dining Room, touching residents when visiting, opens food packaging, returns to fluid cart and prepares more cups/containers of fluids, and delivers to other residents all without evidence of hand sanitation between contacts. A review of the Nebraska Food Code, effective 3/8/12, at 2-301.14 revealed food employees shall clean their hands immediately: (A) after touching bare human body parts, (D) after coughing, sneezing, using a handkerchief or disposable tissue; and (F) during food preparation, as often as necessary to prevent cross contamination when changing tasks. B. Observations on 09/05/18 at 11:36 AM and 09/11/18 at 11:38 AM, revealed an insulated cart with trays of food being delivered to the 300 hallway. Staff were noted to immediately deliver the meal trays to 4 residents (Residents 7, 13, 15, and 33). Continued observation revealed that the plastic cups, used for fluids being served and bowls used for other food items, were not covered as the trays were transported from the cart to individual resident rooms. A review of the Nebraska Food Code, effective 3/8/12, at 3-302.11 revealed (A) food shall be protected from cross contamination by: (4) storing the food in packages, covered containers, or wrappings. An interview on 9/11/18 at 11:40 AM, with the Administrator, confirmed the cups and bowls used to serve food items needed to be covered as staff transported the food to the residents, in order to prevent cross contamination of the food items.",2020-09-01
975,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-06,684,D,1,0,T83311,"> LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D2 Based on observation, record review and interview; the facility staff failed to monitor the size of a wound for 1 (Resident 7) of 3 sampled residents. The facility staff identified a census of 68. Findings are: Record review of a Weekly Skin Check (WSC) sheet dated 8-06-2019 revealed Resident 7 was evaluated as having a Calloused area to the right stump area. Record review of a WSC dated 10-14-2019 revealed the right stump area measured 1.0 centimeters (cm) buy 1.3 cm by 0.1 cm. Record review of Resident 7's medical record revealed there were not additional measurement of the wound until 11-05-2019. Observation on 11-05-2019 at 1:35 PM of wound care revealed Licensed Practical Nurse (LPN) A used hand sanitizer and donned gloves. LPN A removed a dressing that had covered the right amputation area revealing an open area that measured approximately 0.5 centimeters (cm) roundish in shape. On 11-06-2019 at 8:15 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview, the ADON reported wounds are to have weekly measurement. The ADON further confirmed measurement had not been completed weekly for Resident 7. Record review of the facility Policy titled Weekly Wounds/Skin Documentation dated 12-14-2018 revealed the following information: -1. The nursing management designee is responsible to ensure that all wounds are measured weekly and recorded on the appropriate form.",2020-09-01
976,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-06,880,D,1,0,T83311,"> LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.17 Based on observation, record review and interview; the facility staff failed to utilize handwashing and gloving techniques to prevent potential cross contamination during the provision of care for 2 (Resident 10 and 7) of 3 sampled residents and failed to ensure soiled linen was not placed on the floor or resident tray table for 2 (Resident 7 and 9) of 3 sampled residents. The facility staff identified a census of 68. Findings are: A. Record review of Resident 10's Order Summary Report (OSR) printed on 11-05-2019 revealed Resident 10 had wound to the back of right thigh area with ordered treatment. Observation on 11-05-2019 at 2:15 PM of the wound care treatment revealed Licensed Practical Nurse (LPN) A washed hands and donned gloves. LPN A obtained 3 wash cloth and wet them and placed them on Resident 10's tray table. LPN A had Resident 10 roll to the left revealing a large amount of draining on a bath blanket that was under Resident 10 and Resident 10's dressings to the right thigh wounds were saturated with drainage. LPN A pulled down netting that had been in place to hold the dressing in place. The Netting ( a sock like covering that helps hold dressings in place) had dried red drainage on it. LPN A removed the saturated dressing on the right thigh area causing 2 of the wounds to bleed. LPN A discarded the soiled dressing and using one of the wet wash cloths began to clean the back of Resident 10's right thigh area wounds . LPN A obtained another wet wash cloth and covered the 2 would the had began to bleed and wiped until wound drainage had decreased. LPN obtained a dry wash cloth and dabbed at the wounds. LPN A removed the soiled gloves cleansed the hands with hand sanitizer and donned another pair of gloves. LPN A applied the ordered ointment to the wounds. LPN A after applying the ointments, LPN A removed the gloves , used hand sanitizer and donned another pair of gloves. LPN A applied 4 dressings to the wounds on Resident 10's back thigh area touching the wounds with the gloved hands. LPN A with the same soiled glovers, cut a new netting dressing to help hold the new dressing in place. LPN A cut the soiled netting, and without changing the soiled gloves, applied the new netting. LPN A without changing the soiled dressing, held onto Resident right leg and began to pull at the soiled old netting. LPN A then placed the soiled dressing onto the resident bed linen. LPN A without changing the soiled gloves. LPN A without changing the soiled gloves assisted Resident 10 with positioning touching, Resident 10's hip area, arm, pillows, foot board with the soiled dressings. LPN A gathered up the soiled items including a pair of scissors and placed the scissors into (gender) pocket. LPN A removed the soiled gloves, washed hands left Resident 10's room. On 11-05-2019 at 2:58 PM an interview was conducted with LPN A. During the interview LPN A confirmed gloves should have been changed when soiled. B. Record review of Resident 7's OSR printed on 11-05-2019 revealed Resident 7 had orders for a right leg wound to a amputation area. Observation on 11-05-2019 at 1:35 PM of wound care revealed LPN A used hand sanitizer and donned gloves. LPN A removed a dressing that had covered the right amputation area revealed an open area that measured approximately 0.5 centimeters (cm) roundish. LPN A obtained a wash cloth and using wound cleanser solution, cleaned Resident 7 wound to the right amputation site. LPN A placed the soiled wash cloth on top of Resident 7's tray table. LPN without handwashing and changing gloves applied a new dressing to the right amputation site wound. LPN completed the treatment. Washed hands and left Resident 7's room. LPN A did not clean off Resident 7's tray table. On 11-05-2019 at 3:05 PM an interview was conducted with LPN A. During the interview LPN A confirmed the soiled wash cloth should not have been placed on top of Resident 7's tray table and further confirmed Resident 7's tray table had not been clean and should have been. C. Record review of Resident 9's OSR printed on 11-05-2019 revealed Resident 7 had wounds to the buttocks. Observation of a treatment to Resident 7's buttocks revealed LPN B donned gloves and assisted Resident 7 into a right laying position. Further observation revealed Resident 7 had a pad underneath that had stains of wound drainage and Bowel Movement (BM). LPN B completed Resident 7's treatment. LPN B removed the soiled pad and placed it on the floor next to the hand washing sink.",2020-09-01
977,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-26,623,D,0,1,WS4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure notification of reason for transfer in writing for 2 (Resident 70 and 27) of 3 sampled residents. The facility staff identified a census of 74. Findings are: [NAME] Record Review of Progress Notes for Resident 27 revealed that the POA (Power of Attorney) was notified of hospital transfer on dates, 8/17/19 and 7/18/19 by phone. No explanation for the transfer in writing was present in the record. B. Record Review of Progress Notes for Resident 70 revealed the resident was hosptalized on [DATE]. There was no written notification for the reason of transfer in writing. C. Interview on 11/25/19 at 01:38PM with the Director of Nursing (DON) and Nurse Consultant, confirmed that they did not send out a letter of notification to the POA for the reason the resident was transferred. The Nurse Consultant stated that this was a cooperate decision.",2020-09-01
978,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-26,684,D,0,1,WS4511,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview the facility staff failed to ensure the coordination of care between the facility and the hospice provider for 1 (Resident 36) of 1 sampled resident. The facility staff identified a census of 74. The findings are: Review of the Hospice contract with dated 7/19/19 revealed that Hospice will establish a coordinated P[NAME] (Plan of Care) for each resident. The P[NAME] must identify the care and services that are needed and specifically identify the provider that is responsible for performing the respective functions that have been agreed upon and included in the P[NAME]. Further review of contract revealed Patient Care Information Provided to the facility as follows: A copy of the most recent Plan of Care specific to each Resident A copy of the Hospice Election form and any advance directives specific to resident A copy of the physician certification and recertification of terminal illness Names and contact information for Hospice personnel involved in the hospice care of each patient Instructions on how to access the Hospice 24 hour on call system A copy of medication information specific to each patient. Record review of the physician orders [REDACTED]. Review of the Medical Record for Resident 36 revealed no evidence of Hospice documentation. On 11/25/19 at 01:14 PM an interview with the Director of Nursing confirmed that Resident 36 has been on Hospice since 5/2019 and there was no hospice documentation available in Resident 36's medical record.,2020-09-01
979,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-26,690,D,0,1,WS4511,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and interview: the facility failed to ensure a suprapubic catheter (a tube inserted into the bladder to drain urine) was changed according to physician orders [REDACTED]. The facility staff identified a census of 74. The findings are: On 11/20/19 at 08:29 AM an interview with Resident 29 revealed the suprapubic catheter was due to be changed on Saturday and it still hadn't been changed. Review of Resident 29's Comprehensive Care Plan revealed to change the catheter bag/tubing every 3 weeks dated 1/29/19. Review of Resident 29's current physician orders [REDACTED]. Review of TAR (Treatment Administration Record) for (MONTH) 2019 revealed an order to change suprapubic catheter q 3 week with 20FR 10cc bulb. Documentation revealed no initials on (MONTH) 25th to indicate catheter had been changed Record review of Resident 29's progress notes for (MONTH) 2019 revealed no documentation as to why suprapubic was not changed. Review of the TAR for (MONTH) 2019 revealed an order to change suprapubic catheter q 3 weeks with 20FR 10cc bulb. Documentation revealed no initials to indicate change on 11/15/19. Review of Resident 29's progress notes for (MONTH) 2019 revealed no documentation as to why suprapubic catheter was not changed. On 11/21/19 at 01:01 PM an interview with the Director of Nursing confirmed there was no documentation of the suprapubic catheter being changed on the (MONTH) 25th date and the (MONTH) 15th date.,2020-09-01
980,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-26,698,D,0,1,WS4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to ensure communication with the [MEDICAL TREATMENT] unit on [MEDICAL TREATMENT] days and failed to document fluid intake for the fluid restriction for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 74. The findings are: Record review of [MEDICAL TREATMENT] Policy and Procedure dated 09/13 revealed the following: Assure facility [MEDICAL TREATMENT] Communication form accompanies resident to [MEDICAL TREATMENT] on treatment days to communicate resident information and coordinate care between [MEDICAL TREATMENT] Center and facility. [MEDICAL TREATMENT] center personnel to complete [MEDICAL TREATMENT] communication form and return to facility. Upon return from facility review information provided on [MEDICAL TREATMENT] communication form. Communicate and address as appropriate. Complete post-[MEDICAL TREATMENT] information and place in residents medical record. Further review of the [MEDICAL TREATMENT] Policy and Procedure revealed: Maintain fluid restrictions as ordered. Record intake if fluid restriction ordered. Review of physician orders: 1000mL fluid restriction, dietary to provide 240ml for breakfast, 180ml for lunch, and 180ml for dinner. Nursing to provide 150ml on 6-2 shift, 150ml on 2-10 shift, 100ml on 10-6 shift. Physician order [REDACTED]. Review of EMAR for (MONTH) revealed a start date of 11/19/2019 of 1000ml fluid restriction revealed no documentation of fluid intake. On 11/21/19 at 01:04 PM an interview with the DON (Director of Nursing) confirmed the facility does not consistantly have [MEDICAL TREATMENT] communication sheets. 11/21/19 02:21 PM Interview with DON confirmed there was no documentation of fluid intake for fluid restriction.",2020-09-01
981,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-26,812,F,0,1,WS4511,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview and record review; the facility staff failed to ensure the thermometer to test the temperature of food on the steam table was sanitized to prevent potential cross contamination. This had the potential to affect 69 residents that receive meals from the kitchen. The findings are: On 11/21/19 at 11:20 AM an observation of Cook A taking temps of food on the steam table revealed after each temp was taken Cook A wiped the thermometer off with a dry wash cloth. On 11/21/19 at 11:40 AM an interview with the DM (Dietary Manager) revealed the usual way the staff cleans the thermometer is with alcohol preps between each temp.",2020-09-01
982,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-11-26,880,D,1,1,WS4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.17B Based on observation, record review and interview; the facility failed to ensure a [MEDICAL CONDITION] (Continuous positive airway pressure used to help breathe more easily during sleep) mask was cleaned for 1 (Resident 32) of 1 sampled resident. The facility staff identified a census of 74. The findings are: On 11/20/19 at 02:31 PM and interview with Resident 32 revealed that the mask for the [MEDICAL CONDITION] does not get cleaned. On 11/25/19 at 08:11 AM observation of the [MEDICAL CONDITION] mask and tubing was lying on Resident 32's over bed table uncovered. On 11/25/19 at 02:35 PM observation of the [MEDICAL CONDITION] mask laying on Resident 32's bed uncovered. Review of Resident 32's medical record revealed no evidence that the [MEDICAL CONDITION] mask was cleaned. On 11/25/19 at 09:37 AM a review of the Infection Control Policy for Cleaning Respiratory Equipment dated 5/1/17 revealed [MEDICAL CONDITION] Machines should have the external surfaces cleaned twice a week. Change tubing when contaminated. On 11/25/19 at 02:42 PM an interview was conducted with Director of Nursing which confirmed there was no documentation in the medical record of cleaning the [MEDICAL CONDITION].",2020-09-01
983,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-12-23,580,D,1,0,NU9V11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE 1[AGE] NAC 12-006.04C3 (6) Based on record review and interview the facility staff failed to ensure physician orders [REDACTED]. The facility staff identified a census of 70. The findings are: Record review of Resident 400's December 2019 MAR (Medication Administration Record) revealed an order dated 11/13/19 for Accuchecks twice a day. Call Hospice if less than [AGE] or greater than 400 every morning and at bedtime. Documentation on the MAR for December 2019 for Resident 400 revealed the following: On 12/3/19 at 0700 the blood sugar result was documented as 471. On [DATE] at 0700 the blood sugar result was documented as 418 and at 2100 the result was 427. On 12/5/19 at 2100 the blood sugar result was documented as 439. On 12/6/19 at 0700 the blood sugar result was documented as 427 and at 2100 the result was 413. On 12/7/19 at 0700 the blood sugar result was documented as 448. On 12/8/19 at 0700 the blood sugar result was documented as 419. On 12/12/19 at 0700 the blood sugar result was documented as 445 and at 2100 the result was 425. On 12/13/19 at 0700 the blood sugar result was documented as 411 and at 2100 the result was 434. On [DATE] at 0700 the blood sugar result was documented as 419. On 12/22/19 at 0700 the blood sugar result was documented as 424 and at 2100 the result was 499. Record review of Resident 400's progress notes revealed no evidence that Hospice had been notified of the blood sugars above 400. An interview with the Director of Nursing on [DATE] at 12:35 PM confirmed there was no documentation of Hospice being notified of blood sugars above 400.,2020-09-01
984,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-12-23,692,D,1,0,NU9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D8 Based on observation, record review and interview; the facility staff failed to ensure that 2 (Resident 400 and 700) of 2 sampled resident received the amount of tube feeding to meet nutritional needs. The facility staff identified a census of 70. A. Record review of Resident 700's Electronic Medication Administration Record [REDACTED]. Further review of Resident 700's EMAR for December 2019 revealed the [MEDICATION NAME] was scheduled to start at 10:00 AM and end at 6:00 AM the following day. Observation on 12-23-2019 at 5:40 AM revealed Resident 700 was in bed and the tubing for administering the [MEDICATION NAME] was not connected to Resident 700. Observation on 12-23-2019 at 10:35 AM revealed Resident 700 was in bed. Resident 700's feeding pump was turned on and the infusion rate of the [MEDICATION NAME] 1.5 was set at [AGE] ml per hour, however, the tubing was not connected to the resident and Resident 700's [MEDICATION NAME] Formula was dripping onto the floor. On 12-23-2019 at 10:40 AM an interview and observation of Resident 700's feeding was completed with the DON. During the interview, the DON conformed Resident 700's feeding was not connected to Resident 700. B. Record review of a practitioners order dated 11-14-2019 revealed Resident 700 was to receive [MEDICATION NAME] 1.5 at [AGE] ml per hour for 20 hours. Based on the practitioners order dated 11-14-2019 Resident 700 should receive 1[AGE]0 ml of the [MEDICATION NAME] formula in a 20 hour time frame. Record review of Resident 700's EMAR for December 2019 revealed the following information: -12-12-2019, the amount of [MEDICATION NAME] given was 2450 ml's. -12-13-2019, the amount of [MEDICATION NAME] given was 2640 ml's. -12-14-2019, the amount of [MEDICATION NAME] given was 2400 ml's. -12-15-2019, the amount of [MEDICATION NAME] given was 25[AGE] ml's. -12-16-2019, the amount of [MEDICATION NAME] given was 0 ml's. -12-17-2019, the amount of [MEDICATION NAME] given was 10[AGE] ml's. -12-19-2019, the amount of [MEDICATION NAME] given was 2[AGE]0 ml's. -12-21-2019, the amount of [MEDICATION NAME] given was 2670 ml's. -12-23-2019, the amount of [MEDICATION NAME] given was 1324 ml's. On 12-23-2019 at 11:50 AM an interview was conducted with the DON. During the interview, the DON confirmed the amount of [MEDICATION NAME] formula recorded on Resident 700's December EMAR was not the correct amount Resident 700 should have received. C. On [DATE] at 10:38 AM an observation of Resident 400 revealed the tube feeding was disconnected. The bag of tube feeding was dated 12/22/19 and timed for 10A. Further review of Resident 400's current physician orders [REDACTED]. Turn on at 10AM and turn off at 6 AM to equal 1300ml. Observation and interview with RN B on [DATE] at 10:45AM confirmed the tube feeding was disconnected and should have been turned on at 10AM. D. Record review of Resident 400's current physician orders [REDACTED]. Record review of the Nutritional assessment dated [DATE] revealed Resident 400's Nutritional Needs for total calories to be 1[AGE]0-2220. Resident with increased needs for wound healing. Calories provided with tube feeding at 65ml for 20 hours provided 1950 Calories. Review of the EMAR (Electronic Medication Administration Record) for Resident 400 recording of tube feeding amounts revealed the following: On 12/1/19 the tube feeding amount was documented as 1122ml. On 12/2/19 the tube feeding amount was documented as 687ml. On 12/3/19 the tube feeding amount was documented as 10[AGE]ml. On [DATE] the tube feeding amount was documented as 874ml. On 12/6/19 the tube feeding amount was documented as [AGE]6ml. On 12/7/19 the tube feeding amount was documented as [AGE]4ml. On 12/8/19 the tube feeding amount was documented as 650ml. On 12/9/19 the tube feeding amount was documented as 763ml. On [DATE] the tube feeding amount was documented as [AGE]7ml. On 12/11/19 the tube feeding amount was documented as 496ml. On 12/12/19 the tube feeding amount was documented as 1240ml. On 12/13/19 the tube feeding amount was documented as 1120ml. On 12/15/19 the tube feeding amount was documented as [AGE]4ml. On 1[DATE] the tube feeding amount was documented as 498ml. On [DATE] the tube feeding amount was documented as 687ml. On [DATE] the tube feeding amount was documented as 699ml. On 12/22/19 the tube feeding amount was documented as 1120ml. On [DATE] at 11:50 AM an interview with the DON was conducted and confirmed the tube feeding intake documented on the EMAR was not consistent with the physicians order and did not meet the nutritional needs of Resident 400.",2020-09-01
985,EMERALD NURSING & REHAB OMAHA,285097,5505 GROVER STREET,OMAHA,NE,68106,2019-12-23,693,D,1,0,NU9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 1[AGE] NAC 12-006.09D6(1) Based on observation, record review and interview; the facility staff failed to ensure 1 (Resident 400) of 1 sampled resident tube feeding bag was changed. The finding are: On [DATE] at 07:35 AM observation of Resident 400's tube feeding bag revealed a date of 12/22/19 and a time of 10A. On [DATE] at 02:45 PM observation of tube feeding bag revealed a date of 12/22/19 and a time of 10A. Record review of Resident 400's current physician orders [REDACTED]. On [DATE] at 11:30 AM an interview was conducted with RN B and revealed the policy is to change out the bottles of tube feeding and bags of tube feeding at Midnight. Observation and interview with RN B in resident 400's room confirmed the tube feeding bag was dated 12/22 and timed 10A. RN B confirmed the tube feeding bag should have been discarded and a new bag hung at midnight. On [DATE] at 11:45 AM an Interview with Director of Nursing confirmed the order should state to change the tube feeding bag at 1:00 AM and also confirmed the bag that is hanging and infusing that is dated 12/22/19 and timed at 10 A should not be hanging.",2020-09-01
986,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,225,D,0,1,PWJJ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to report an allegation of neglect for 1 resident (Resident 91) within 24 hours to the State Agency and failed to complete an investigation of potential verbal abuse of 1 (Resident 23) of 3 residents reviewed. The facility staff identified a census of 83. Findings are: [NAME] Record review of an Adult Abuse/Neglect Report Form (AANRF), dated 10-31-2016, revealed Resident 91 was found to be soiled with dried urine and Bowel Movement (BM). According to the information in the AANRF ,dated 10-31-2016, the date of occurrence was 10-23-2016 at 10:30 AM and the State agency was notified on 10-25-2016. An interview was conducted on 2-21-2017 at 8:44 AM with Licensed Practical Nurse (LPN) [NAME] During the interview, LPN A reported finding Resident 91 with dried on BM. LPN A reported being so upset about the condition Resident 91 was found in, started to cry. During the interview, LPN A reported thinking that the incident of Resident 91 with dried BM might be potential neglect. When asked when a report was made, LPN A reported 2 days later as (I was concerned no one took care of (gender) .). B. A review of Resident 23's Progress noted revealed a Nurses Note dated 8/25/16 at 3:15 PM, created by the DON (Director of Nursing), that revealed, the DON had overheard a conversation on the phone between Resident 23 and Resident 23's sister. Resident 23's sister was yelling at Resident 23. Resident 23's sister was quoted as yelling I am just done with this. I am done with all of this. You think you are going to be able to do this? You think that you can go to your appointment tomorrow? Who is going to be there for you? I have changed my whole day for this? I just can't believe you. Why don't you just use your crutches, why don't you think that you can just pivot into the car, you know that you can do that. The note revealed Resident 23's sister continued to yell at Resident 23 until Resident 23 hung up the phone. A review of Resident 23's Progress notes revealed a Nurses Note dated 8/26/16 at 10:24 AM created by Registered Nurse (RN) N that revealed the resident had been reviewed for therapy risk. The note revealed the DON would be calling Adult Protective Services (APS) to report witnessed verbal abuse over the speaker phone with Resident 23 and Resident 23's sister. A review of Resident 23's Progress notes revealed a Nurses Note dated 8/26/16 at 11:44 AM created by the DON revealed the DON called APS to report the phone conversation that the DON had overheard the day before between Resident 23 and Resident 23's sister. A review of Resident 23's Progress notes revealed a Social Services Note dated 8/26/16 at 3:28 PM that revealed the Ombudsmen was informed that the DON contacted APS regarding the way Resident 23's sister talked to the resident. An interview conducted on 2/16/17 at 12:02 PM with the DON revealed they did an investigation and Resident 23 told the sister not to come to the facility anymore. The DON reported the sister had not been at the facility since and there have been no other issues. An interview conducted on 2/16/17 at 12:34 PM with the DON revealed that the staff felt Resident 23's sister was demanding and overstepping with Resident 23. The DON reported they called APS due to the way Resident 23's sister would speak to the resident. They did not send in a report to state agency after calling APS because they had called APS related to the relationship between Resident 23 and the sister. An interview conducted on 2/16/17 at 1:18 PM with the DON revealed that the DON had talked to RN N and that RN N was going to remove their documentation from Resident 23's record regarding verbal abuse. The DON reported that they had not submitted an investigation to the state agency as they did not feel it was abuse because it was an issue between Resident 23 and the sister. The DON reported they called APS because of the sister being the way she was with Resident 23. A review of the facility's Abuse and Neglect Policy and Procedure dated 11/2016 revealed the following: Purpose: To ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals. To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. Procedure: 11. The social worker or designated employee will report the results of all investigations to the state survey and certification agency and other officials within five working days of the incident, unless otherwise specified by state law, whichever is stricter. Policy: The location will evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency within five working days of the incident, or sooner as designated by state law. If the alleged or suspected violation is verified, appropriate corrective action will be taken.",2020-09-01
987,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,279,D,0,1,PWJJ11,"**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 staff failed to develop a Comprehensive Care Plan (CCP) of a pain management program for 1(Resident 96) of 2 residents reviewed . The facility staff identified a census of 83. Findings are: Observation on 2-15-17 at 7:05 AM of wound care to the front of the left knee revealed RN C explained to Resident 96 the task for wound care. RN C reported Resident 96 did have pain and was on pain medication. RN C asked Resident 6 if the medication helped and Resident 96 shook (gender's) head no. RN C began to cleanse Resident 96 left knee wound when Resident 96 indicated having pain. RN C continue to ask Resident 96 if it was ok to continue with the wound treatment. RN C completed the wound treatment. Record review of Resident 96's Medication Administration Record [REDACTED]. It affects chemicals and nerves in the body that are involved in the cause of [MEDICAL CONDITION] and some types of pain) 300 milligrams (mg) at bed time; [MEDICATION NAME] ( muscle relaxer and an antispastic agent)10 mg, twice a day; [MEDICATION NAME] as needed for pain; [MEDICATION NAME] 2% Gel to be applied topically to the left knee pain, and [MEDICATION NAME] 5 mg every 6 hours as needed for pain. Further review of Resident 96's MAR for (MONTH) (YEAR) revealed Resident 96 received [MEDICATION NAME] 5 mg 6 times, that included after the treatment was completed on 2-15-2017. According to the information, Resident 96's pain level was between a 4 and 6 on a scale of 0 to 10. Further review of Resident 96's MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] was given with a pain level of 0. Record review of Resident 96's CCP dated 12-06-2016 revealed Resident was a new admit to the facility with a [DIAGNOSES REDACTED]. An interview was conducted on 2-21-2017 at 11:19 AM with Registered Nurse (RN) D. During the interview, RN D confirmed Resident 96 current CCP did not include any information on how to manage Resident 96 pain and further confirmed Resident 96 CCP did not identify a goal the resident wanted for pain management. Record review of the facility Procedure for Pain Data Collection and assessment dated ,[DATE] revealed the following: -Purpose: -To promote well-being by ensuring that residents are as comfortable as possible. -To determine what pain relief interventions that are specific to the resident can be used and established to aid in maintaining a comfortable level of function and quality of life. -Note: A pain management plan can include, but not limited to, a medical regime. The analysis should help determine what other methods or alternatives of pain control/relief may be implemented before contacting a physician. -Procedure: -Develop a care plan including pain, a goal and interventions.",2020-09-01
988,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,309,G,0,1,PWJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 LICENSURE NUMBER 175 NAC 12-006.09D2c Based on observation, record review and interview; the facility staff failed to identify skin breakdown and failed to evaluate a pain management program for 1 (Resident 96) of 4 residents reviewed. The facility staff identified a census of 83. Findings are: [NAME] Record review of Resident 96's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 12-28-2016 revealed the facility staff assessed the following about the resident: -Resident 96 had short and long term memory problems. -Required extensive assistance with bed mobility, transfers, dressing, toilet us and personal hygiene. -Required total assistance with eating. - No pain. -1, Stage II pressure sore-(Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister). -The [DIAGNOSES REDACTED]. Record review of a Wound Data Collection (WDC) sheet dated 1-18-2017 revealed Resident 96 had developed a left heel wound that measured 0.3 centimeters (cm) by 0.5 cm and no depth. The color was dull dark purple. Causes of the development of the left heel wound were identified as poor circulation, limited mobility and dependent on tube feeding. Record review of a WDC sheet dated 1-10-2017 revealed Resident 96 was assessed with [REDACTED]. According to the WDC sheet, facility staff were unable to determine the depth. The description of the wound was evaluated as 85% yellow tissue, 5% red tissue and sheath (connective tissue). Record review of a weekly Skin Observation sheet dated 2-14-2017 revealed staff had identified Resident 96 had no skin conditions observed. Further review of the weekly Skin Observation sheet revealed Resident 96 did have a skin tear on the right hand that was almost healed, a wound on the left knee and heel and that a barrier cream was applied. Observation on 2-15-2017 at 10:18 AM of a bath being given to Resident 96 by Nursing Assistant (NA) K revealed an area that was approximately 0.7 cm on the back of the left knee area. The area was dark black. NA K reported, as the bathing continued, that the area behind the left knee has been there a while. In addition, the right upper thigh area had a red area that measured approximately 3 cm by 2 cm, along an area that had a scar. Register Nurse (RN) C was notified of the wound areas Resident 96 had developed. Review of Resident 96's record revealed there was not any evidence the facility staff had identified the wound area behind the left knee. On 2-15-2017, after being notified of the new skin issues, RN C assessed the following about Resident 96's wound: -Right Hip - an area of red tissue, which blanched and measured 3.5 cm by 4 cm with no depth noted. -Both buttock and scrotum - reddened and denuded. -Left knee (rear) - an area of eschar (eschar presents as dry, thick, leathery tissue that is often tan, brown or black.) measuring 1 cm by 0.7 cm with 100% necrotic (dead) tissue with minimal redness to the wound borders. An interview on 2-15-2017 at 3:15 PM was conducted with RN C. During the interview, RN C reported not being made aware of the new wound behind Resident 96's left knee prior to 2-15-17. B. Observation of wound care on 2-15-2017 at 7:05 AM to the front of the left knee revealed RN C explained to Resident 96 the task for wound care. RN C reported Resident 96 did have pain and received pain medication. RN C asked Resident 6 if the medication helped and Resident 96 shook (gender's) head no. RN C began to cleanse Resident 96's left knee wound. Resident 96 indicated having pain. RN C continued to ask Resident 96 if it was ok to continue with the wound treatment. RN C completed the wound treatment. Record review of Resident 96's Medication Administration Record [REDACTED]. It affects chemicals and nerves in the body that are involved in the cause of [MEDICAL CONDITION] and some types of pain) 300 milligrams (mg) at bed time; [MEDICATION NAME] (muscle relaxer and an antispastic agent) 10 mg, twice a day, [MEDICATION NAME] as needed for pain; [MEDICATION NAME] 2% Gel to be applied topically to the left knee pain; and [MEDICATION NAME] 5 mg every 6 hours as needed for pain. Further review of Resident 96's MAR for (MONTH) (YEAR) revealed Resident 96 received [MEDICATION NAME] 5 mg 6 times, that included after the treatment was completed on 2-15-2017. According to the information, Resident 96's pain level was between a 4 and 6 on a scale of 0 to 10. Further review of Resident 96's MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] was given with a pain level of 0. Record review of Resident 96's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of Resident 96's (MONTH) MAR indicated [REDACTED]. Record review of Resident 96's Comprehensive Care Plan (CCP) dated 12-6-2016 revealed the facility staff had identified Resident 96 was a new admission with a [DIAGNOSES REDACTED]. An interview was conducted on 2-21-2017 at 11:19 AM with Registered Nurse D. During the interview, RN D reported there was not a recent re-evaluation of Resident 96's pain management program and reported one should have been completed.",2020-09-01
989,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,312,D,0,1,PWJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 (2) Based on observation, record review, and interview; the facility failed to provide toileting, for Resident 26, 1 of 5 sampled. The facility Census was 83. Findings are: Record review of Resident 26's Admission Record, dated 2/21/17, revealed that Resident 26 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 26's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed 12/22/16 revealed that Resident 26's Brief Interview for Mental Status (BIMS) score was 11 out of possible 15. Resident 26 required extensive assistance of two persons to physical assist for Bed Mobility (how resident moves to and from lying position, turns side to side and positions body while in bed), Transfer (how resident moves between surfaces) and Toilet use (how resident uses the toilet room, commode, bedpan, or transfers on/off toilet). Resident 26's MDS revealed that Resident 26 was frequently incontinent of urine and bowel. Record review of Resident 26's Comprehensive Plan of Care (CPC), dated 4/25/13 and revised on 1/10/17, revealed that Resident 26 had Activity of Daily Living (ADL) deficit and decreased mobility and required assist with all ADL's and mobility. A goal was developed for Resident 26 to maintain the current level of function through the review date with a target date of 1/10/17. Interventions were present for bathing, dressing, eating, oral care, and toilet use. Resident 26 required extensive assist with EZ stand (a type of positioning lift that requires resident to assist), or a Hoyer Lift (lift that does not require resident assist) to transfer the resident to the toilet. On night shift offer the bed pan or check and change with rounds. This was initiated on 4/25/13 and revised on 12/19/16. The CPC revealed that Resident 26' had bladder incontinence related to Dementia, functional incontinence, and needs assist with toileting, which was dated 04/26/13 and revised on 01/10/17. The goal for the resident was to remain free from skin breakdown due to incontinence and brief use through the review date target date of 1/10/17. Interventions included for the resident to drink more fluids during the morning and afternoon and limit fluids in the evening, which was initiated on 1/5/16. The Toileting Program consisted of Check and offer toileting every 2 hours, use EZ stand and transfer to toilet with 2 staff assist. The date of initiation was 1/10/17. Observation of Resident 26 on 2/13/17 at 1:52 PM revealed that resident was sitting in a wheelchair and was visibly wet. Resident 26 was aware of the incontinence and was pulling down the shirt to try to hide the visible wetness of the pants. Resident 26's call bell was attached to the grab bar rail of the bed. Resident 26's wheel chair was positioned in front of the grab bar with the handle bars of the wheelchair flush with the lower end of the hand rail. Therefore, the resident was unable to call for assistance. Interview with Staff Member F on 2/13/17 at 1:52 PM confirmed that Resident 26 was visibly wet and had not been toileted since Resident 26 was gotten out of bed at approximately 10 AM. Observation of Resident 26 on 2/15/17 at 10:12 AM revealed that Staff Member F had assisted Resident 26 out of bed and into wheelchair. Observation revealed that Resident 26's call bell was positioned around the grab bar of the bed, Resident 26's wheel chair was positioned in front of the grab bar with the handle bars of the wheelchair flush with the lower end of the hand rail. Interview with Staff Member G on 2/15/17 at 10:20 AM confirmed that Resident 26's call bell was not able to be reached by Resident 26. Observation of Resident 26 on 2/15/17 at 1:31 PM revealed that Resident 26 remained in the dining room. On 02/15/2017 at 1:44:16 PM, Resident 26 was in their room with a urine odor present. There was no visible signs of urine on the resident's pants as the pants were dark black polyester. Resident 26 revealed that no one had taken the resident to the toilet since getting out of bed this am. Observation of Resident 26 on 2/15/17 at 2:04 PM revealed Resident 26 was assisted to the toilet by Staff Member F and Staff Member H. Staff Member F revealed that it took two staff to assist Resident 26 to the toilet and confirmed Resident 26 had not been taken to the toilet before lunch. Interview with Staff Member F on 2/15/17 at 2:04 PM revealed that Resident 26 was on a two hour toileting program, and that Resident 26 had been incontinent of urine.",2020-09-01
990,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,314,D,0,1,PWJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2a Based on observations, interviews, and record review; the facility staff failed to identify the development of a pressure ulcer and implement assessed interventions for Resident 32 and failed to identify indicators of a pressure area for Resident 1. These were 2 of 4 residents sampled. The facility staff identified the resident census at 83. Findings are: [NAME] A review of Resident 32's Care Plan dated 9/20/16 revealed that Resident 32 was admitted on [DATE] with the following Diagnoses: [REDACTED]. An observation conducted on 2/15/17 from 9:59 AM to 10:40 AM of morning cares completed on Resident 32 revealed Nursing Assistant (NA) I and NA J rolled Resident 32 to the left side. Resident 32 was observed to have a reddish purple linear area to the back of the left thigh. NA I was observed to point out the area to NA J and told NA J that it must be new and NA I would report it to the nurse. Licensed Practical Nurse (LPN) L entered room and proceeded to remove Resident 32's immobilizer and the stocking underneath and inspected the top and sides of Resident 32's left thigh for skin issues. LPN L cleansed Resident 32's thigh with wet washcloth, applied lotion to Resident's left lower leg and foot and reapplied the stocking and immobilizer. LPN L was observed to leave Resident 32's room. NA I and NA J were then observed to roll Resident 32 to the side to place lift sling under resident. Resident 32 was observed to have a reddish purple area on the back of their left thigh just above the immobilizer. An interview conducted on 2/16/17 at 8:50 AM with LPN M revealed that Resident 32 was not reported to have any new skin breakdown on their thighs. An observation conducted on 2/16/17 at 8:56 AM with LPN M of the back of Resident 32's left thigh revealed a reddish purple area linear area with a larger circular area on one end with a white/yellow center. The area was observed to not blanche when LPN M pressed on it. An observation conducted on 2/16/17 at 9:00 AM with Registered Nurse (RN) C of the back of Resident 32's left thigh revealed the reddish purple area measured 2.5 by 10.0 centimeters. An interview conducted on 2/16/17 at 9:00 AM with RN C revealed that the area on the back of Resident 32's left thigh was a pressure area. RN C reported they did not know about this area. An interview conducted on 2/16/17 at 9:25 AM with NA I revealed that NA I had forgotten to report the area observed on Resident 32's thigh to LPN L during morning cares on 2/15/17, but did report the area to LPN L prior to leaving at the end of their shift. A review of Resident 32's physician's orders revealed a physician order dated 11/14/16 to remove brace daily and check skin daily for skin integrity. A review of Resident 32's care plan dated 9/23/16 revealed Resident 32 was at risk for skin breakdown with an intervention to remove brace daily and check skin for skin breakdown. B. Record review of the facility policy titled Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements dated Revised 4/16 revealed: Purpose: * To systematically assess resident with regard to risk of skin breakdown * To accurately document observations and assessments of residents * To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. 2. The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk, on all residents quarterly or when the resident has a change in condition that could affect the development of ulcer. 5. A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant responsible for this will report any abnormal findings of skin impairment to the licensed nurse. 6. Residents who are unable to reposition themselves independently, as indicated on the Mobilization Support Data Collection Tool, should be repositioned, as often as schedule is required, for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the residents skin over a period of time. The Positioning Assessment and Evaluation is a required tool that is used to determine an individualized repositioning schedule. Record review of Resident 1's Admission Record, dated 2/15/17 revealed that Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning), dated 1/17/17, revealed that Resident 1's Brief Interview for Mental Status (BIMS), score was a 4, revealing that Resident 1 had cognitive impairment. The MDS revealed that Resident 1 required extensive assist of two persons to physically assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Resident 1 required extensive assist of two persons, to physically assist to toilet and transfer, and that Resident 1 did not walk. The MDS revealed that Resident 1 was always incontinent of urine and frequently incontinent of bowel. The MDS Section M revealed that Resident 1 was at risk of developing pressure ulcers, and that a turning and repositioning program was to be used for Resident 1. Record review of Resident 1's Mobilization Support Data Collection Tool-V4 dated 1/17/17 revealed that Resident 1 required Extensive support with weight bearing support required to turn to one or both sides with resident participation. Record review of Resident 1's Braden Score Risk assessment dated [DATE] revealed a score of 18. Resident 1 was considered High Risk for pressure sore development (score of 18 or below was considered High Risk for pressure sore development). Record review of Resident 1's medical record did not reveal a Positioning Assessment. Record review of Resident 1's Dietary assessment dated [DATE] revealed that Resident 1 intakes of meals were 50-75 % and that resident was on diuretic therapy. Resident was on a low sodium diet with thin liquids and that weight fluctuations may occur with diuretic usage. Observation of Resident 1, on 2/15/17 at 5:19 AM, revealed Staff Member B providing incontinent care. Resident 1 had been incontinent of bowel and bladder and was lying on the left side. Upon Staff Member B turning Resident 1 to provide care, observation revealed a pink area over the left hip bony prominence was present. Upon completing cares to Resident 1, Staff Member B assisted resident to lie on the left side. Observation of Resident 1, on 2/15/17 at 6:19 AM, revealed Resident 1 lying on left side in same position. Observation of Resident 1 on 2/15/17 at 7:37 AM, revealed Resident 1 lying on left side in same position. Observation of Resident 1 on 2/15/17 at 7:42 with Staff Member C revealed that resident had not been repositioned and that the pink area was present with minimal blanching. Interview with Staff Member C, on 2/15/17 at 7:42, confirmed that the pink area on Resident 1's left hip was an indicator of a pressure area. Interview with Staff Member C on 2/15/17 at 2:43 PM confirmed that the indication of pressure area was not identified for Resident 1 and that measures were not in place to prevent the development of a pressure area to Resident 1. Staff Member C confirmed that a Braden Score of 18 for Resident 1 was an indication of the need for prevention measures to be in place to prevent pressure areas from developing. Interview with the facility DON (Director of Nursing) on 2/15/17 at 3:45 PM confirmed that a Positioning Assessment was not performed for Resident 1. The DON confirmed that a Positioning Assessment would assist in developing a designated turning schedule, and that Resident 1 did not have a turning scheduled developed.",2020-09-01
991,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,315,D,0,1,PWJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D3 Based on observation, interview, and record review; the facility failed to evaluate clinical justification for indwelling catheter use and failed to complete catheter care for Resident 32. The facility also failed to evaluate a toileting program for Resident 91. These were 2 of 3 residents sampled. The facility staff identified the resident census to be 83. Findings are: [NAME] A review of Resident 32's Care Plan dated 9/20/16 revealed that Resident 32 was admitted on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 32's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 9/27/16 revealed Resident 32 had an indwelling catheter. A review of Resident 32's Care Area Assessment for the MDS date 9/27/16 revealed that Resident 32 was readmitted to the facility with an indwelling catheter related to right leg fracture, incontinence, not ambulating, and pain with movement. A review of Resident 32's Care plan dated 10/6/16 revealed that Resident 32 had an indwelling catheter related to [MEDICAL CONDITION] and comfort that was placed in the hospital after a left femur fracture in (MONTH) (YEAR). An interview conducted on 2/21/17 at 11:33 AM with the Director of Nursing (DON) revealed that Resident 32 had an indwelling catheter for [MEDICAL CONDITION] and comfort. The DON reported that Resident 32 had a [MEDICAL CONDITION] and the pain was too much for Resident 32 to use the bedpan. The DON reported that they were unaware if Resident 32 still had that much pain. The DON reported that Resident 32 had not seen an urologist related to indwelling catheter or [MEDICAL CONDITION]. The DON reported there was not any other [DIAGNOSES REDACTED]. An interview conducted on 2/21/17 at 1:51 PM with the DON revealed that there had not been an evaluation of clinical justification for indwelling catheter use completed on Resident 32. An observation conducted on 2/15/17 at 9:59 AM to 10:40 AM of morning cares revealed Nursing assistant (NA) I completing perineal and catheter cares with the assistance of NA [NAME] NA I cleansed Resident 32's perineal area with a wet washcloth. NA I started at Resident 32's right abdominal fold and wiped from outer fold into the perineal area and down toward the perirectal area. NA I then repeated this same procedure on the left side. NA I took a clean washcloth and wiped resident's left thigh down toward perineal area and, without folding washcloth, continued down toward Resident 32's perirectal area. NA I was not observed to cleanse the catheter tubing. An interview conducted on 2/15/17 at 12:04 PM with NA I revealed that the NA staff were responsible to complete catheter cares. An interview conducted on 2/16/17 at 9:25 AM with NA I confirmed that NA I was observed on 2/15/17 completing catheter cares on Resident 32. A review of the facility Catheter Care Procedure dated 11/2013 revealed: Procedure: 4.Cleanse urinary meatus in female resident from front to back with washcloth, cotton balls, or gauze pads. Then, cleanse for four inches down catheter tubing. B. Record review of Resident 91's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed and dated 1-16-2017 revealed the facility staff assessed the following about the resident: -Had long and short memory problems. - Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Frequently incontinent of bowel and bladder with no trial of a toileting program. Record review of Resident 91's Comprehensive Care Plan (CCP) dated, dated 10-27-2016 and revised on 1-16-2017, identified Resident 91 was occasionally incontinent of bowel. Further review of Resident CCP dated 1-16-2017 revealed Resident 91 had bladder incontinence related to Dementia and that Resident 91 would toilet (gender) without calling for assistance. Record review of an incident information sheet dated 11-18-2016 revealed Resident 91 was found on the floor. According to the information in the incident information sheet, a new intervention was to assist Resident 91 with using the bathroom at 2 AM as this was a common time Resident 91 would attempt a self transfer to the bathroom. Review of Resident 91's Record revealed there was no evidence the facility staff had evaluated Resident 91 for a toileting program. An interview was conducted on 2-16-2017 at 3:39 PM with the MDS Coordinator D. During the interview The MDS Coordinator reported that an evaluation program had not been completed for Resident 91 and should have.",2020-09-01
992,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,323,E,0,1,PWJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7a Based on observations, interviews, and record reviews; the facility failed to maintain hot water at a temperature to prevent potential hot water burns for Residents 20, 53, 141, 79, 30, and 106 and failed to implement interventions to prevent falls for Resident 46. The facility staff identified the resident census at 83. Findings are: [NAME] An observation conducted on 2/13/17 at 10:51 AM revealed the hot water temperature in the bathroom of Resident Room 510 of 123.7 degrees Fahrenheit. An observation conducted on 2/13/17 at 11:03 AM revealed the hot water temperature in the bathroom of Resident Room 512 of 125.6 degrees Fahrenheit. An observation conducted on 2/13/17 at 11:21 AM revealed the hot water temperature in the bathroom of Resident Room 507 of 133.3 degrees Fahrenheit. An interview conducted on 2/13/17 at 11:03 AM with Resident 30 revealed the resident felt the water in the bathroom was very hot. Observations conducted on 2/13/17 from 12:32 PM to 12:37 PM with the Environmental Services Director, using the facility thermometer, revealed hot water temperatures of 128.2 degrees Fahrenheit in the bathroom for Resident Room 512, 127.8 degrees Fahrenheit in the bathroom for Resident Room 507, and 128.2 degrees Fahrenheit in the bathroom for Resident Room 510. An interview conducted on 2/13/17 at 12:33 PM with the Environmental Services Director revealed that hot water in the resident rooms should have been no more than 120 degrees Fahrenheit. An interview conducted on 2/13/17 at 3:13 PM with the Environmental Services Director revealed that the water temperatures in the resident rooms were to be checked on a weekly basis, but there was only one documented monitoring for (MONTH) (YEAR). An interview conducted on 2/13/17 at 3:30 PM with the Director of Nursing (DON) revealed the residents in rooms 507, 510, 512 were all considered cognitively impaired. Residents 53, 79, 30, and 106 are able to access the bathroom on their own. A review of the facility's documentation of water temperature monitoring revealed the facility had documentation of the water temperatures in resident rooms being checked 2 times in (MONTH) (YEAR), 1 time in (MONTH) (YEAR), and 0 times in (MONTH) (YEAR) A review of the facility's Policy and Procedure for Domestic Water Temperatures dated (MONTH) (YEAR) revealed: Procedure: -Domestic Water Temperature Ranges: 1. The recommended temperature range for domestic hot water, at point of use, is between 105 degrees and 115 degrees Fahrenheit or lower if required by state or local statute. -Monitoring Domestic Water Temperatures (Rehab/skilled) 1. Domestic water temperatures should be monitored on a weekly basis (or more frequently if conditions require) to ensure a comfortable and safe environment for residents. B. Record review of Resident 46's Comprehensive Care Plan (CCP), dated on 9-20-2016 and revised on 2-15-2017, revealed Resident 46 was at risk for falls. The goal for Resident 46 was not to sustain a serious injury. Interventions identified on Resident 46's CCP included the following: -Ensure the resident wore appropriate non-skid footwear. -Make sure glare free lighting used to maximize resident safety. -Personal alarm: bed alarm used to alert staff to the resident's movement and to assist staff in monitoring movement. -Make sure the walker was next to Resident 46 at all times. -Staff to ensure alarms are in place and working before leaving the room. Record review of an Orders Summary Report sheet, signed and dated 12-14-16, revealed an order for [REDACTED]. Also, leave the pressure alarm in place as well. Record review of an incident report sheet, dated 2-08-2017, revealed Resident 46 was found sitting on the floor. According to the information on the incident report sheet, Resident 46's fall alarms were sounding. Observation on 2-15-2017 at 5:14 AM revealed Resident 46 was in bed asleep and there was no tabs alarm connected to the resident. Observation on 2-15-2017 at 9:54 AM revealed Resident 46 was in bed sleeping, the walker was not within reach nor was a tabs tab alarm connected to Resident 46. Observation on 2-15-2017 at 1:49 PM revealed Resident 46 was lying in bed eating chocolates. No tabs alarm was in place. An interview on 2-15-2017 at 1:53 PM was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview, LPN A confirmed Resident 46 was to have a tabs alarm and did not have one attached.",2020-09-01
993,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,363,E,0,1,PWJJ11,"LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, record review and interview; the facility staff failed to ensure correct portion sizes were served to residents who received mechanical altered meals. The facility identified 6 (Resident 149, 73, 96, 79, 141 and 85) who received mechanical altered diets. The facility staff identified a census of 83. Findings are: Record review of a weekly Menu dated 2-12 to 2-18 revealed lunch service was changed to Pork Roast, brown gravy, whipped potatoes, a bread selection, fruited Gelatin and beverage of choice. Record review of the Diet spread sheet for the 3rd week cycle revealed the amount of Roast Pork to be served to each of the resident was 3 ounces (oz.) including residents on mechanical diet. Observation of the meal service on 2-15-2017 at 11:23 AM to 12:49 PM revealed Dietary Cook (DC) [NAME] served residents their meals that included the residents on mechanical altered diets. An interview with DC [NAME] on 2-15-2017 at 12:49 PM revealed the scoop size used for the mechanical altered pork roast was a #12 scoop. During the interview, when asked how much was in a #12 scoop, DC [NAME] looked at a chart and reported the #12 scoop provided 2 and 3/4 oz. of the roast pork. The DC [NAME] confirmed the residents who were on mechanical altered diets received less than the required amount of roast pork. A follow up interview was conducted with the Dietary Service Manager (DSM) on 2-15-2017 at 1:33 PM. During the interview, the DSM confirmed the incorrect sized scoop was used and that it provided 2 3/4 oz. of the roasted pork.",2020-09-01
994,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-02-21,412,D,0,1,PWJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.14 Based on observation, interviews, and record reviews; the facility failed to ensure dental services were provided for Resident 32 . Facility census was 83. Findings are: An interview conducted on 2-13-17 at 10:30 AM with Resident 32 revealed that Resident 32 had been having issues with dentures not fitting and had been unable to wear them. Resident 32 reported that facility staff were aware of the issue, but Resident 32 did not know if facility staff had done anything as they had not talked to the resident about it. An observation conducted on 2-13-17 at 10:54 AM revealed that Resident 32 was missing teeth and was not wearing dentures. A review of Resident 32's Care Plan dated 9/20/16 revealed that Resident 32 was admitted on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 32's Minimum Data Sets (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 9/27/16, 11/15/16, and 12/20/16 revealed that Resident 32 had an issue with loose fitting or broken dentures. A review of Resident 32's Dental Care Area Assessment for Resident 32's MDS dated [DATE] revealed that Resident 32's dentures were too loose and Resident 32 did not wear them. Resident 32's daughter was aware of this. A review of Resident 32's Care Conference note date 10/6/16 revealed that Resident 32's daughter wanted Resident 32 seen by a dentist to look at loose fitting dentures. This not revealed that Resident 32 was to be added to the dentist's list. A review of Resident 32's Social Services note date 12/30/16 revealed that Resident 32 was being placed back on a regular consistency diet on the condition that Resident 32 wear their dentures. Resident 32's daughter reported that dentures needed to be looked at and requested the mobile dentist to see Resident 32. An interview conducted on 2/16/17 at 10:44 AM with the Director of Health Information Manager (HIM) revealed that the HIM had sent out a referral via email to the mobile dentistry service on 12/30/16 but the referral had been missed and Resident 32 was not placed on the dentist's patient list. An interview conducted on 2/16/17 at 2:38 PM with the HIM revealed that the mobile dentistry service visited the facility on 2/10/17 but did not see resident. The HIM reported that the mobile dentistry service left a list of what residents were seen. The HIM reported that they check that list to make sure each resident on the list had a progress note from the dentist, but it was not their practice to check it to make sure the residents that needed services were seen.",2020-09-01
995,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2018-04-24,690,D,0,1,YJVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure 1 resident (Resident 34) 1 of residents sampled met criteria for continued use of antibiotic therapy. The facility staff identified the census at 74. The findings are: A review of Resident 34's Admission Record dated 4-24-18 revealed that Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 34's (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of Resident 34's Urinalysis with Culture and Sensitivity revealed that the urine was positive for Escherichia coli (E.coli-a bacteria that normally lives in the intestines of humans) and was sensitive to all the antibiotics tested . A review of Resident 34's Progress Note dated 4-10-18 revealed that the medical practitioner ordered a Urinalysis with Culture and Sensitivity to be done due to Hematuria (blood in the urine). A review of Resident 34's Progress Notes dated 4-11-18 to 4-20-18 revealed that Resident 34 did not exhibit or report any signs or symptoms of a UTI, fevers, or Hematuria. A review of Resident 34's Progress Note dated 4-21-18 revealed that Resident 34 did not exhibit or report any signs or symptoms of a UTI. The resident had several bruises noted on bilateral hips from the [MEDICATION NAME] injections. An interview conducted on 4-24-18 at 9:49 AM with the Director of Nursing (DON) and Registered Nurse (RN) A confirmed that Resident 34 did complete a 7 day course of [MEDICATION NAME] for a UTI on 4-19-18 and was started on another 7 day course on 4-20-18. The DON and RN A reported they thought Resident 34 was retested for a UTI and that the resident still had a UTI. They reported they were not aware that the urine culture from 4-10-18 was sensitive to all the antibiotics. The DON and RN A reported they did not know why the resident was on [MEDICATION NAME] instead of an oral antibiotic and were unaware that the resident had multiple bruises from receiving the daily injections. A review of Resident 34's Late Entry Progress note for 4-20-18 that was created on 4-24-18 at 11:18 AM revealed that the resident was catheterized and the urine was blood tinged. The resident had not any signs or symptoms of UTI. The Medical Practitioner was called and an order was received for another 7 days of [MEDICATION NAME] injections. An interview conducted on 4-24-18 at 11:30 AM with the DON confirmed that the Late Entry Progress Note was just documented by the Assistant Director of Nursing due to there not being any documentation present regarding the resident starting on [MEDICATION NAME]. An interview conducted on 4-24-18 at 11:41 with the Nurse Practitioner revealed that the facility staff called the Nurse Practitioner to report the results of the culture and sensitivity completed on 4-10-18, but had not reviewed and signed the results. The Nurse Practitioner was not able to recall what bacteria was present in Resident 34's urine and what antibiotics the bacteria was sensitive to. The Nurse Practitioner reported the facility staff did call them on 4-20-18 to report that Resident 34 had blood in their urine, but did not report that the urine was collected through catheterization. The Nurse Practitioner reported that the blood in the urine could have been caused by trauma during the catheterization and that they may have done things differently had they known the urine was collected through catheterization. The Nurse Practitioner reported that they did not order another urinalysis because the resident had hematuria which was the UTI symptom the resident had before. The Nurse Practitioner reported they would like to have the resident on oral antibiotics, but the resident is noncompliant. An interview conducted on 4-24-18 at 12:22 PM with Licensed Practical Nurse (LPN) B revealed that Resident 34 did not refuse to take their oral medications or being catheterized twice a day, but does request that only same gender nurses complete the catheterization. An interview conducted on 4-24-18 at 2:51 PM with LPN C revealed that Resident 34 did not refuse catheterizations. LPN C reported that the resident would have an episode of hematuria every couple of months. A review of Resident 34's Progress Notes dated 4-20-18 to 4-24-18 revealed that Resident 34 did not exhibit or report any signs or symptoms of a UTI, fevers, or Hematuria. A review of Resident 34's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of Resident 34's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of Resident 34's (MONTH) (YEAR) MAR indicated [REDACTED]. The resident received [MEDICATION NAME] (an oral antibiotic commonly used to treat UTI) from 2-4-18 to 2-10-18 for a UTI. A review of Resident 34's Urinalysis Final Report dated 2-4-18 revealed that the urine had no bacterial growth present. A review of the facility's Antibiotic Stewardship Policy dated 1/2018 revealed the following: Guideline: Criteria for Initiation of Antibiotics In Long-Term Care Centers: Urinary Tract Infections: Residents without indwelling catheter: Acute dysuria or Fever and New or worsening symptoms in at least one of the following (in the absence of fever, two or more of the following): Costovertebral angle tenderness (back pain in the area of the kidneys), frequency, gross hematuria, suprapubic pain, urgency, urinary incontinence.",2020-09-01
996,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2018-04-24,693,D,0,1,YJVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6(1) Based on observations, interviews, and record reviews; the facility failed to administer gastrostomy tube flushes to 1 resident (Resident 67) of 1 resident sampled according to practitioner's orders and in accordance with standards of practice. The facility staff identified the census at 74. The findings are: A review of Resident 67's Admission Record dated 4-23-18 revealed the resident was admitted to the facility on [DATE] with a gastrostomy tube and dysphagia (difficulty swallowing). An observation conducted on 4-23-18 at 8:40 AM revealed Licensed Practical Nurse (LPN) D used a 4 ounce container of Normal Saline (a salt water solution) to flush Resident 67's gastrostomy tube before and after the administration of medications through the tube. An interview conducted on 4-23-18 at 9:08 AM with LPN D revealed that LPN D usually used Normal Saline to flush gastrostomy tubes when giving medications. An interview conducted on 4-23-18 at 9:28 AM with the Director of Nursing revealed that the facility policy for flushing gastrostomy tubes with medication administration was to use sterile water, but that the DON was trying to get the policy changed to use tap water. A review of Resident 67's Order Summary Report dated 4-23-18 revealed an order to flush the gastrostomy tube before and after every medication administration using 30 milliliters (ml) of water. A review of the facility's Tube (Enteral) Feeding: General Information policy dated 10/2017 revealed that the facility policy was to use either sterile water or tap water for administration of medications. A review of the facility's Procedure for Medication Administration Via Tube dated 11/2013 revealed the following: Procedure: 6. Flush tube with 30 ml of sterile water before and after administering each medication pass. A review of http://static.abbottnutrition.com/cms-prod/abbottnutrition.com/img/M4619.005%20Tube%20Feeding%20manual.pdf, pages 16-17 revealed the following: Prevention of mechanical complications: C. Routinely flush feeding tube with 30 mL water: a. Every 4 hours during continuous feeding. b. Before and after intermittent feedings. c. After residual volume measurements. d. Use sterile or purified water for immunocompromised or critically ill patients, especially when the safety of tap water is questionable.",2020-09-01
997,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2018-04-24,923,E,0,1,YJVJ11,"Licensure Reference Number 175 NAC 12-007.04 D Based on observation, record review and interview; the facility failed to ensure that the ventilation system was operational in 12 (Rooms 201, 208, 211, 215, 304, 306, 308, 507, 509, 511, 513, 518) of 54 occupied resident rooms. The facility census was 74. Findings are: Observation on 04/23/18 between 3:35 PM to 04:09 PM with Administrator , Director of Nursing and the Environmental Services Director revealed no working ventilation system in the bathroom in resident rooms 201, 208, 211, 215, 304, 306, 308, 507, 509, 511, 513, 518. A one ply square of toilet paper was held against the surface of the ventilation system cover in the bathrooms of rooms 201, 208, 211, 215, 304, 306, 308, 507, 509, 511, 513 and 518. The ventilation system in those rooms did not hold the paper to the outside of the ventilation cover which indicated that there was no air draw and the ventilation system was not working. Interview on 4/23/18 at 4:05 PM with the Environmental Services Director confirmed that the ventilation systems were not working and that the ventilation system exhaust fans on the roof were checked monthly but were not routinely checked in resident rooms for draw to ensure the system remained operational. Record review of documentation of ventilation system checks entitled Work History Report for the last 12 mnths revealed that the last time the facility ventilation system exhaust fans had been checked was 3/8/18. Interview on 4/24/18 at 4:50 PM with the facility Administrator confirmed that the ventilation system had been checked over a month ago. The Administrator confirmed that the system should be checked more frequently and that checks should be done in resident rooms to ensure that the system remained operational.",2020-09-01
998,GOOD SAMARITAN SOCIETY - MILLARD,285098,12856 DEAUVILLE DRIVE,OMAHA,NE,68137,2017-08-28,323,G,1,0,7VGT11,"> LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to ensure facility staff used a shower table correctly for 1 (Resident 1) and failed to implement assessed interventions for prevention of falls for 2 (Resident 3 and 4) of 4 sampled residents. The facility staff identified a census of 74. Findings are: [NAME] Record review of Resident 1's Comprehensive Care Plan (CCP) dated 11-21-2016 and revised on 3-24-2017 revealed Resident 1 required total assistance with bathing. Resident 1's CCP identified staff were to use a mobile shower table for bathing. Further review of Resident 1's CCP revealed Resident 1 had both legs amputated. Record review of a facility Injury of Unknown Origin (IOUO) report sheet with an attachment dated 8-11-2017 revealed Resident 1 had fallen off a mobile shower table during bathing. According to the information on the IOUO dated 8-11-2017 Nursing Assistant (NA) A whom was identified as the bath assistant had placed Resident 1 onto the bathing table and pushed the bathing table with Resident 1 on it up against the wall and started to give Resident 1 a bath. According to NA A in the IOUO report, Resident 1 started .to fight against''' NA [NAME] NA A turned Resident 1 onto the other side when Resident 1 pushed against the wall, causing Resident 1 to fall off the bathing table onto the floor. When asked if the safety rails on the bathing table were being used, NA A reported not being aware the bathing table had safety rails and none were used. NA A reported Resident 1 was not seen to hit (gender) head. According to the IOUO reported dated 8-11-2017, Licensed Practical Nurse (LPN) B was notified Resident 1 was on the floor. LPN B had observed no blood or obvious breaks and Resident 1 was moving both arms. LPN B requested assistance via a walkie talkie type of device with LPN C responding. LPN B and LPN C using a shower blanket lifted Resident 1 back onto the table. LPN [NAME] (Resident 1's charge nurse) had entered the shower room and seeing that Resident 1 was displaying verbal and nonverbal cues that (gender) did not what Vital Signs (VS, normally consist of blood pressure, pulse and temperature) suggested they take Resident 1 to Resident 1's room and obtain the VS. The IOUO also contained information that Resident 1 was sent to the hospital on 8-05-2017 and on 8-06-2017 Resident 1's family had notified the facility Resident 1 had sustained a pelvic fracture, heart attack, Urinary Tract Infection (UTI) and a brain bleed. On 8-28-2017 at 12:20 PM an interview was conducted with the facility Administrator. During the interview the Administrator confirmed there was no evidence the facility had taught NA A on the use of the bathing table and further reported was not a policy or procedure for the use of the bathing table until after Resident 1 had fallen. On 8-28-2017 at 12:52 PM an interview was conducted with LPN B. During the interview, LPN B reported not being aware the bathing table had safety rails and further reported not knowing how to use the bathing table. On 8-28-2017 at 1:05 PM a phone interview was conducted with NA [NAME] During the interview NA A reported .was just thrown into the bath (assistant) position and was not oriented or taught how to use the bathing table. The Director of Nursing (DON) brought it in (bathing table) and told me to use it without instructions''. NA A reported not seeing Resident 1 hit (gender) head. Record review of NA A personal file revealed there was no evidence NA A had been oriented to the bath assistant position or how to use the bathing table. On 8-28-2017 at 3:12 PM a phone interview was conducted with LPN C. During the interview LPN C reported not being aware the bathing table had safety rails. On 8-28-2017 at 3:16 PM a phone interview was conducted with LPN D. During the interview LPN D reported not being aware the bathing table had safety railed. Observation on 8-28-2017 at 12:20 PM with the facility Administrator of the bathing table revealed the frame was constructed with white PVC type of tubing. During the observation the safety rails were down blending in with the frame construction. The facility administrator demonstrated how to lift and secure the safety rails. Record review of a Progress Note dated 8-06-2017 revealed Resident 1 had fallen at the facility with a resulting .broken left pelvis, and has inter cranial hemorrhage with altered mental status. B. Record review of Resident 3's CCP dated 6-20-2017 and revised on 8-25-2017 revealed Resident 3 was at risk for falls. The goal for Resident 3 was to be free of falls with injury. The interventions identified on the CCP included a fall mat, personal alarm and nonskid socks. Record review of an incident report sheet dated 8-25-2017 revealed resident 3 was found on the floor mat. Further review of the incident report sheet dated 8-25-2017 revealed a new intervention was to use a scoop type of mattress for Resident 3. Observation on 8-28-2017 at 10:35 AM revealed there was not a a scoop mattress on Resident 3's bed. An interview on 8-28-2017 at 12:52 PM was conducted with LPN B. During the interview LPN B confirmed the scoop mattress had not been on Resident 3 bed. C. Record review of Resident 4's CCP dated 4-19-2017 and revised on 8-12-2017 revealed Resident 4 was at risk for falls related to right leg fracture and mobility deficit. The goal for Resident 4 was to be free of fall related injuries. Interventions to meet this goal was to ensure Resident 4 was wearing non-skid socks, a personal alarm when in bed and to trial hip protectors. Observation on 8-28-2017 at 10:45 AM revealed Resident 4 was in the bathroom, hip protectors were in a chair outside of the bathroom. LPN B entered the room and assisted Resident 4 with dressing. LPN B placed Resident 4's pants on, the hip protectors were not applied. The hip pads were not offered, nor did Resident 4 refuse them at the time of the observation. Observation on 8-28-2017 at 2:31 PM revealed Resident 4 was seated in a wheelchair. Resident 4 reported not wearing the hip protectors and that might be helpful.",2020-09-01
999,STANTON HEALTH CENTER,285102,"P O BOX 407, 301 17TH STREET",STANTON,NE,68779,2019-02-06,684,D,0,1,3YZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observations, record review and interview; the facility failed to assess wounds in order to monitor healing and the effectiveness of treatments for 2 of 4 residents (Residents 26 and 57) who were reviewed related to a history of and/or existing wounds. The facility census was 60. Findings are: [NAME] Review of the facility policy titled Skin Care and Management dated 9/27/15 revealed the following: -skin breakdown was to be monitored on a regular basis as set forth in the Care Plan; and -residents receiving skin treatments were discussed weekly at resident review, including an assessment of progress or change in the compromised area, interventions in place, and physician's orders/changes. B. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/5/18 included the following: -[DIAGNOSES REDACTED]. -had no identified skin problems. Review of Resident 26's Care Plan dated 1/11/19 revealed the left lower leg was noted to have 3 superficial open areas measuring 1) 1 cm (centimeter) x (by) 1 cm x 0.1 cm with 0.5 cm x 0.3 cm slough (dead tissue described as yellow, tan, white or stringy) in the center, 2) 1 cm x 0.8 cm, and 3) 1 cm x 1 cm and covered with slough. There was no redness or warmth noted, and there was a scant amount of serous (clear, watery) drainage. Nursing interventions included the following: -monitor/document/report changes in the wound color, temperature, sensation, pain, or presence of drainage and odor; -weekly treatment documentation to include the measurements of each area of skin breakdown including width, length, depth, type of tissue and exudate (drainage), and any other notable changes or observations; and -change dressing and record observations of the wound site. Review of a Weekly Wound Review form (used by facility staff to document the assessment of wounds) dated 1/11/19 revealed the following: -3 open areas on the left lower inner leg that were diabetic/ischemic (due to lack of blood flow to the tissues); -the top wound had slough, and the bottom wound had eschar (dead/necrotic tissue described as brown, black or scab-like) and slough; and -the areas were cleansed with Normal Saline (NS), [MEDICATION NAME] (a type of wound dressing) and PolyMem (a type of wound dressing) were applied, and the dressing were secured with Kerlix (a gauze dressing) and Coban (compression bandage wraps). Review of the Treatment Administration Record (TAR) dated 1/2019 revealed documentation that wound care was provided 3 times weekly as ordered by the physician. However, there was no evidence of measurements and/or assessments of the wounds on Resident 26's left lower leg since the initial assessment completed on 1/11/19. During observation on 2/4/19 from 10:06 AM until 10:31 AM, Licensed Practical Nurse (LPN)-A changed the dressings on Resident 26's left lower leg. There were 3 dark spots of dried drainage on the old dressing. LPN-A measured the 3 wounds, cleansed the area with NS and applied new dressings. Review of 3 separate Weekly Wound Review forms dated 2/4/19 revealed the following: -Wound 1 - top of left lower leg shin, started with blisters that opened due to [MEDICAL CONDITION] (fluid retention), scant serous drainage, measured 5 mm (millimeters) x 5 mm x 1 mm, surrounding skin was light red in color with no increase warmth noted; -Wound 2 - lower shin to outer side right of wound 1, from large amount of [MEDICAL CONDITION], scant serous drainage, measured 7 mm x 5 mm x 1 mm, red around wound, edges of wound were smooth and fragile; -Wound 3 - left lower leg outer side more toward back, from [MEDICAL CONDITION], scant serous drainage, measured 7 mm x 6 mm x 1 mm, red around wound no increase warmth, smooth fragile edges; and -the wounds were observed to be improved in healing. During interview on 2/5/19 at 7:43 AM, the Director of Nursing (DON) verified wounds were supposed to be assessed and recorded weekly, and Resident 26's wound assessment was not completed until 2/4/19 (3 weeks and 3 days following the initial wound assessment). C. Review of Resident 57's TAR dated 1/2019 revealed an order to measure the resident's right buttock wound weekly on (MONTH) 7th, 14th, 21st, and 28th. Review of Resident 57's Progress Notes revealed: - On 12/26/18 at 10:33 AM, the resident had a dime size open area to the right buttock. - On 1/1/19 at 10:09 AM, the resident had multiple small abrasion like areas to the right inner buttock. The area was very fragile with a small amount of blood on the resident's incontinence product. - On 1/7/19 at 3:41 PM, a [MEDICATION NAME] (an absorbent foam dressing used to treat a wide range of wounds) was applied to the right buttock abrasion area. - 1/14/19 (there was no evidence to indicate the right buttock wound was assessed or measured) - 1/21/19 (there was no evidence to indicate the right buttock wound was assessed or measured) - On 1/28/19 at 9:12 AM, the area to the resident's right buttock remained open. The area measured 7cm by 3cm. During an interview with the DON on 2/5/19 at 9:35AM, the DON confirmed all wounds should be assessed at least weekly and major wounds should be assessed and measured at least weekly. The DON confirmed wounds had not been monitored/assessed weekly.",2020-09-01
1000,STANTON HEALTH CENTER,285102,"P O BOX 407, 301 17TH STREET",STANTON,NE,68779,2019-02-06,686,D,0,1,3YZR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 6.09D2b Based on observations, record review and interview; the facility failed to assess pressure ulcers in order to monitor healing and the effectiveness of treatment for 2 of 2 residents (Resident's 36 and 9) who were reviewed related to a history of and/or existing pressure ulcers. The facility census was 60. Findings are: [NAME] Review of the facility policy titled Skin Care and Management dated 9/27/15 revealed the following: -skin breakdown was to be monitored on a regular basis as set forth in the Care Plan; and -residents receiving skin treatments were discussed weekly at resident review, including an assessment of progress or change in the compromised area, interventions in place, and physician's orders/changes. B. Review of Resident 36's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/21/18 included the following: -admitted [DATE] with [DIAGNOSES REDACTED]. -had 1 unstageable (wound bed covered by slough/eschar (dead tissue) making the depth of the wound undeterminable) pressure ulcer. Review of Resident 36's Care Plan dated 10/5/18 revealed suspected deep tissue injury (pressure-related injury to tissues beneath intact skin, having the appearance of a deep bruise) as the right heel was discolored and soft upon palpation (touch) . The area measured 3.5 x 3.5. Nursing interventions included the following: - wear heel protectors in bed; -no shoes, may wear gripper socks; -air mattress to bed (to relieve pressure); -assess/record/monitor wound healing; measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to the physician; and -follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of a Skin/Wound Nursing Progress Note dated 9/21/18 at 5:35 AM revealed and admission skin assessment was completed. There was no evidence in the medical record that indicated the results of the assessment and/or if there were skin problems identified. Review of Nursing Progress Notes revealed the following: -10/5/18 at 7:30 AM the RN (Registered Nurse) was alerted by the NA (Nursing Assistant) that Resident 36's right heel was discolored and soft upon palpation. A dressing was applied for protection, and the area measured 3.5 x 3.5; and -10/14/18 at 2:42 AM (9 days later) Continue to c/o (complain of) pain to right foot, no swelling, no redness noted to leg or below foot dressing, foot is warm and able to move toes. pulse felt in foot. Dressing is dry and remains intact. Review of a Weekly Wound Review form (used by facility staff to document the assessment of wounds) dated 10/26/18 (3 weeks following the initial observation of a pressure ulcer) indicated Resident 36 had pressure areas black in color on the right heel, described as Stage 2 (partial thickness skin loss that presents as an abrasion, blister or shallow crater), dry with no drainage or odor, and measured 3 mm x 3 mm x 0 mm. Review of Skin/Wound Nursing Progress Notes revealed the following related to the pressure ulcer on Resident 36's right heel: -11/2/18 at 9:51 AM continue to have a hard covering over 50% of wound and the other half is noted to be loose scab with red wound bed in patches. Resident does complain of pain. Small amount of drainage noted. Area measures 3.5 X 2.5 cm (centimeters - 1 cm=10 mm); and -11/9/18 at 10:39 AM noted 50% of wound to be covered in slough and 50% noted to have a harden (sic) dark area covering wound bed. Area measures 4 x 1 cm. Moderate amount of drainage noted. No s/s of infection noted. Resident does complain of discomfort in right heel. Review of a Nursing Progress Note dated 11/13/18 at 11:56 AM indicated Resident 36 returned to the facility from an appointment with the Podiatrist. The pressure ulcer was debrided (removal of damaged tissue from a wound). Wound measures 11 x 12 and 17 x 6 today in office. Documentation did not specify if the wounds were measured in cm or mm, and whether the measurements involved 1 or 2 pressure ulcers. Review of a Weekly Wound Review form dated 11/17/18 revealed a pressure ulcer on Resident 36's right heel, described as Stage 3 (full thickness tissue loss that may expose subcutaneous fat) with slough tissue and scant amounts of serous (clear, watery) drainage. Documentation indicated 1 wound that measured 33 mm x 15 mm, and the wound bed was tan in color. There was no evidence Resident 36's pressure ulcer was assessed again until Nursing Progress Notes dated 11/30/18 at 2:32 PM (13 days since the last assessment). Documentation indicated Resident 36's right heel was evaluated by the Podiatrist and Wound #1 is 1.0 cm x 0.4 cm x 2 mm. Wound #2 is 0.8 cm x 0.6 cm x 2 cm. Review of 2 separate Weekly Wound Review forms dated 1/8/19 (5 weeks and 4 days since the last measurements/assessment) revealed the following related to Resident 36's pressure ulcers: -Wound 1 - right heel pressure ulcer, unchanged, dry, measured 7 mm x 2 mm x 1 mm; and -Wound 2 - right heel 2nd (second) site, clean, unchanged, dry, no odor or drainage, measured 4 mm x 4 mm x 1 mm. During observation on 2/04/19 from 1:39 PM until 1:52 PM, Licensed Practical Nurse (LPN)-A changed the dressings on Resident 36's right heel. There were 2 small pressure ulcers observed on the heel, 1 covered with yellow colored matter and the other with a small open area at the center, approximately the size of a lead pencil. No measurements were completed of the wounds. Review of the Nursing Progress Note completed by LPN-A on 2/4/19 at 2:23 PM documented with treatment was very moist from the [MEDICATION NAME] (topical antibiotic) ointment skin is white noted to have pin point opening to then center of wound denies any pain, no redness or increase warmth or [MEDICAL CONDITION] to heel. During interview on 2/05/19 at 8:10 AM until 9:33 AM, the Director of Nursing (DON) confirmed weekly assessments were not completed for Resident 36's pressure ulcers, and verified the results of the admission skin assessment completed on 9/21/18 were not documented in the medical record. C. Review of Resident 9's New Wound assessment dated [DATE] revealed the resident had a stage 2 pressure ulcer to the right inner buttock. Review of Resident 9's Progress Notes dated 12/4/18 through 12/21/18 revealed: - On 12/4/18 at 7:21 AM, the resident had an open area to the right inner buttock that measured 1cm by 0.5cm. The resident complained of tenderness to the area. - On 12/21/18 at 7:41 AM, the resident's right inner buttock was healed. (There was no evidence to indicate the wound was measured or assessed from 12/4/18 to 12/21/18) During an interview with the DON on 2/5/19 at 9:35AM, the DON confirmed all wounds should be assessed at least weekly and major wounds should be assessed and measured at least weekly. The DON confirmed wounds had not been monitored/assessed weekly.",2020-09-01